2014 Conference, Track 1: Querying for ICD-10-PCS Documentation

Natalie Sartori, MEd, RHIA, AHIMA Approved ICD-10-CM/PCS Trainer, and Rebecca A. “Ali” Williams, RN, MSN, CCDS, present ways to expand CDI efforts to include the specific documentation needed for ICD-10-PCS code assignment. This presentation helps CDI professionals recognize additional  specificity needed in common ICD-10-PCS codes and enumerates documentation requirements to capture the clinical details to support ICD-10 codes for specific surgical cases. For each surgical procedure discussed, a comparison of the clinical details captured in ICD-9 vs. ICD-10-PCS and explicitly describe the clinical elements that must be documented.