Does Your Clinical Documentation Hit the Specificity Target?

Does Your Clinical Documentation Hit the Specificity Target?


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On July 6, 2015, the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) announced joint efforts to help physicians prepare for ICD-10.  Included in that announcement was additional guidance from CMS allowing for flexibility in the claims auditing and quality reporting process.  Specifically, CMS established a 12-month “grace period” post implementation in which Medicare contractors would not deny claims billed under the Medicare Part B (outpatient) physician fee schedule if the ICD-10 code was incorrect, as long as a valid code from the correct family was used.

The ICD-10 flexibility will end in one month, after which all physicians in the U.S. will be required to code to accurately reflect the clinical documentation in as much specificity as possible.  Those who don’t, risk an increase in rejected claims, fines and audits.

As the October 1, 2016 conclusion to the one-year grace period approaches, there are some proactive steps practices should take to prevent and prepare for post payment claim reviews.

Assess “Unspecified” ICD-10 Code Use

Conduct internal audits to identify trends in unspecified clinical documentation and diagnosis code assignment.

  • Review reports of most commonly used “unspecified” ICD-10 diagnosis codes
  • Identify trends of unspecified diagnosis code use
  • Review provider documentation to identify opportunities for more specific code assignment and/or need for improved clinical documentation.
  • Provide education to appropriate providers and/or staff based on findings

Check EHR Configuration

Well-designed electronic health records (EHRs) can support ICD-10 coding and documentation requirements.  Conversely, those poorly designed can cause provider frustrations leading to incorrect or nonspecific code selection.

  • Consider modifications to existing templates and prompts.
  • Check for faults and errors in the EHR software and encoder decision trees. Issues have been reported with EHR ICD-10 code look-up tools. These can result in claim rejections and reimbursement delays.
  • If the EHR allows selection of unspecified ICD-10 codes by default, consider changing settings to encourage providers to drill down further for codes offering more specificity.

Prepare for New ICD-10-CM Code Updates

In addition, for the first time in 5 years, International Classification of Diseases codes will be updated on October 1, 2016.  This will be the largest update to the code set due to the code freeze that was implemented during the lengthy transition to ICD-10-CM.  There will be 1,943 new diagnosis codes, the update also includes 422 revisions and 305 deletions.

Of course, no physician practice will use all of the new codes. Of note, most of the code additions belong in the diabetic, musculoskeletal and injury code categories. However, each specialty will need to review the additions and changes relevant to their patient population.

Establishing a Clinical Documentation Improvement (CDI) Program enables the assessment and monitoring needed to ensure compliant and optimal ICD-10 coding practices. Additional benefits of a CDIP include ensuring a successful impact on Centers for Medicare and Medicaid Services quality measures, present on admission, pay-for-performance, value-based purchasing, data used for decision making in healthcare reform, and other national reporting initiatives that require the specificity of clinical documentation.

Galen’s Transformation Services Team has RHIA and CDIP certified staff to assist your organization in developing new documentation criteria, and to aide in training your providers to meet the increased documentation requirements.  Galen’s Clinical Documentation Improvement (CDI) program focuses on improving the quality of clinical documentation, facilitating an accurate representation of healthcare services through complete and correct reporting of ICD-10 diagnoses and procedures, as well as improving CMS Hierarchical Condition Category (HCC) scores.

Please contact us today to find out more about Galen’s CDI services!

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