Clinicians - What is Needed in Documentation and Practice to Succeed with ICD-10 and Surveys

Event Information
Product Format
Prerecorded Event
Sharon Litwin, RN, BSHS, MHA, HCS-D
Conference Date
Wed, Aug 31, 2016
90 minutes
Product Description

Tips and Tools for Clinical Documentation Success in ICD-10


ICD 10 requires more specific information for patients related to the diagnosis.  The clinician will need to collect more assessment information on admission, recertification and ROC, and document this info.  Also, the clinician will have to query the physician for questions regarding symptoms and specific diagnosis.  Without all of this being done initially by the clinicians, coders will not be able to code, which means that it will be sent back to the clinician, causing delay in timeframe for getting the POC out the door, the OASIS locked and the RAP billed.

This comes at the same time that Medicare / State surveys have intensified – many more survey days mean surveyors having time to scrutinize more clinical records, which may lead to more deficiencies including condition level deficiencies. Clinicians must be aware of what is needed in documentation to understand what causes condition level deficiencies and immediate jeopardy, and how to be compliant.

In this audio session, expert speaker Sharon Litwin, RN, BS, MHA, will address both of these very critical areas that clinicians in homecare need to understand in order to be compliant. She will review ICD-10 and address common and challenging diagnoses. The focus will be on what the clinician needs to identify, query physician and document resulting from SOC admission, recert and resumption visits.

She will also discuss what the clinician is required to document in order to maintain compliance to state and Medicare regulations. Additionally, this session will provide information on variances between standard and condition level deficiencies, and what can cause immediate jeopardy. This session will increase the clinician’s knowledge of the “rules” so that they can be more adept at documentation.

Session Highlights:

  • Learn how coding must be done in ICD-10
  • Insights on challenging codes and how to document them
  • Discussion on:
    • Wounds
    • Laterality
    • Specific rather than non-specified diagnoses
    • 7th digit Changes
    • Excludes 1 note changes
  • Review of common deficiencies related to clinician documentation
  • Find out the requirements for documentation

Session Snapshots:

  • Clinical documentation for ICD-10
  • Reasons for changing to ICD-10
  • Differences between ICD-9 & ICD-10
  • Challenges in ICD-10
  • Assessing clinician
  • Physician confirmation of Diagnoses
  • Clinician documentation to code
  • Coding Wounds- Non Pressure Wounds Depth
  • Changes in guidance for ICD 10
  • Character S  for Sequela
  • Hospice- Major Coding Changes
  • Diabetes with Hyperglycemia
  • Homecare Documentation
  • Common deficient areas seen in homecare clinical records
  • Ongoing skilled nurse vulnerabilities
  • Documenting Medical Necessity of Skilled Therapy
  • OT evaluation documentation

Who should attend

Clinical Directors, Managers, QA Coordinators, Clinicians

Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

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About Our Speaker

Sharon Litwin

Sharon M. Litwin, RN, BSHS, MHA, HCS-D, Founder and Senior Managing Partner, 5 Star Consultants, LLC (2003 - Present)


Sharon Litwin, founder and senior managing partner of 5 Star Consultants, a national consulting and coding firm specializing in homecare and hospice services since 2003.  Sharon was also an ACHC surveyor until December 2013, and a former CHAP surveyor, performing Medicare deemed surveys for ten years.


In her consulting firm, Sharon assists...   More Info
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