October 14, 2013

ICD-10: An Opportunity to Improve Healthcare

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Now that we are one year out from the ICD-10 implementation deadline, we have to consider that this transition is about something much larger than a change in the way we code.

ICD-10 highlights the need for us to change our perspectives on how we think about the quality of our clinical documentation. In the same way focus is shifting away from volume-based reimbursement and toward value-based reimbursement, clinical documentation and coding efforts must reflect the severity of illness and quality of care. ICD-10 makes up only one part of the movement toward quality documentation. We also must consider the importance of accurately capturing hospital-acquired infections (HAIs), patient safety indicators, core measures, and physician and hospital profiling – just to name a few factors. 

If your organization does not have a clinical documentation improvement (CDI) program currently in place, you already are beginning to fall behind as it pertains to efforts to drive quality data, capture accurate patient severity, and secure the appropriate reimbursement for the services your clinical teams are delivering. For those organizations that already have a CDI program in place, now is a great time to evaluate and assess your program according to best-practice benchmarks and recommended critical success factors.

Some suggestions worthy of consideration include the following:

Assess your staff: Industry standards suggest that staffing levels should include one clinical documentation specialist (CDS) for every 1,900 annual discharges. After ensuring you have proper staffing support, consider the following: What is the focus of the CDS review? Does your CDS staff need to work on changing how they think about documentation quality? Are they encouraged to review for matters outside of MS-DRG impact clarifications or queries? Are they involved in the Recovery Auditor (RAC) denial and appeal processes? Do they identify conditions that are patient-safety indicators and assess the related clinical documentation? Are they identifying opportunities to clarify for present-on-admission status? Does your CDI program have the ability to track and report this type of data?  

Assess your workflow: Now is the time to analyze staff productivity levels and look for improvement opportunities. Take into consideration the placement of CDS staff on hospital floors or units. Some facilities rotate staff, while others believe that each CDS should have a permanent assigned floor or unit to cover. There are pros and cons to both approaches, and depending on the culture and atmosphere of each facility, as well as relationships among CDS staff and physicians, either can prove effective. The one critical success factor pertinent to both methods is that CDS staff must remain visible and accessible to the medical staff and providers. This interaction is vital to the success of any CDI program. During your workflow assessment, it is also important to consider what types of records and payors your CDS reviews, and whether there is opportunity to review payors other than Medicare. 

Evaluate clarification and query rates: Each clarification, regardless of whether it is an MS-DRG impact clarification or severity clarification, must be clinically supported and written or verbalized in a compliant format. The clarification rates for each CDS should be assessed for productivity and the ability of the CDS to identify appropriate clarification opportunities. Keep in mind that not all floors or units have equal clarification opportunities; therefore, it is unrealistic to hold each CDS to the same productivity level standard if you are not rotating them throughout all types of floors or units within your facility. However, your overall CDI program should meet an identified clarification goal for both impact and severity clarifications. Another goal of any high-functioning CDI program is a concurrent response from providers. This will be a critical success factor in assisting with timely coding and billing as organizations work through ICD-10 implementation next year. The industry expectation is that coding productivity will decrease with the introduction of the new ICD-10 code sets; therefore, by implementing best practices and a CDI program, providers will be able to mitigate such setbacks.   

Assess your level of physician involvement: Obviously, physician involvement in any CDI program is vital to its success. If your organization does not have a physician champion, now is the time to seek out one who is willing to take on this role. Surveys show that physician indifference to ICD-10 is one of the biggest obstacles facing healthcare organizations. The best solution to this problem is peer-to-peer physician education and involvement. Remember, striving for concurrent documentation is the ultimate goal, so it is important to have the ability to track and review concurrent physician response rates to clarifications or queries. An active physician champion can assist your CDS staff with encouraging physician response to all clarifications or queries. Additionally, administrative support of any CDI program is integral to achieving positive physician involvement.

A well-tuned CDI program not only will help drive a successful transition to ICD-10, but it will help change and mold how organizations perceive and value quality clinical documentation. After all, ICD-10 is not just about having more codes to choose from; it is about the subsequent data these codes will produce and the impact this information will have on the future of healthcare. 

About the Author

Lisa Roat, RHIT, CCS, CCDS, is the manager of HIM product development and compliance for J.A. Thomas & Associates, a Nuance Company. In this capacity, Lisa serves as the ICD-10 technical product specialist expert and is responsible for the development of ICD-10 product and service lines for J.A. Thomas & Associates. She is an AHIMA-approved ICD-10 CM/PCS Trainer.

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Lisa Roat, RHIT, CCS, CCDS

Lisa Roat, RHIT, CCS, CCDS is manager of HIM Services for Nuance Healthcare. She has more than 23 years of experience and expertise within the healthcare industry specializing in clinical documentation improvement, coding education, reimbursement methodologies and healthcare quality for hospitals. She is an American Health Information Management (AHIMA)- Approved ICD-10 CM/PCS Trainer and Ambassador. Lisa has worked extensively with the development of ICD-10 education and services for Nuance Healthcare.