Updated on: March 14, 2016

Readying CDI Programs for ICD-10 without Breaking the Bank

Original story posted on: November 4, 2013

The debt ceiling crisis of 2013 temporarily brought the U.S. government to a halt and pushed both political parties into an arduous, lengthy budget showdown. Just like the U.S. government, hospitals annually struggle to rob Peter to pay Paul. Cost reductions and expenditure cuts are commonplace for healthcare providers.


However, with the advent of ICD-10 fewer than 12 months away, hospitals are being pressured to take on new, additional expenses for ICD-10 preparation, training and testing. These represent difficult budget decisions, and health information management (HIM) professionals often are caught in the fray.

Here are three ways for budget-conscious HIM professionals to ready their clinical documentation improvement (CDI) programs for ICD-10 without breaking budgets or adding staff. 

Step One: Assessment and Education

Assess your CDI staff and educate them. Focus on shoring up areas of weakness and addressing knowledge gaps. Include a medical health science review, an ICD-10 coding guidelines overview, and specific ICD-10 code descriptions and changes. Shave dollars and days with these three best-practice guidelines:

  • Focus on the diagnoses treated and procedures performed most often by your physicians.
  • Evaluate current documentation to identify what additional documentation will be needed by physicians to assign ICD-10-CM/PCS codes in these areas.
  • Provide awareness and education to medical staff based on your findings.

Step Two: Inventory and Update Query Forms and Templates

Generate a report on volume and condition type/diagnosis currently being queried for, and then ask this important ICD-10 question: Will my existing physician query process work with ICD-10-CM/PCS implementation, even with the expected increased volumes of procedural queries? Review current query forms and templates, and revise policies and procedures with ICD-10 in mind.

Step Three: Introduce New Requirements

With queries revised, it is time to make physicians fully aware of specific documentation changes in ICD-10. Side of dominance, laterality, and ordinarily are new concepts to be understood and well-documented. 

Other specific changes include the use of the National Heart, Lung, and Blood Institute’s asthma severity classification scale, the Glasgow Coma Scale, and the Gustilo Open Fracture Classifications. The documentation of seizures, pregnancies and substances related to adverse effects, poisoning or toxic effects also change in ICD-10.

Not When, But How

2014 is the year for HIM to work hand-in-hand with CDI teams to prepare physician documentation for greater granularity in ICD-10. Collaboration, specific examples, focused education, and tips sheets all will help.

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.
Kim Carr, RHIT, CCS, CDIP, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer

Kim Carr brings more than 30 years of health information and clinical documentation improvement management experience and expertise to her role as Director of Clinical Documentation, where she provides oversight for auditing and documentation improvement for HRS clients. Prior to joining HRS, Kim worked as a consultant implementing CDI programs in varied environments such as level-one trauma centers, small community hospitals and all levels in between.

Before joining the consultant arena, Kim served as Manager of CDI in an academic level-one trauma center. She was responsible for education and training for physicians and clinical documentation specialists. Over the past 30 years, Kim has held several HIM positions; including HIM Coding Educator, Quality Assurance/Utilization Management Coordinator, DRG Coding Coordinator and Coding Manager. Kim holds a degree in Health Information Management and is a member of AHIMA, THIMA, ACDIS and AAPC.