The switch to ICD-10 is delayed, but not abated. With the new implementation date of October 1, 2015 will your organization be ready for the best possible transition? The best place to start is by analyzing your clinical documentation improvement (CDI) program to determine the quality of documentation. Consider using you coder and case managers to identify educational opportunities for physicians and areas for improvement. Specifically, enlist the assistance of your case managers to focus on documentation trends across the board, and work with physicians who are your largest admitters.
Documentation improvement initiatives can be conducted parallel to coder education for ICD-10 preparation. Throughout the next 12 months, conduct coder gap analyses to determine strengths and weaknesses. Coders will need deep knowledge in anatomy and physiology, medical terminology, pathophysiology, and pharmacology. Your case managers should also be included in this assessment.
Multiple new mandates, including ICD-10, RAC, Medical Necessity and pay-for-performance are making accurate clinical documentation more important than ever, and the growth in volumes resulting from the ACA are impacting all organizations. Your ability to get reimbursed is directly dependent on the quality of your clinical documentation. As you are well aware, missing, poor, or non-specific clinical documentation will result in lost revenue.
You can be prepared to mitigate this loss by engaging professional CDI specialists. These professionals are credentialed, highly-trained, and they can ensure your documentation is ready for the transition to ICD-10. Whether you use these CDI professionals to assess your program or supplement your staff, they can help you develop, improve, and maintain your clinical documentation. They can quickly get you “up to speed” with the interim or permanent CDI professionals you need. These highly skilled and experienced CDI professionals can fit seamlessly into your current program.