South Florida Hospital News
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September 2011 - Volume 8 - Issue 3




The Importance of a Strong Clinical Documentation Program for the Transition to ICD-10

The switch to ICD-10 CM/PCS is converging on the healthcare industry. With the implementation date of October 1, 2013, for this major overhaul. Is your organization ready for the best possible transition possible?
Medical coding has become more complex and scrutinized over the years, and you can’t deny we’ve outgrown ICD-9. A major key to proper coding is timely documentation. Traditionally, a team of coders housed in the medical records department coded the inpatient admission post-discharge. At times, a coder would find unclear documentation, conflicting statements, or missing information. When this occurred, he or she would write a query, usually a paper form the physician would fill out and sign. These retrospective queries were problematic, not just in obtaining the doctor’s response in a timely manner, but also ensuring the doctor wasn’t led toward one conclusion or another. It was also unclear whether the form should be part of the permanent medical record.
Improving the documentation process
With the emergence of Electronic Health Records, the query process changed from a paper form to an electronic one, but the challenges remained similar. The best practice is to have clear and complete documentation in the medical record at the time of coding. Rather than waiting for the patient to be discharged, why not obtain the appropriate records in real time, while the patient was still in-house?
A Clinical Documentation Improvement (CDI) program can help hospitals and other providers achieve this. CDI programs have been a Health Information Management initiative for many years, with increased focus over the past few years, and aim to improve the quality of clinical documentation, regardless of the effect on revenue. They are tailored to a hospital’s size and type, and require unprecedented collaboration between the HIM department and nursing.
CDI programs facilitate an accurate representation of health care services through complete and precise reporting of diagnoses and procedures. This new approach makes coders more visible in patient care areas and requires them to discuss a patient’s condition, diagnosis, and documentation in person with the physician. As a result, coders are now part of the patient care team committees/meetings in many organizations.
The advantages of better recordkeeping
There are also revenue and regulatory benefits with the emergence of CMS quality measures, Present on Admission, (POA), pay for performance, and other national reporting initiatives. The more detailed the documentation, the better to demonstrate quality, identify POA, and support these other CMS programs. Accuracy can reduce compliance risks, minimize vulnerability during external audits, and provide insight into legal quality of care issues.
Another benefit to add to that list: a strong CDI program will assist in the transition to ICD-10 CM/PCS. Under ICD-10, records will need to be much more specific to be able to code for services. Completing a physician documentation assessment will help determine how your organization’s documentation lines up in an ICD-10 environment. Because of the code structure in ICD-10, without specific records of the patient’s condition(s), there will be instances where a diagnosis or procedure code will not be found.
CDI’s importance to ICD-10 preparation, training, and implementation process
The best place to start is by analyzing the findings within your CDI program to determine the quality of documentation:
• Use the coder and case manager observations to identify educational opportunities for physicians and areas for improvement.
• Enlist the assistance of the case managers to focus on trends across the board, or work with physicians that are the largest admitters.
Documentation improvement initiatives can be conducted parallel to coder education for ICD-10 preparation. Throughout the remainder of 2011, conduct coder gap analyses to determine strengths and weaknesses. Coders will need deep knowledge in anatomy and physiology, medical terminology, pathophysiology, and pharmacology. Case managers should also be included.
The numerous changes in health care can be quite overwhelming. Documentation improvement and ICD-10 CM/PCS are just part of the large puzzle, but preparing for them will make the transitions in the coming years much smoother.
Ira E. Shapiro is CEO of International Alliance Solutions Inc. For more information, call (646) 526-7867 or visit
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