February 9, 2015

Clinical Documentation Improvement in the Medical Practice in Preparation for ICD-10


Back in November, I wrote about clinical documentation improvement (CDI) in the medical practice and the importance of this critical step in adopting ICD-10. It will not only improve diagnosis coding, but also compliance for procedures and services reported by the practitioner.


I have worked and am working with medical practices of various sizes to develop a solid CDI process, not only to improve coding and documentation for ICD-10, but to develop a protocol to support all services provided to the patient. Right now I am in the middle of developing a process for a large medical practice and would like to share the steps I have taken in CDI development. In the medical practice, it can be more difficult, as there are typically not electronic CDI tools or software programs to perform the necessary data mining to assist with CDI. But it can be accomplished.

First, let’s review the steps associated with implementation of a quality CDI program in a medical practice:

Step 1: Conduct a baseline review (assessment phase)

Step 2: Develop a protocol or process for managing CDI (development phase)

Step 3: Develop a query process (development phase)

Step 4: Educate all practitioners and applicable staff on the CDI process and purpose (development phase)

Step 5: Begin implementation of the CDI program (monitor and manage)

Step 6: Reevaluate the program and make improvements (monitor and manage)

Step 7: Provide ongoing education and training (monitor and manage)

Over the next several months I will discuss in detail each individual step and how to accomplish it.

Again, the first step is to conduct a baseline review. What does that really mean? You will need to perform an in-depth assessment of the following:

  • Workflow, from patient intake to receipt of payment
  • Baseline chart review (audit) of each practitioner to determine compliance with not only procedures and services, but specificity in the diagnosis coding

It may sound simple enough, but this will involve hours of time and effort. So where do you begin?

I would suggest that you begin by conducting an impact assessment of the practice workflow.  Start by identifying what information the patient relays at intake and move through the assessment up through receipt of payment.

1.  Patient Intake

  • Is there a form (electronic or paper) for review of systems and history, or does the nurse/MA/physician obtain the information?
  • If there is a form that is completed, who reviews the form for completeness if the patient is filling it out? I have found many times the information is not complete and the practitioner is using this information to guide the visit. 
  • Does the practice use superbills (paper or electronic)?
  • Is there review of who enters data into the medical record, whether in the electronic health record or the paper chart? 
  • Does the practitioner enter the information himself/herself or does the nurse/MA assist?
  • Does the practitioner use a scribe, either in person or virtually?

 2.  Templates: A close look at how templates are built is very critical to the CDI process.

  • From where does the information pull?
  • Does the practitioner pull all the data from a previous visit for an established patient? 
  • Does the diagnosis come from the problem list or the assessment for an evaluation and management visit? 
  • For office procedures, is there a separate template to enter the information? 
  • Are the templates set up by procedure or condition (disease, symptoms, etc.)? You will find that in many cases the templates either came with the electronic health record (EHR) or that they have not been modified to accommodate the specificity necessary for ICD-10. Maybe building more dropdown options and logic trees will be necessary for CDI.

3.  Shadowing: As part of a CDI assessment, I like to shadow a few of the physicians to observe their workflow when seeing patients (and how they enter data). I also interview many of the practitioners to gain insight regarding what works well for them and what challenges they face when documenting in the medical record. 

  • Are the practitioners performing their own coding?
  • If the practitioners are performing their own coding, do they select their own procedure and diagnosis codes? 
  • Does the practitioner use a calculator in the medical record to select the codes?
  • If they have coders/billers who are performing coding, how does the information flow to them?

4.  Clinical Staff: Understanding what role the clinical staff plays as it pertains to documentation is very beneficial.

  • Does the clinical staff obtain the chief complaint and  review the patient’s history in the medical record?
  • Does the clinical staff obtain the advanced beneficiary notification (ABN) for Medicare patients when services may not be covered in certain circumstances?  If yes, what information is included on the ABN form?
  • Does the clinical staff assist with the coding?
  • Is there any other instance in which clinical staff enters data into the electronic record (such as injections, infusions, procedures, etc.?)

 5.  Chart Review: It is a good idea to conduct a baseline chart review (audit) to determine current levels of compliance in coding and documentation.

  • Is there a review process in place to make sure the documentation supports the claim submitted to the insurance carrier? 
  • Does staff review every patient encounter, or do they have a process to review the higher-utilized procedures or diagnoses?
  • Does the practice have a schedule for auditing and monitoring annually? 
  • Is there a follow-up or education process once the audit is completed?
  • Is there a standard or policy governing coding and compliance? 
  • What follow-up reviews or education is in place to assist practitioners in maintaining or reaching an acceptable compliance standard?

6.  Coding/Billing: An assessment of the coding and billing department(s) is necessary to determine the workflow of the department.

  • How does each patient encounter flow into the coding/billing staff’s workflow?
  • Does the coder/biller review encounters before submitting to the insurance company, or do they use superbills? If so, who enters the information into the system?
  • Does the coder/biller use electronic coding tools?
  • How does the department query practitioners when there are questions about the billing?
    • Paper process
    • Electronic process
    • Verbal request
    • Does not query
  • Does the coder/biller ever change the procedure or diagnosis code without the practitioner’s knowledge?
  • When claims are submitted, do they have a medical necessity screen or process in the billing system that identifies claims that might not be appropriate?
  • Is there a process that identifies claim errors prior to submission?
  • Does the practice use a clearinghouse?
  • What reports are run on a daily, weekly, and monthly basis?
  • Is there a productivity standard for coder/billers in place?
  • Does the department run frequency reports for procedures and diagnoses to identify outliers?
  • Does the practice rely on bell curve data to review documentation for practitioners who might be considered outliers?
  • How many days of delay does the practice have from the patient encounter to claim submission?
  • When claims are denied, what is the protocol for resolving the denials?
  • How are payments posted? 
  • Is there a communication protocol in place in the practice to inform the practitioners regarding denials, suspended claims, bundled services, medical necessity issues, etc.?
  • If using a billing service, what written processes are in place to receive denial reports, payment reports, etc.?

These are some of the questions you must ask during the impact assessment. Once you complete the impact assessment, compile the results into a report with recommended changes to operationally identify gaps or deficiencies in the practice. From this point, you will be ready for step 2: developing a protocol or process for managing CDI. 

Stay tuned next month for a step-by-step look at how to begin the development phase of the CDI project.


Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner

Deborah Grider has 34 years of industry experience and a recognized national speaker, consultant and American Medical Association Author who has been working with ICD-10 since 1990 and is the author or Preparing for ICD-10, Making the Transition Manageable, Principles of ICD-10 and the ICD-10 Workbook, Medical Record Auditor, and Coding with Modifiers for the AMA.  She is a senior healthcare consultant with Karen Zupko & Associates.  Deborah is also the 2017 American Health Information Management Literacy Legacy Award Recipient. She is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.

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