I have been educating Provider’s on the documentation challenges and changes that are inherent in the ICD-10 coding system for the past year and it seems that many Providers are unprepared for the specificity required in medical documentation. Clinical documentation integrity begins with the Providers, and training in this area is critical to a successful ICD-10 transition, however, the impact of education regarding documentation is negated if we do not have Provider engagement. To encourage engagement, a basic understanding of the CDI and coding process is needed to facilitate ‘buy-in’ and make the documentation education and training better received.
I don’t believe the training has to be in-depth, but can be relatively high level. For example, many Providers are unaware that coders are bound by strict guidelines that dictate what can and cannot be reported based on the documentation provided. Sharing small concepts such as this promote better understanding as to why coders and CDI may be requesting further information on a particular diagnosis when the Provider may feel it is perfectly clear in his or her documentation.
With the increased granularity of the ICD-10 Coding system, the need for a robust functioning CDI program or process is a necessity for a successful ICD-10 transition. It includes:
- Having a CDI program in place that has been measured and monitored prior to ICD-10. This ensures that the data elements that need to be captured to facilitate coding are being evaluated both concurrently and retrospectively.
- Development and initiation of query templates along with an effective tracking system that is specific to each facilities case mix. It is cognizant of time management for Physicians, CDI and Coders and has the potential to minimize the impact on reimbursement decrease due to inaccurate patient severity and outcomes. Queries help to bridge the gap between clinical language and coding language and the need for established tools in this area is crucial.
- Training involving the query process, both concurrent and retrospective. This can pave the way for training on the documentation challenges associated with ICD-10 and is a good starting point by keeping the cart behind the horse and not in front of it!
Promoting collaborative relationships between Provider’s, CDI and coders can help facilitate a successful ICD-10 transition. An understanding that ‘we are all in this together’ can alleviate pressure that may be felt by individual groups and aids in developing good processes to ensure clinical documentation integrity. A common theme amongst Providers is that ICD-10 is a ‘coding thing’ and education addressing this will start the foundation for concise, specific documentation which in turn will facilitate concise, specific and accurate coding.
How do you suggest bridging the gap between providers and documentation?