Having the best and most up-to-date Electronic Medical Records (EMR) software will significantly ease the ICD-10 transition, allowing for better familiarity, faster adoption, and less disruption in cash flow after the deadline. Specific EMR features and functionalities exist within these software systems that can assist healthcare providers with ICD-10-CM as they train and integrate these codes into their specialty-specific practice. Here are four must-have, key EMR features to look for when purchasing or updating their software to fulfill ICD-10 and Meaningful Use requirements.
1. EMR clinical documentation templates
Since ICD-10-CM is characterized by a much higher level of detail, physicians need to capture medical data that matches ICD-10-CM’s specificity. Clinical documentation for each medical encounter doesn’t have to increase in volume, but it does need to increase in precision (e.g. laterality, comorbidity, anatomic location, etc.).
EMR templates help physicians incorporate all necessary elements for proper ICD-10 clinical documentation in a clear, organized, and structured manner. Another crucial advantage is that EMR templates can be used to remind physicians to ask patients specific questions for documentation purposes. Having correct and complete patient data to enter into the documentation template will expedite the process of finding the appropriate ICD-10 code for the medical diagnosis and treatment. Customized templates are available for various kinds of patients and medical services.
2. ICD-10 code search interface
Standard, updated EMR software should have an intuitive, easily navigable interface that makes it possible for healthcare professionals (end users) to input a word, term, or phrase and receive a list of matching ICD-10 codes. This interface will come with guides that will tell you if the correct ICD-10-CM code has been selected or if further steps need to be taken to find the right ICD-10-CM code.
3. ICD-10 side-by-side code tool
This EMR functionality is an excellent training tool as physician practices transition to ICD-10. After a physician or coder enters in a medical keyword or phrase, the ICD-10-CM side-by-side feature will display the relevant ICD-9 codes on the left side and ICD-10 codes on the right side so the healthcare professional can compare both code sets for a particular diagnosis, treatment, and so on.
For example, a physician enters in “nasal fracture” as a search term. Two ICD-9 codes come up for this injury:
- 802.0 Close fracture of nasal bones
- 802.1 Open fracture of nasal bones.
Seven ICD-10 codes come up for the same search term, some of which are:
- S02.2XXG Fracture of nasal bones subsequent encounter for fracture with delayed healing
- S02.2XXK Fracture of nasal bones subsequent encounter for fracture with nonunion
- S02.2XXS Fracture of nasal bones sequela
Healthcare professionals would facilitate their familiarization and adjustment to ICD-10-CM codes by utilizing this side-by-side coding capability while coding in ICD-9 for now.
4. ICD-10 General Equivalency Mappings (GEMs)
Similar to ICD-10 side-by-side coding tools, GEMs will display matching, or equivalent, ICD-10-CM codes when one inputs an ICD-9-CM code. It works in reverse too. When a physician enters an ICD-10-CM code, the GEM will list the matching ICD-9-CM codes. A GEM translates medical codes bi-directionally, but it can’t be used as a short-cut to regular ICD-10 training measures.
ICD-9-CM and ICD-10-CM aren’t equivalent in every aspect of their coding systems. ICD-9 has some codes that ICD-10 doesn’t have, and ICD-10 has a vast number of codes that ICD-9 doesn’t have. Medical concepts incorporated into ICD-10 may be non-existent in ICD-9, and vice-versa. Therefore physicians can’t rely solely on side-by-side coding and GEM capabilities. They were designed in part to supplement the medical professional’s coursework and ICD-10 books as they relate to the medical professional’s specialty.
Having an EMR solution with these four key features can help eliminate the stress of transitioning to ICD-10. If you are looking implement an EHR for the first time, or if you are looking to make a switch, make sure you give yourself ample time to be up and running and to have all staff properly trained on the system before the October 1, 2015 deadline.