Customer Experience and Design

Clinical Documentation – The Make or Break Component of ICD-10

Does the mere mention of “ICD-10” bring on an anxiety attack of some sort? For the majority, the answer is yes! This is probably because, like numerous organizations, you still haven’t begun the necessary planning for the transition from ICD-9 to ICD-10. Hospital administrators, physicians and medical coders are dropping to their knees and praying that the recent buzz around the potential delay of the October 1, 2013, ICD-10 compliance date will in fact take place. However, the simple fact remains that either by October 1, 2013, or soon thereafter, it WILL happen. So my advice, you might as well begin or continue planning and preparing for it now.

We’ve all heard the importance of proper planning and preparation for ICD-10. In fact, in one of my previous blog posts, I mentioned that the ICD-10-Impact Assessment was the key to a successful transition. Assuming you are aware of the different components within the Impact Assessment, if I were to ask you what you thought was one of the most important items, what would your answer be? If you answered, “clinical documentation assessment,” ding, ding, ding, you win! Unfortunately, if you choose not to assess your clinical documentation, you will certainly lose!

Clinical documentation

The medical record is the most important source of information within a healthcare organization. It is used not only for providing patient care but also for assessing the effectiveness and quality of that care, as well as for billing and reimbursement, research and to set healthcare policies as needed. Therefore, any insufficiencies in this documentation can drastically impact the clinical, financial and business operations of the organization. The increase in the number of codes with ICD-10 will require an unmatched level of specificity of clinical information and allow for greater granularity of detail within the medical record. It will certainly support providers with meeting the increasing demands of regulatory and quality reporting requirements, but more importantly it will improve the overall quality of care being delivered. However, this will not come without some challenges given that most organizations aren’t quite up to par with their current clinical documentation. In a recent study evaluating the assessments of more than 3,000 medical records across the country, it was discovered that on average, only 37% of the current physician documentation would support the newer standards that will be required by ICD-101.

Impact on patient care and revenue

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Clinical documentation has always proven to be a challenge. Medical coders face the difficult task of obtaining complete and accurate documentation. Many professional coders state that more often than not the documentation they receive is vague, inconsistent and/or is missing information and therefore, they are left to their own assumptions and interpretations when assigning the appropriate code(s), leading to countless errors and rework. If this is occurring with the current ICD-9, there is no doubt it will only worsen with ICD-10. The ICD-9-CM and ICD-10-CM Official Guidelines for Coding and Reporting state2, “The importance of consistent, complete documentation in the medical record cannot be overemphasized.” Poor documentation can lead to errors and inefficiencies which can directly impact patient care and revenue.

Since the medical record contains details of the patient’s entire medical history, along with the diagnosis, treatment, procedures, outcomes, and recommendations for further treatment, the documentation gives tremendous collaborative support to other healthcare providers that the patient will encounter along the continuum of care, resulting in more effective and efficient patient care3.

In addition to enhanced patient care, improved clinical documentation can result in significantly faster billing and maximize reimbursement for healthcare organizations. The less time required for medical coders to interpret clinical notes and/or track down physicians to resolve queries, the faster documentation is completed and the quicker the billing and claims can get processed, reducing the turnaround time for payment. The accuracy and completeness of clinical documentation is even more important and essential to ensure proper reimbursement4. When assessing and defending reimbursement rate, accuracy minimizes the potential for disputed billing and thoroughness ensures all billable items are included in the patient’s medical record, which proves to be advantageous, because we all know that in the eyes of the payor, if it isn’t documented, it didn’t happen4!

Education and physician acceptance

Accessing clinical documentation and identifying gaps is a MUST to ensure that an organization will meet the documentation requirements for ICD-10. Modifications and reworking of clinical documentation and its associated processes and workflows will require time and extensive training of physicians, coders and hospital staff and should start NOW. Physicians are a key component; without their support and acceptance, ICD-10 will fail. Physician education needs to be collaborative, with a range of human and technology support5. In order to ensure successful clinical documentation with ICD-10, it is imperative that physicians be educated on the expectations of ICD-10 and how to align their documentation with coding guidelines6. They certainly won’t need to acquaint themselves with all 140,000 codes, but they should, at minimum, familiarize themselves and drill down the specifics with those codes that have the greatest clinical impact to them. Medical coders will also need additional training, as they will need to possess a much deeper understanding of physician documentation, anatomy and physiology and disease processes6. Finally, it will be up to the hospital administrators to provide the structure, technology and support to engage and empower their physicians and coders. Effective clinical documentation can only occur when concerted efforts are made among this core team.

Five key steps to improving clinical documentation

Healthcare organizations need to make clinical documentation assessments a priority. Caroline Piselli, from 3M, provides her thoughts and suggestions for improving clinical documentation with ICD-107:

  1. Assess documentation for ICD-10 readiness. Focused documentation audits by specialty are critical to determining patterns of missing information that may impact coding and reimbursement under ICD-10. By understanding the clinical areas impacted most by the transition, your organization can tailor clinician education and improve documentation processes where needed.
  2. Analyze the impact on claims. Do you know how ICD-10 will impact reimbursement? If clinical documentation is incomplete, coding will be inaccurate and claims will be impacted. Concentrate initial improvement efforts on those providers and/or service lines that offer the greatest opportunity or risk in terms of revenue impact.
  3. Implement early clinician education. There has always been a disconnect between the language clinicians use to document care and the language coders need in order to code from the documentation. Recent CMS guidelines prevent coders from questioning diagnoses or suggesting intended diagnoses to providers. If it isn’t documented, it can’t be coded. Early education allows medical staff to adjust documentation practices well in advance of ICD-10 implementation.
  4. Establish a concurrent documentation review program. When coders or documentation specialists can review documentation and query clinicians about inconsistencies before the patient is discharged, the complete clinical status, including secondary diagnoses and complications, can be captured. Many organizations are implementing concurrent review programs today; with ICD-10, these programs will be essential.
  5. Streamline clinical documentation workflow. Automated tools are available that integrate documentation advice with clinical workflow, prompting documentation specialists and coders when the patient record is incomplete. These applications provide clinically driven concepts and alerts to query clinicians for additional information, saving time and improving efficiency.

Have you begun the ICD-10 transition? What tips and advice have you found most useful?

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About the Author

Priyal Patel is a healthcare industry expert, strategist and senior solutions architect for Perficient. With more than 10 years of healthcare industry experience, Priyal is a trusted advisor to C-level executives, senior managers and team members across clinical, business, and technology functions. Priyal has a proven track record of helping providers and health plans execute enterprise-level transformation to drive business, clinical, financial and operational efficiencies and outcomes.

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