ICD-10 Clinical Documentation Improvement (CDI) Readiness

Co-Author: Laura Gold


As many of you know, while ICD-10 was created by the World Health Organization (WHO) in 1994, the United States is one of the last countries to adopt this coding standard. In part, ICD-10 was created to provide an updated medical terminology and disease classification, which aids in the ability to improve healthcare services and metrics. While all past implementation dates have been pushed, the current go-live date is October 1st, 2015.  Majority of healthcare organizations spent the past year preparing their systems to accept and use ICD-10 coding standards.

Organizations should be in the process of educating their providers, clinicians, end users and billing/coding staff on the new ICD-10 coding complexities. Choosing the correct ICD-10 code alone will be meaningless without the required supporting elements to substantiate the clinical note.

For instance, it is common everyday practice throughout the healthcare community to document otitis media w/ spontaneous rupture of ear drum with an ICD-9 code of 382.01. ICD-10 coding requires a much higher level of specificity not currently supported or required for ICD-9. Moving forward when documenting a patient with otitis media, it will be imperative to be precise in code selection as well as in recording the patient’s visit via the office note. This will include Type, Infectious Agent, Temporal factors, Side, Tympanic membrane rupture status, and Secondary causes e.g. tobacco smoke usage or exposure.

Otitis Media: ICD-9 vs. ICD-10

Documentation Differences at a Glance (*ICD-10 Changes Appear In BOLD)

  • Acuity
    • Acute
    • Chronic
    • Unspecified
  • Type (use as many as needed to depict presenting problem)
    • Allergic
    • Mucoid
    • Nonsuppurative
    • Sanguinous
    • Serous
    • Suppurative
    • Unspecified
  • Site
    • Atticoantral
    • Tubotympanic
    • Unspecified
  • Document
    • Spontaneous rupture of eardrum, when present
    • Underlying conditions, such as
      • Influenza
      • Scarlet fever
  • Laterality
    • Right
    • Left
    • Bilateral
    • Unspecified
  • Acuity
    • Acute
      • Recurrent
    • Subacute
    • Chronic
    • Unspecified
  • Type
    • Allergic
    • Mucoid
    • Nonsuppurative
    • Sanguinous
    • Serous
    • Suppurative
    • Unspecified
  • Site
    • Anticoantral
    • Tubotympanic
    • Unspecified
  • Document
    • Underlying conditions
    • Associated perforated tympanic membrane (ruptured eardrum)
    • Tobacco exposure, use or dependenceext

Preparing your staff with the tools to be able to select the correct ICD-10 code is only the first step. The second step is to have the visit documentation mirror the ICD-10 code. Even providers who have been doing a stellar job documenting and coding their patient care for ICD-9 are more than likely going to need guidance and assistance navigating through the intricacies of ICD-10 and its documentation needs.  Clinicians, therefore will need help capturing the new information or expanding on old required documentation standards.

How to prepare - The new ICD-10 guidelines will increase the time a provider spends accurately documenting a patient visit, but it doesn’t have to. Creating ICD-10 Compliant and Provider Friendly forms will remove this time consuming annoyance and help ease the transition to ICD-10.

What can be done - As healthcare organizations navigate the new ICD-10 coding requirements, a Clinical Documentation Improvement (CDI) assessment of internal notes should be performed. A review of your existing forms and practices by a Clinical Documentation specialist will greatly ensure all the required supporting elements are available in a provider friendly format.

Who is going to do the work – Ideally, this CDI project would include a note specialist who is familiar with your notes and documenting practices as they are today, an ICD-10 certified coder, and clinical documentation specialist.

When do you start – Regardless of the number of note forms and templates you use today, reviewing them can be a laborious process. If your organization has not already started reviewing your clinical documentation practices for ICD-10, start NOW! Don’t let the implementation date catch you off guard!

Galen has a team of skilled ICD-10 clinical document improvement analysts available to guide your organization through this process, and has already contracted with several clients at various levels to assist in their efforts.  For additional information, please contact us at sales@galenhealthcare.com.

