ICD-10: Clinical Documentation Improvement (CDI) – Now is the Time!

Now is the time!  Don’t wait until there’s a problem to address Clinical Documentation Improvement (CDI).  The best defense in any game always starts with a good offense.  How good is your game?

CDI 100 Days

With ICD-10 lurking just 100 days away, many organizations are feeling comfortable with where they stand.  Do you work at one of those organizations?  If so, can you say with any level of certainty that providers know what the documentation requirements are for ICD-10?  Sure, it’s possible for them to know SOME of the requirements for the diagnoses they see frequently, but what about all of the other requirements?  Since the requirements differ by diagnosis, it’s going to be pretty difficult to remember everything, right?

As most of us already know, the average person only retains a small percentage of what they learn in a given training session.  With that being said, relying solely on providers to remember all of the documentation requirements for a specified diagnosis could result in claims payment problems and even denials.  In addition, many diagnoses require sequencing and/or have additional code rules.  Of course I don’t expect providers to know every scenario in which this applies, however with an appropriate guide they can be trained to be more mindful and aware of what is “necessary” documentation to get to an appropriate ICD-10 and/or to add secondary codes.

Take the example of an asthmatic patient: most clinicians know that exposure to smoke can be an aggravating factor, and are savvy enough to document such an exposure, especially now that tobacco assessment is a requirement for Meaningful Use.  But what happens if a patient was exposed to occupational tobacco smoke?  This small tidbit might not be mentioned in the visit note and it could impact how much gets paid out on the claim.  That equates to money left on the table…yikes!

If you have done your due diligence in preparing for ICD-10, you are probably in good shape.  But if you have not looked at the existing documentation associated with your top or high dollar diagnoses, compared it to what is going to be required, trained your providers on all those requirements, AND provided them with useful methods by which to remember all those conditions, then you should be very concerned.  If your organization falls in the latter category, rest assured that Galen is here to help.  Not only are we positioned to assist you with ICD-10 readiness from a global perspective, but we are also here to help you improve your clinical documentation in your Epic, TouchWorksTM, and MEDITECH EHR’s.

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