ICD-10 starts at clinical documentation

If physicians don't document their care, it can't be captured or coded
By Bernie Monegain
10:15 AM
ICD-10 starts at clinical documentation

Physicians and other healthcare professionals will have to employ much more accurate and specific documentation of their care if ICD-10 coding is to work right, speakers asserted in an education session this week at the AHIMA Convention and Exhibit.

ICD-10, which takes effect Oct. 1, 2014, increases the number of diagnosis and procedure codes from about 13,000 to more than 141,000. The idea is to provide much more granular detail on patient care.

"Clinical documentation impacts both the quality of care and reimbursement and bringing physicians up-to-speed about the level of granularity included in ICD-10 is one of our most important jobs as health information management professionals," Theresa Jackson, director of health information management at the University of Kansas Hospital, said in a statement.

[See also: AHIMA to ONC: Better clinical documentation needed to ensure EHRs.]

Jackson explained that while the goals of clinical document improvement programs are geared toward clinical data integrity and reliability, an important and undeniable benefit of the programs is to improve capture of data, which enables better coding.

In her view, proper documentation has the potential to improve:

  • Patient care,
  • Clinical data and information integrity
  • Reliability of quality measures and demonstration of meaningful use
  • Timely and appropriate claims payment

"For example, in ICD-9, myocardial infarction is coded in one of two categories depending on factors such as the acuity, duration and timing of MI," Jackson noted. "In ICD-10-CM, many additional details are recorded, such as information about the type and sequence of any underlying diseases, as well as factors such as tobacco use and exposure to environmental/workplace smoke; and, where applicable, the status of administration of the clot-busting drug tPA performed at a different facility within 24 hours of admission to the current facility. This will help guide the treatment a patient receives. ICD-10 should be seen for its benefits and not as a burden."
In a separate presentation on clinical documentation, Kristi Richison, director of HIM at Hillcrest Medical Center, Ardent Health Services in Tulsa, Okla., stressed the importance of assembling a cohesive, multi-disciplinary team of HIM and clinical documentation specialists, coders and physicians.  
"There are differences between what’s going on with the patient in real-time versus coding guidelines," Richison said, in a news release. "There are gaps between coding and clinical speak that we must address."

At Hillcrest Medical Center, she said, "We conduct chart reviews and hold one-on-one meetings with physicians to discuss deficiencies in documentation. After another chart review, there is a follow-up meeting for which we prepare a physician dashboard that includes the number and type of documentation queries, response rates, and issues such as missing discharge summaries, physical exam results and other omissions that can influence revenue."

[See also: Brainstorming About the Future of Clinical Documentation.]
AHIMA offers more strategies for successful clinical documentation improvement programs:

  • Gain the buy-in of leadership, including the CEO, CFO, CMO and CMIO
  • Conduct specialty-specific training and enlist a physician advocate for each specialty; Provide education tools for physicians by specialty, including online training; one-on-one meetings to discuss specific cases and queries; and presentations at department meetings.
  • Expand the staff of clinical documentation specialists as needed
  • Promote coder/CDS collaboration through tactics such as pairing each coder with a CDS for coder training and the handling of queries
  • Perform chart reviews and implement dual coding to identify gaps in documentation well in advance of ICD-10 implementation
  • Provide opportunities for greater CDS visibility to and interaction with clinical staff.