With ICD-10 coming in just over a year, it’s going to be important for organizations to determine the best way to minimize the impact to providers. Most people understand that with the transition to ICD-10 comes a drop in productivity for billers, coders and providers. However, documenting correctly the first time around can save providers time by minimizing the need for queries, which in turn allows for faster payment of claims. Given this theory, there are a couple of things that organizations can do to prepare:
- Run reports to determine top diagnoses by specialty and/or to determine high impact diagnoses
- Review the ICD10 requirements for the diagnoses listed above
- Review existing EHR templates for documentation that supports ICD-10 coding as it relates to those top diagnoses.
- Option 1: Color code ICD-10 requirements (on condition specific EMR templates, if possible) so that providers know exactly what the minimum requirements are. Also, add in missing requirements (where reasonable).
- Option 2: Remove any checkboxes/radio buttons that don’t support ICD-10 coding. Also, add in missing requirements (where reasonable).
- Allow a section or multiple sections where providers can use voice-recognition software or free text to tell a complete story about the patient.
Understand however that these recommendations do not negate the need for all other discreet data as it relates to Meaningful Use (MU). Be sure to inform providers that although Clinical Documentation Improvement is the focus (CDI), Meaningful Use still applies and appropriate actions need to be taken to meet those requirements as well.
It is possible that many organizations don’t have the resources or the time to take action as recommended above. It’s also very easy to say that all the required information lives somewhere amongst the “templates”. Sound familiar? The bigger question is…can the providers find it? Given that troublesome thought, making the time and devoting one or more resources to clinical documentation improvement could net the organization in short and long term gains.