Updated on: September 23, 2013

On the road to ICD-10: Clinical Documentation Improvement

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Original story posted on: August 12, 2013

Approaching the fourth quarter of 2013, which coincidently is the quarter that marked the original ICD-10 implementation date, it might be wise to take a moment to look down the road toward 2014.

In thinking and reading about ICD-10, we continually hear about the need for specificity within documentation in order to support the more detailed code set. Clinical documentation specialists are responsible for ensuring that the documentation in a health record is complete and accurate as possible.

The goal is to have a thorough record that provides the detail needed for patients to receive the best quality of care and for physicians and organizations to get credit for the quality of care. Additionally, the documentation should provide the most accurate reflection of the severity of illness of the patient while utilizing terms recognized by the Centers for Medicare & Medicaid Services (CMS) that will allow for the most precise code assignment possible by the coding professional. In other words, clinical evaluation of documentation for gaps and/or inconsistencies should be the role of the clinical documentation specialist, while the assignment of ICD-10 codes should be the role of the coding professional. Is there any overlap as we head down the road to ICD-10? Yes! I would be remiss to say that there is not some knowledge of coding needed to understand ICD-10, however, the basic process of clinical documentation improvement remains the same as in ICD-9-CM. Although the implementation of ICD-10 will increase the need for communication and collaboration among clinical documentation specialists and coding professionals, it will not change their roles.

Still, preparing for ICD-10 from a clinical documentation perspective is somewhat different than preparing for ICD-10 from a coding perspective. As we consider being just a little over one year away from implementation, clinical documentation specialists should be focusing on increasing the specificity of documentation related to the most current, clinically accurate descriptions of diseases and surgical procedures – rather than how to code in ICD-10. This knowledge, combined with the understanding of where changes lie in the ICD-10 Official Guidelines for Coding and Reporting (either sequencing-specific or chapter-specific), will help train documentation specialists for ICD-10.

Applying this same thought process to ICD-10-PCS, the clinical documentation specialist currently also should be reviewing operative reports with a critical eye. Is the intent of each procedure clear? Are all components of the operation being described in the documentation? What about specificity of body parts: is this clearly documented? Is the information related to any type of device or implant readily available and easy to locate? Again, I would be remiss not to mention that the clinical documentation specialist will need to study and learn the ICD-10-PCS root operation definitions, along with understanding the approaches and the ICD-10-PCS guidelines in order to analyze MS-DRG assignment and impact – bearing in mind, however, that the intent is not to turn the clinical documentation specialist into a coder.

An effective step that should be featured in any clinical documentation program, as we move into 2014, is to identify the top MS-DRGs in the facility, both medical and surgical. Once the top MS-DRGs are established, a review of the associated medical diagnoses and surgical procedures for required ICD-10 specificity is recommended. This knowledge will assist clinical documentation specialists in understanding where documentation improvement efforts and physician education need to be targeted approaching the implementation date. As a reminder, even though the number of available codes is increasing monumentally, the patient population of each facility is not changing.

In addition, the clinical documentation specialist should dedicate time exclusively for following industry updates related to ICD-10. Some ideas include participating in ICD-10 webinars, reading articles or newsletters, skimming through the ICD-10 code books to become more familiar with terminology, and reviewing the latest American Hospital Association coding clinics, which now incorporate ICD-10 advice and information exchange.

Although the task of implementing ICD-10 may seem daunting, the ability to keep perspective regarding the impacts on professional roles and responsibilities will help keep clinical documentation improvement programs focused on taking the most direct route on the road to ICD-10.

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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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.
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.