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:
- 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.
- 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 firstname.lastname@example.org.