Epic: Clinical Documentation and ICD-10 Readiness
Much of ICD-10 is focused on the surface-level shift from ICD-9 codes to ICD-10 Clinical Modification (ICD-10 CM) and ICD-10 Procedure Coding System (ICD-10 PCS). This movement away from ICD-9 codes to ICD-10 involves utilizing crosswalks between the two code sets, training coders, clinicians, and educating your operations on how to properly document, read and code a patient’s chart.
Epic has provided specific documentation within the Epic Userweb that covers the broad spectrum of how to successfully manage an ICD-10 implementation in order to successfully begin submitting claims using ICD-10 on October 1, 2014. Within this documentation, Epic’s whitepaper on Enhancing Clinical Documentation Specificity outlines some of the tools that can be used to improve documentation as part of your ICD-10 conversion.
Several master files that will need to be updated for enhanced specificity are listed below:
- VCG – Diagnosis Groupers
- LGL – Best Practice Advisories
- HBD – Block Definition Records
- EAP – Procedures
- ETT – Text Templates
- LPP – Extensions / Programming Points
- LQH – Visit Navigator History Template Definitions
In addition, any (ETX) SmartTexts, (ETL) SmartLists, or (HH1) SmartPhrases that reference free text ICD-9 codes must be updated to now refer to the appropriate ICD-10 codes. For a full list of master files, contact your Epic representatives.
In addition to clinical documentation, clinical content must also be updated for alerts, suggestions and other logic leveraging ICD codes. Be sure to review and evaluate your content as part of the ICD implementation plan. The October transition date is coming quickly; many providers report being unprepared for training or the transition. Be sure to focus on usability and documentation tools as part of your ICD transition.