April 18, 2011

Clinical Documentation Improvement (CDI) and ICD-10 Coding: The Train Has Left the Station

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The ICD-10 train has left the station….no doubt about it.

There is no turning back. The train now needs willing passengers with expectations that ICD-10 is good, that it provides data that will ultimately improve patient care and outcomes.  Herein is the challenge. Yes, Health Information Management (HIM) professionals appreciate the need for ICD-10.  The current ICD-9 code set is simply running out of codes. But do providers appreciate the benefit of the ICD-10 expanded code set?

Clinical Documentation Improvement (CDI) in the world of ICD-10 will require a higher level of rigor and precision for coders and Clinical Documentation Specialists (CDS).  CDI programs must provide compelling and convincing education for providers regarding the benefits of ICD-10 documentation requirements.

This compelling education should be a collaborative initiative from the CDI medical director, the documentation specialists, HIM professionals and C-level leadership. Without support and acceptance from physicians CDI for ICD-10 will be dead in the water.

Today is the day when CDS’s should begin their CDI programs and launch their campaigns for provider/physician support.

Providing and delivering compelling ICD-10 education infers that the CDI team is well educated and prepared. CDI programs at this time should at the minimum created awareness of the changes ICD-10 will bring. A solid plan for skill assessment and education for the CDI team should be mapped out at this time.

The number of codes in ICD-10 increases from about 13,000 to 68,000. This will provide a greater level of specificity and comprehensive data for clinical decision support, public and population health, clinical data, research, quality measurement and patient safety. As Accountable Care Organizations develop and expand effective population health management depends on accurate clinical documentation.

Comprehensive clinical documentation and accurate coding drive that metaphoric train. CDI will always be paramount for improving patient care and outcomes.

In the words of another ICD10monitor.com contributing editor Paul Wegandt, MD, “Hospitals should provide the infrastructure necessary to assist the physician in providing the most accurate, concurrent, compliant documentation of the condition and treatment of each patient, and assignment of the appropriate DRG”.

About the Author

Melinda Tully, MSN, CCDS, is Senior Vice President of Clinical Services and Education for J.A. Thomas & Associates. Melinda has 25+ years in Acute Care as a Clinical Specialist and Nurse Practitioner. Her area of specialty is clinical documentation education focused on continuous quality improvement.

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Read 30 times Updated on September 23, 2013