September 22, 2014

Is ICD-10 on Your Mind These Days?

By Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS and an AHIMA-approved ICD-10-CM/PCS trainer

I am excited to be attending the AHIMA 2014 Convention in San Diego next week to hear more buzz about what keeps HIM professionals up at night!

 

From most HIM Directors that I have talked with about their fall 2014 activities, ICD-10 preparation is definitely top of mind. While everyone is excited about the new compliance date of October 1, 2015, I hear more trepidation and anxiety about whether or not the date will actually be enforced. I do hope we can count on Washington, D.C. to not let us down.

As we are now 12 months from going live with ICD-10, the time is now for precise ICD-10 preparation plans.

Here are a few observations and recommendations that I can share as we transition to ICD-10 compliance:

  • I have seen a renewed focus on clinical documentation integrity and a growing interest in information governance. Observing some changes in objectives and expectations of some committees and work groups, such as changing the name of the ICD-10 Steering Committee and renaming it the Clinical Documentation Integrity or Clinical Data Governance Committee. Some leading large academic medical centers have created an enterprise-wide information governance project management office (PMO) or committee. This reflects a transition to an organization-wide effort focused on clinical documentation integrity and the inherent need for information governance. Everything we do from this day forward in the HIM profession is focused on the integrity of the clinical documentation, whether you are a paper, electronic, or hybrid environment. Why? Because you cannot move forward with coding compliance for ICD-9 or ICD-10 if you have not specified your core clinical documentation record set for coding compliance.
  • Update or create a Coding Compliance Program. What has never been clearly and uniformly defined are the actual core medical record documents or clinical documentation that should be used as the core designated record and clinical documentation set for all coding. Your coding compliance policy must identify medical record documents and clinical documentation that require a mandatory review by your coding staff and/or the outsourcing providers of coding for your organization.

All coders should review clinical documentation according to the hospital's established clinical documentation record set for coding compliance. This enables them to identify all diagnoses and procedures requiring coding and specify the location in the paper medical record, hybrid, or EHRs. This step will align clinical documentation with clinical coding integrity by increasing the accuracy and specificity of coding. Once you have clearly defined your coding compliance best practices, you can enable your coding team to move forward with dual coding in preparation for the ICD-10 (shortcut for ICD-10-CM and ICD-10-PCS) deadline on October 1, 2015.

  • Create your project plan for dual coding which must be a key part of the journey to ICD-10. Most of the HIM Directors that I have surveyed are in the midst of conducting a refresher ICD-10 education program for their coding staff. This requires structured planning with a reality check as you must address timing, resources, budget, technology, and quality monitoring, in addition to keeping current with the daily expectations for coding quality.
  • Develop your strategic plan for HIM solutions. Many organizations are searching for a business partner/vendor that can confirm that their encoder and computer-assisted coding (CAC) solution are up for the challenge of dual coding. As you develop your plan and workflow for dual coding, ensure the business partner understands your needs and that it has an encoder with dual-coding readiness, which means you can code in ICD-9 and ICD-10.
    • Drive physician engagement: With documentation demands on the rise, HIM professionals need to work with physicians to determine how best to approach clinical documentation in their desired workflow. For some, that may mean typing, and for others, it may mean using a fully voice-enabled clinical documentation solution that allows them to capture patient notes and edit them in real time.

With ICD-10 less than one year away, it’s critical that HIM professionals begin planning for the increased documentation specificity, time, and resources required and determine how best to engage and educate their medical staff to ensure that the accuracy of clinical data is not compromised as a result of this transition.

  • Lead the enthusiasm and effective management of your Clinical Documentation Improvement (CDI) program. Regardless of where CDI reports to administratively in an organization, HIM experts need to collaborate with clinical documentation specialists (CDS) and offer further training and tools, since they will work closely with physicians to drive ongoing improvements in clinical documentation specificity that will be needed for ICD-10 coding.

Addressing documentation quality up front with a strong CDI program enhanced with a coding compliance program will leave you well positioned for success and clinical documentation integrity. Ensuring accuracy up front with physician documentation will pay dividends when it comes to helping coders support ICD-10 and helping to drive their overall precision and productivity.

The HIM profession has been pivotal in highlighting the importance of clinical documentation integrity and compliance—whether the information was on index cards, paper medical records, dictated and transcribed records, a hybrid approach, or EHRs. It remains the HIM professional’s role and responsibility to renew his/her commitment to clinical documentation integrity and its importance to emerging healthcare reform initiatives, such as population health management. The time is now for current HIM professionals to set the bar for the next-generation HIM workforce by embracing the education and research requirements that will enable them to thrive amidst this ongoing transformation of the healthcare industry.

I enthusiastically believe that the HIM profession will rise to the occasion when it comes to ICD-10 and demand clinical documentation integrity for coding compliance. At the end of the day, we in the HIM profession must work with our business partners to align clinical documentation integrity and coding compliance because we will never successfully transition to ICD-10 without this collaboration. Focusing your efforts on clinical documentation integrity will enable and position your team for success with dual ICD-9 and ICD-10 coding, and in the overall transition to ICD-10.

Hope to see you in San Diego!

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.