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The (enhanced) documentation is in the details

The International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) is an international coding system for diseases and clinical procedures, as classified by the World Health Organization. Most of the world has been using ICD-10 for decades – but not the U.S. However, on Oct. 1, 2014, the U.S. gets on board, replacing its version of ICD-9 (ICD-9-CM) with ICD-10-CM (the U.S. clinical modification of ICD-10).

Why now? ICD-10 is a much more expressive and flexible classification system for sharing patient information among physicians, payers, reporting agencies, and patients. ICD-10 has five times more codes than ICD-9-CM and two additional digits, allowing for more detailed classification of patient diagnosis and clinical procedures. For example, ICD-9 has one code for the suture of an artery. ICD-10 has 180 different codes to describe more details for the same procedure.

Despite clear advantages, ICD-10’s complexity will challenge physicians’ ability to document patient episodes and will put clinical documentation tools and processes to an even greater test. To ensure appropriate reimbursement in ICD-10, patient information must be highly specific and clearly recorded.

Nuance Healthcare provides ICD-10 ready clinical documentation and coding solutions. These solutions will include Computer Assisted Physician Documentation (CAPD), a breakthrough technology being developed for clinical document improvement (CDI), and computer assisted coding (CAC).

CAPD will help physicians capture the necessary information needed for ICD-10 coding in "real time" and at the point of documentation. CAPD will leverage Nuance’s Clinical Language Understanding (CLU) technology and J.A Thomas’s extensive knowledge base of CDI guidelines and coding standards to help physicians improve documentation, while reducing the burden of the transition to ICD-10 on physicians and staff.

Similarly, CAC helps medical coders improve productivity and workflow. CAC is a key tool for helping medical coders transition to ICD-10 coding. We understand that you need innovative and intuitive solutions that address your current and future challenges. Our clinical coding, abstracting, ICD-10 and documentation improvement solutions and services will deliver improved quality and HIM performance to help mitigate the risk of impending ICD-10 productivity losses while increasing efficiencies across the enterprise. Clinical coding and documentation solutions.

Relevant Links

American Academy of Professional Coders (AAPC)

National Center for Health Statistics (NCHS)
Basic ICD-10-CM information

Centers for Medicare & Medicaid Services (CMS)
2011 ICD-10-PCS and General Equivalence Mappings (GEMs)

ICD-10 Overview

American Health Information Management Association (AHIMA)
ICD-10 Education

Workgroup for Electronic Data Interchange (WEDI)
Strategic National Implementation Process (SNIP)

ICD-10: Health care’s Y2K bug or something more serious?

White Paper
Nuance Clintegrity 360: A Clinically Driven Approach to ICD-10

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