Are You Ready for the Shift to Value based Payment Models? – Part 3

Erin's image

The level of excitement organizations are feeling with the prospect of moving to a value-based care approach, which we discussed in Part 2, is trumped only by the questions and apprehensions with how to get there.  Galen Healthcare Solutions is excited about the benefits of moving into value-based care, but how do our partners and our clients achieve the Triple Aim, while at the same time, adopting new payment models?  Is it possible to improve the experience of care, improve the health of populations, all while reducing costs?

The simple answer is, yes.

As organizations begin their journey to assume the financial risks associated with managing the care for large populations of patients, knowing where to start that journey is the challenge.  At Galen, we look to find the most efficient and effective ways to assist our clients in accomplishing their goals as they transition from fee-for-service to pay-for-performance models.  In an effort to help our clients find a care coordination solution that results in better care, better health, and lower costs, Galen made the decision to collaborate with PinpointCare.  The purpose of the PinpointCare solution is simple – develop a cutting edge platform to connect all of a patient’s care providers.  Together, PinpointCare and Galen have implemented a powerful solution for clients who participate in the Medicare Bundled Payments for Care Improvement initiative (BPCI), organizations who participate in bundled payment initiatives with private payers, and organizations seeking to better manage episodic events, chronic diagnoses, and wellness care plans.

The PinpointCare platform allows the care team to work with a patient to create a personalized, but dynamic care plan to support the patient through all phases of care.  An intuitive dashboard gives the care team the ability to closely monitor adherence to the care plan and make the necessary adjustments along the way.  The web-based platform that is available anywhere, anytime, allows real-time collaboration around the patient’s care in the acute setting, ambulatory setting, rehabilitation, skilled nursing facility, home health and outpatient physical therapy.  The care plan truly follows the patient throughout the entire span of their care, so at any point, if a patient is off-plan, immediate real-time adjustments are made to better care for the patient.  A patient’s involvement in their care plan is key.  With PinpointCare, the patient is involved from start to finish in developing the appropriate care plan to best meet their needs.  See how one patient was able to keep herself on plan when things went off course: Penny’s Story.

Whether the need is to track patients through a particular surgical or medical episode, through diagnosis and treatment of a chronic condition, or to track patients on a wellness care plan, PinpointCare is the solution.  The results PinpointCare have enabled are real.  A single organization utilizing the PinpointCare solution has seen a 14% reduction in hospital readmissions, a reduction of cost per DRG of 18%, and savings of over $3 million dollars – and those results are from a single year alone!  The agility of the easy-to-use platform, along with connecting the patient and the patient’s entire care network, truly allows for better health, better care, at a much lower cost.

Galen’s implementation methodology ensures that the execution of PinpointCare is very low impact to any organization.  Within a few months, Galen will configure the system, build necessary integrations with existing ancillary systems, develop customized care plans, train end-users, and launch the new platform for immediate use and cost savings.

The need to depart from an antiquated fee-for-service model is real and upon us.  The PinpointCare solution sets your organization firmly on the path to value-based care and puts the goals of the Triple Aim within reach.

Interested in seeing how PinpointCare helps move us into the new world of pay for performance AND helps achieve the Triple Aim by coordinating care by design?  Contact me at erin.sain@galenhealthcare.com

A Letter From Galen’s New CEO

Press Release

Dear Clients & Colleagues,

Almost two years ago, we announced a new leader for Galen Healthcare Solutions in Joel Splan, and we have been instituting positive change since the day Joel walked through the doors. One of the most meaningful initiatives Joel helped cultivate while at Galen was a strong partnership and investment opportunity with PinpointCare, a powerful platform for value-based payment models.


Along with leading Galen to a remarkable year, Joel also served as the Interim CEO of PinpointCare.  During this time, Joel became the face of the organization and spearheaded the growth and direction of the product and the organization. As we came up on the end of year, we were faced with a decision as to what our next step would be. With all of the activity ongoing at PinpointCare and Galen, we felt it was best to have Joel focus on PinpointCare and become their fulltime CEO. This partnership is an important part of Galen’s future, giving us resources to continue to invest in future initiatives while also helping us diversify into other areas of healthcare IT.

Joel has done an amazing job in his tenure at Galen, instituting many operational changes, building a better company vision, and teaching us how to better adapt to the rapidly changing healthcare IT landscape. We learned a vast array of strategies from him, learning not only how to utilize them, but also to expand upon that foundation. We are sad to lose Joel’s focus at Galen; however, we are excited to retain his advisory guidance on our board along with a continued presence on specific initiatives within Galen.  We wish him the best of luck in his new role!


