ICD-10 and clinical documentation: From EHR to claims, better documentation offers better revenue

_This article first appeared on NueMD’s industry blog. NueMD is one of Practice Fusion’s preferred billing partners. _

At the recent American Health Information Management Association (AHIMA) Convention and Exhibit in Atlanta, different educational sessions and presentations stressed the importance of accurate and useful documentation for ICD-10 coding.

Healthcare IT News, which covered the AHIMA event, noted that ICD-10 increases the number of diagnosis and procedure codes from ICD-9′s 13,000 to more than 141,000. The purpose is primarily to provide more “granular” data on patients, thereby improving care. But in order to provide more detailed claims and improve medical billing solutions, many providers will need to improve their current documentation habits.

“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,” said Theresa Jackson, director of health information management at the University of Kansas Hospital, as quoted by Healthcare IT News.

Clinical documentation improvement programs are an important tool for providers gearing up for ICD-10 compliance. But enhanced capture, which leads to improved coding and better yield on claims, is just one perk. Perhaps more important than its impact on ICD-10, bolstering documentation leads to greater clinical data integrity and reliability, said Jackson. As a result, patient care improves – as do a provider’s chances of demonstrating Meaningful Use quality measures.

Jackson outlined exactly why improved documentation is necessary for ICD-10 coding, comparing the data required for a myocardial infarction in ICD-9 to the new code set. She noted that with ICD-9, the myocardial infarction is coded in only one of two different categories, chosen based on factors such as the acuity, duration and timing of the heart attack. However, for ICD-10, a number of additional details will be recorded in the code. These include information about underlying diseases, risk factors like tobacco use or exposure to environmental hazards, or the use of clot-busting drugs in the case of readmission within a 24-hour period.

“This will help guide the treatment a patient receives,” Jackson said, quoted by Healthcare IT News. “ICD-10 should be seen for its benefits and not as a burden.”

Creating more effective clinical documentation
According to Healthcare IT News, AHIMA offered six core strategies for any successful clinical documentation improvement program.

1. Get leadership onboard. In large practices, everyone needs to be ready to tackle major projects.
2. Have training for specialties and choose a doctor to advocate for each specialty.
3. Bring on clinical documentation specialists if necessary.
4. Have coders work closely with clinical documentation specialists.
5. Start early on ICD-10: Begin with chart reviews, then use dual coding to improve documentation.
6. Get the documentation specialists talking with staff. Encourage conversation and facilitate dialog for greater communication.

When documentation isn’t up to par
Coinciding with ICD-10′s one-year countdown, Becker’s Hospital Review recently released a list of reasons a practice, hospital or medical system’s clinical documentation isn’t yet ready for the new code set. Here are four pertinent points.

1. Doctors should be actively monitoring their clinical documentation improvement program and benchmarking themselves against peers. Becker’s borrows the old adage, “You can’t improve what you don’t measure,” to illustrate this point. Members of your ICD-10 leadership team or project manager should not only be accountable for improving documentation, but also comparing data capture to that of peers. In an ideal environment, doctors should be sharing the data they gather from their programs in order to remain competitive. According to the news source, the old adage could use an update: “You can’t improve what you don’t measure and share with those who have the capacity to improve the measured process.”

2. Staff and doctors shouldn’t see clinical documentation improvement as a way to maximize on money alone. While improving revenue cycle management through better documentation is important, medical staffers need to recognize that this initiative is about quality of care and quality of data, noted Becker’s.

3. There should be clinical documentation specialists on staff. Echoing AHIMA on this point, Becker’s noted that for larger providers, the need for documentation improvement will escalate once the process is underway. Having specialists on staff can ensure that things advance smoothly.

4. Computer-assisted coding (CAC) is not the answer. While some providers are finding CAC to be a useful way to ease into ICD-10, it’s not a cure for documentation problems. In fact, it’s not even a bandage. Providers who really want to improve claims coding need to follow problems to the source and fix them.

Visit our ICD-10 Center

Practice Fusion’s Director of Clinical Program Management will provide an overview of the changes to expect with ICD-10, as well as how to transition to ICD-10 in your daily workflows.