With medical records needing to be documented as much as possible due to the high specificity required in the ICD-10-CM (Clinical Modification) code sets, physicians and billers and coders are in the process of recognizing the significance of upgrading their clinical documentation knowledge and processes that best serve ICD-10 and HIPAA 5010 requirement. With this foreground, let us proceed to understand:

“How clinical documentation will change with ICD-10”

With medical records needing to be documented as much as possible due to the high specificity required in the ICD-10-CM (Clinical Modification) code sets, physicians and billers and coders are in the process of recognizing the significance of upgrading their clinical documentation knowledge and processes that best serve ICD-10 and HIPAA 5010 requirement. With this foreground, let us proceed to understand:

“How clinical documentation will change with ICD-10”

Well, as we know ICD-10 is going to increase the quantum of diagnostic and procedural codes to 140,000 codes (which is roughly 3 times the codes that we had to contend with during the ICD-9 regime). Consequently, this quantum leap in codes will support providers in meeting the increasing demands of regulatory and quality reporting requirements, and improve the overall quality of care being delivered.

But, given the fact that most of our physician facilities are yet to come on par with current clinical documentation standards (a recent study evaluating the assessments of more than 3,000 medical records across the country, has found that only 37% of the current physician documentation would support the newer standards that will be required by ICD-10), the turnaround in terms of clinical and operational efficiency will not come without challenges.

One of the biggest challenges associated with ICD-10 is the level of specificity of clinical information granularity of detail that physicians will have to contend with while preparing medical record.

• Analyzing physicians’ current level of documentation skills and identifying gaps vis-à-vis ICD-10 should take precedence over any other tasks
   
• Such proactive gap analysis will pave the way for modifications and reworking of clinical documentation and its associated processes and workflows aligned to support ICD-10 clinical documentation mandate

But, such comprehensive realignment requires time and extensive training of physicians, coders, and hospital staff. And, with physicians and coders being the key components, the education needs to be collaborative involving human and technology support. This invariably brings the Clinical Documentation Improvement (CDI) into focus:

• Clinical Documentation Improvement starts with focused documentation audits, which determine patterns of missing information that may impact coding and reimbursement under ICD-10. By understanding the clinical areas impacted most by the transition, physicians and coders can respond with the requisite clinician education and improve documentation processes where needed
   
• The next step in clinical documentation improvement process is knowing how incomplete clinical documentation can result in inaccurate coding, which would eventually result in delay or denial of reimbursements. Such analysis would pave for implementing an early clinical education
   
• Implementing early clinical education is seen as the remedy for minimizing the disconnect between the language clinicians use to document care and the language coders need in order to code from the documentation. Early education will bring physicians and coders on the same ICD-10 wavelength
   
• Another important component in ICD-10 CDI process, concurrent documentation review program enables establishing factuality of the clinical procedures before they are produced as valid documents for coding
   
• Updating clinical documentation workflow with automated tools is one of the prerequisites in the CDI program. Such automation of clinical documentation workflow enables instant access, verification, and transmission of clinical documentation across the networked entities, such as physicians, coders, payers, and healthcare authorities

As you (medical billers and coders along with physicians) measure up to the challenges in the collaborative clinical documentation under the ensuing ICD-10 and HIPAA regime, our unique Training Program on ICD-10 Transition – interspersed with webinars, forums, and online learning materials – should make your clinical documentation improvement job more meaningful and fulfilling.

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