Effective immediately, I will be taking over as CEO, and I am excited to be filling the role. Our board  continues to consist of myself, Steve McQueen as Chairman, and Matt Nice as President.  Steve, Matt and I founded Galen in 2005 and will continue to determine the strategic direction of the company and provide oversight and guidance to our leadership Team. While we will remained focused on high-level initiatives, we will continue to assist where needed within the company on a daily basis.

I am thrilled and excited to announce some additional changes we have made, refocusing the top levels of the organization. While our leadership team remains constant and truly is the team that has been running the organization, we needed to make some adjustments to the focus of each team member. The result will be a more efficient Galen that produces even more consistency for our partner clients while making us easier than ever to work with.

Mike Dow, Chief Information Officer –Mike will be instrumental in helping Galen define the future of the company and developing the strategies for delivering the solutions we provide along with ensuring that we have the appropriate tools supporting our employees.

Erin Sain, Chief Operating Officer – Erin will utilize her skills and industry knowledge to help us expand our operational efficiency throughout the organization, while also promoting our teams to execute on providing the best value possible to our clients.

Rita Owens, Vice President of Clinical Solutions - Rita will continue to take advantage of her clinical knowledge to guarantee we are delivering the value proposition and offerings that our partner clients need in order to meet their specific goals and the upcoming changes with health care reform.

Cary Bresloff, Vice President of Sales – Cary will expand his focus as he takes on a greater leadership role within the Sales team while implementing a new sales strategy that we as an organization will utilize as the building blocks of our Go-To-Market strategy.

Justin Campbell, Vice President of Marketing – Galen has an amazing story to tell the industry and we are truly excited to announce that Justin will be taking over our marketing initiatives and delivering a better strategy for solidifying our market presence.

Matt Woodside, Director of Professional Services – Matt will continue his oversight on our Allscripts and Epic practices while also continuing to promote internal initiatives to promote our ratings on the Modern Healthcare Top 100 Places to work list.

Susan Carman, Director of Professional Services – Susan will continue leading our MEDITECH practice, establishing us at many MEDITECH clients, and expanding our footprint in this market.

Bob Downey, Director of Product Development – Bob will continue oversight and development of our Products team, ensuring that our current portfolio of award winning products continues to provide value to our clients, while also continuing to develop new applications that meet the needs of the future of healthcare.

Ray Lape, Director of Technical Services – Ray has taken over the leadership and management of the Technical Services team effective immediately. Ray has been an amazing team member over the years and has demonstrated his skills from both an analyst and sales perspective, and we are excited to see his leadership skills applied to this focus.

As a whole, this group has been extremely influential in the success and direction of the company throughout their entire tenure at Galen. I have worked closely with all of these folks and I know that I have the right people supporting the needs of the organization. I am excited to be able to continue to work with everyone more closely than ever and help lead us to the future state of Galen. We have some lofty, yet achievable goals in 2015, and I know that we will be successful because the entire Galen family is the best at what we do on a daily basis.


Jason Sig

Jason Carmichael
Chief Executive Officer
Galen Healthcare Solutions


Reducing Complexity in Healthcare IT

Mergers and acquisitions of health systems have increased nearly every year over the past 8 years – we also see this anecdotally in story, after story, after story.  The market is driving us in this direction – standardizing care, creating economies of scale to counterbalance reduced margins, and increasing the size of risk pools as healthcare providers continue moving towards value based care contracts.

The bloat that often results from combining two large organizations will slow groups down when left unchecked.  Within IT, we end up with many overlapping and even duplicate applications.  It’s like Noah’s Ark, you end up with two of everything.

And, then it snowballs; a hospital that merged a few years ago merges again.  We can all do the math.  Two health systems merge, and then the combined  system merges again – exponential growth.  That’s exponential growth in the complexity of the application portfolio that CIOs are being asked to manage.  Once IT gets its arms around the increased portfolio of systems, it begins work to integrate and interface the systems together.  This leads to more complicated integrations, which lead to less agility.

Furthermore, each change and upgrade requires integration testing with dozens of other systems.  All of a sudden, you are managing the integrations rather than the critical applications within your environment.  This makes IT slower in serving the rest of the organization and creates more opportunity for mistakes.

