Electronic Health Records

Are clinicians ready for ICD-10 documentation requirements?

Over the past two years, hospitals have invested in modifying applications and workflows to fit the demands of ICD-10. And many have ramped up training on the detailed documentation that the new coding system requires. But a February survey by the Medical Group Management Association (MGMA) indicated that only 10 percent of physician practices were prepared for the change, and a lack of familiarity with the new documentation demands was part of the issue. Documentation remains an Achilles heel for many hospital ICD-10 conversion plans.

No matter how well you have planned and invested otherwise, if your physicians and clinical staff aren’t prepared to provide the detailed documentation required, you aren’t ready for ICD-10.

With so many people involved — nurses, physicians and a host of other clinicians — it is inevitable that wide variations in the quality of documentation will occur. Some clinicians have given serious attention to learning the new requirements while others have procrastinated. The daily demands of patient care can be overwhelming, making the ICD-10 deadline seem remote in comparison.

But the extensive changes in documentation take time to learn, requiring practice and repetition to become automatic. Waiting until just before the deadline to learn the new system is a recipe for disaster. Once ICD-10 is fully implemented, documentation that lacks sufficient detail has the potential to wreak havoc with cash flow. Rejected claims and claims that are reimbursed at a lower rate are real possibilities that can have a serious impact on your bottom line.

To prevent that possibility, hospitals should work with physicians, nurses and other clinical staff to ensure that documentation they are creating now meets the ICD-10 standard.

Beyond the need for ICD-10 preparation, better clinical documentation can help your reimbursements under ICD-9. Several of the hospitals that I work with have included clinical documentation improvement as part of their ICD-10 preparation. As their clinicians began to use the more detailed and specific documentation, the hospitals’ coders have been able to apply a higher DRG to many patient stays. As a result, the hospitals have seen a 15-20 percent increase in their reimbursements.

Clinical documentation improvement will pay off when ICD-10 compliance is required (currently Oct. 1, 2015). Even in the unlikely event that CMS decides to skip over ICD-10 and wait for the ICD-11 update, your hospital will still benefit from improved documentation. And when ICD-11 rolls around, your clinicians will be ready to document under that system as well.

Test your documentation along with your systems

Within your ICD-10 testing program, along with testing the changes to your applications, workflows and coding practices, you should also be testing the effectiveness of your clinical documentation training. You don’t want to waste time and effort on further training for physicians and staff who don’t need it, and testing will help you identify clinicians whose documentation is insufficient for the new system and help you focus your efforts where they are needed.

In addition to testing your systems and documentation practices, you should also be looking at how ICD-10 will affect your reimbursements. A good analytics program can use historical data to help you identify your financial winners and losers under the new coding system, providing an opportunity to adjust operations to fit the coming realties.

Analytics can also help identify current areas that could yield higher reimbursements if the documentation was more detailed and specific. For more insights into an effective testing and analytics program for ICD-10, check out this short video:

No matter how prepared you think your organization is for the ICD-10 transition, taking another look at clinical documentation is worth the effort. Because it relies on individuals, not systems, documentation is the part of the coding process over which hospitals have the least control. That’s why hospitals should use the extra time provided by the delay to make sure that all clinicians – physicians, nurses and other hospitals staff – are fully prepared to document with the level of specificity that ICD-10 will demand.

As chief medical officer and head of Dell’s global healthcare consulting services, Cliff Bleustein, MD, MBA, leads an integrated team of clinical, business and technical professionals who provide expertise to health systems, hospitals, physician practices, health plans and life sciences organizations.

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