August 13, 2013

Clinical Documentation: The Pulse of ICD-10 Compliance

By Judy Monestime, MBA, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer

As the national focus on the importance of clinical documentation integrity (CDI) relative to coding, billing, quality initiatives, risk management, utilization, medical necessity, etc., has intensified, many healthcare organizations across the continuum of care are initiating efforts to improve documentation.

This CDI emphasis can and should be used to refocus physicians on the significance of improved clinical documentation as it pertains to operational compliance, and, ultimately, how this directly affects the quality of patient care every day.

After all, the No. 1 unique consideration needed to achieve ICD-10 compliance is physician documentation improvement: the pulse of the transition. This can be achieved through comprehensive ICD-10 training customized by medical specialty, allowing physicians to focus on the education most relevant to their specific work. Delivering specialty-based ICD-10 training allows

clinicians to document each patient encounter to meet their own needs and to satisfy the language requirements for complete coding—just as they do now.

ICD-10 physician training implementation considerations and/or proper steps include:

  • Identify existing documentation gaps via an analysis of a sample of patient charts.
  • Ensure that ICD-10 implementation involves technical solutions that map diagnostic terminologies to medical concepts, and the correct procedure and diagnosis codes.
  • Pilot training at one or two facilities, measuring effectiveness, and the rollout of more comprehensive training.
  • Leveraging physician champions to communicate the value of improved documentation to physicians and patients.

Remember, early engagement and adoption by physicians and an organization-wide understanding of their role in documenting patient information accurately is pivotal. Physicians will face the need to make documentation improvements to meet medical necessity requirements.

Mid-level professionals, physician assistants and nurse practitioners, also must be engaged at the same time, because many physicians utilize these professionals for documentation support. While computer-assisted coding (CAC), electronic health records (EHRs), and meaningful use all drive the tools of documentation, the quality, specificity and depth of that documentation is still key, and it is a human factor, fully dependent on the physicians.

An article recently published by HIT Consultant revealed that an MGMA ICD-10 survey has cited physicians’ greatest concerns regarding the ICD-10 transition. Those items included concern about changes to clinical documentation:  88 percent were “concerned” or “very concerned” about the expected changes to clinical documentation;, while87.5 percent were “concerned” or “very concerned” about the loss of clinician productivity after implementation.

Being prepared is paramount for ICD-10 implementation. There will be significant consequences to poor preparation for the transition, and making an investment in physician education is a sound financial decision.

Education that is tailored to physicians will ensure that when coders are ready to assign ICD-10-CM/PCS codes, the documentation won’t be a barrier to their success with cash flow (medical necessity denials) – and, most importantly, quality care.

The quality of coding, reimbursement, and reporting under ICD-10 is all dependent on accurate physician documentation: the pulse of ICD-10 readiness.

About the Author

Judy Monestime is the vice president of ICD-10 consulting for The CODESMART Group, specializing in providing ICD-10 transition and education, coding, auditing, and analysis, clinical documentation improvement, and services nationwide; she also helps manage CODESMART UNIVERSITY,™ an online ICD-10 education program for coders, clinicians, and executives. Judy is currently the ICD-10 Task Force chairwoman for the Florida state chapter of the American Health Information Management Association (AHIMA)

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References

Pennic , F. (2013). New ICD-10 Survey Finds Overwhelming Lack of Support from EHR Vendors.  HIT Consultant. Retrieved July 4, 2013, from http://www.hitconsultant.net/2013/06/13/new-icd-10-survey-finds-overwhelming-lack-of-support-from-ehr-vendors/

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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.