Complexity in healthcare IT continues to increase.  Costs continue to go up.  Responsiveness and speed lag.  And, security breaches are becoming daily events.

The fact of the matter is that CIOs cannot simply throw their hands up and stop supporting systems.  Leaders of healthcare organizations cannot simply ignore market forces and stop considering acquisitions.

We must take healthcare IT out of the crosshairs and serve our health systems better by reducing the complexity of our IT application portfolio.

The collective knowledge we have built over the past decade in implementation, optimization, and conversion projects lend itself well to application portfolio management.  Leveraging that knowledge, Galen has assisted health systems improve IT responsiveness, reduce costs, and increase security using a unique, field-tested approach of application portfolio management.  Northwestern Memorial Hospital has already seen success in reducing complexity and driving down costs by using these techniques.

We are excited to announce our work in reducing complexity in the application portfolios our clients are managing. We believe that bringing Galen’s energy, passion, and a proven methodology to reducing the complexity that’s been forced upon us is a winning combination.

Clinical Documentation Improvement and Your TouchWorks V11 Note Forms

We all know ICD-10 is coming. We know that ICD-10 compliance is more than just knowing which code to assign. We know that the increased specificity of the ICD-10 code sets will require physicians to provide documentation that support the assignment of these codes. However, that does not mean physicians will need to document more. It just means that their documentation needs to be more specific.

Implementing strong, physician-focused documentation tools, like customized TouchWorks V11 Note Forms, as part of a Clinical Documentation Improvement plan, is an efficient way to improve physician clinical documentation. By making a few key design decisions and customizing your V11 Note Forms, you can dramatically and positively impact your organization’s transition to ICD-10. The result will be improved patient care, increased physician and coder productivity, and protection of reimbursement and cash flow.

Quality and Continuity of Patient Care

Strategically designed V11 Note Forms offer physicians the benefit of an easier, more efficient workflow. The use of standardized clinical decision prompts adds value by facilitating comprehensive documentation, resulting in a more complete story of the patient’s condition. This allows the patient’s entire care team the ability to manage the patient proactively, resulting in higher quality of care and improved outcomes.

Efficiency and Productivity


There is a tendency to address inadequate clinical documentation after the patient encounter. The level of specificity needed with ICD-10 will increase the need for the physician to document a complete and accurate description of the patient visit at the point of care. Customizing the layout of your V11 Note Forms adds the advantage of guiding physicians to document the required clinical information efficiently, ensuring their documentation complies with the ICD-10 coding guidelines, before the patient leaves the office.


Today, coders address clinical documentation deficiencies reactively by submitting queries for missing documentation. This is a less than ideal approach for two reasons:

  1. It adds several unnecessary steps, slowing the timely completion of the medical record. Without thorough documentation of a patient’s full clinical presentation, coders will have to query the physician for clarification. This will lengthen the medical record completion process.
  2. It ignores the fundamental principle that it is the physician’s responsibility for complete and appropriate documentation to describe the patient’s encounter.

The lengthy query process leaves organizations liable for deficient records, as well as delays in reimbursement due to the additional time spent waiting for physicians to respond to the queries and create the required documentation addendums.


Proper documentation at the point of care that supports the coded diagnoses and justifies the medical necessity of procedures will:

  • Reduce the number of returned or denied claims
  • Capture the details needed so that physicians and facilities are reimbursed the most appropriate amount for patients’ Severity of Illness, Risk of Mortality, and the care provided
  • Protect payments received from being taken back during payor audits

The Galen Clinical Documentation Improvement (CDI) team comprised of senior-level, certified V11 Advanced Note Specialists, possess a vast working knowledge of both Allscripts TouchWorks V11 Note and the new ICD-10 documentation requirements. The CDI team can help customize your organization’s V11 Note Forms to ensure your physicians are prepared to not only document correctly based on the new ICD-10 coding guidelines, but to also complete their documentation as efficiently as possible.

Galen welcomes the opportunity to partner with your organization to help fast track your physician documentation improvement initiative. To learn more about how Galen can assist your organization move toward ICD-10 documentation compliance successfully, please contact Cynthia Gerson at education@galenhealthcare.com.

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