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Don’t Overlook Clinical Documentation in Your ICD-10 Preparations


Is your clinical documentation ready for ICD-10? CMS has prepared a guide called Simple Steps to Improve Clinical Documentation; it’s worth your time to review it.

This little document is good place to start your preparation for ICD-10 implementation activities. By improving clinical documentation now, you will be ready to assign ICD-10 codes when the deadline hits.

Your time won’t be wasted between now and Oct. 1, 2014, and you will realize the following benefits:

  • Complete and accurate medical records that ensure patients receive the right treatment.
  • Your coders will be assigning the proper medical codes which will lead to fewer physician queries and improved medical billing and clinical workflows.
  • Fewer claims rejections because of improper coding and not enough documentation to support diagnoses.
  • Improved clinical documentation that makes it easier to protect against healthcare fraud and disputed fraud charges.

Practice ICD-10 coding with real cases. This will help everyone — from the office staff to clinicians to medical coders — understand where current documentation falls short. Dual coding will be a time-consuming and expensive exercise but a valuable way to demonstrate your CDI needs.

In addition, clinical documentation improvement (CDI) makes computer-assisted coding (CAC) systems work more efficiently. Enlisting technology to help you on your ICD-10 journey just makes sense. CAC is a proven technology that automatically derives and assigns medical codes from within clinical documentation. Many are already ICD-10-ready.

Your organizations can streamline your CDI and revenue cycle processes with CAC, while becoming increasingly more compliant with the requirements of payer and quality reporting.  These technologies can work with your electronic health record and financial systems to produce extremely accurate coding. These systems don’t replace your professional coders; they just aid them and ensure improved: accuracy, compliance, productivity and consistency.  How to improve clinical documentation

If you’re creating a formal CDI plan, according to HIMSS, there are five key steps you need to take to improve your clinical documentation:

  • Assess documentation for ICD-10 readiness.
  • Analyze the impact on claims.
  • Implement early clinician education.
  • Establish a concurrent documentation review program.
  • Streamline clinical documentation workflow.

The time to start you CDI is NOW; your facility should avail itself to every resource possible to be ready for the October 1, 2014 deadline.

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