How Comprehensive Clinical Documentation Improvement Pulls ICD-10 Projects Together

At the 2012 AHIMA Convention and Exhibit, Kelly McLendon, founder of health information management firm HIXperts, explained how "comprehensive" clinical documentation improvement — not just CDI — can help hospitals in their ICD-10 efforts.

Typical CDI projects involve limited chart reviews, physician training and tracking of progress. "Comprehensive" CDI, or CCDI, goes a step further. It involves in-depth chart audits, coding compliance, intense physician training and stimulation of all floor members (coders, nurses, etc.) to help physicians initiate ICD-10 processes, Mr. McLendon said.

The reason why CCDI can help hospitals, he said, is because it focuses primarily on physicians and how they need to be more specific and sufficient in their documentation.

Ed Hock, senior director at The Advisory Board Company, recently reiterated this point to Becker's Hospital Review, saying, "The reality is ICD-10 will require physicians to document things they've never had to document before. If they don't start documenting these new concepts, three things will happen: A claim will be coded lower than it should have and will be reimbursed less than it should have; the claim can be submitted and billed but eventually will be denied; or you don't end up billing it and query the physicians, which is fine, but it slows down the process significantly."

Mr. McLendon said CCDI will work in hospitals if revenue cycle team members and HIM professionals follow a couple keys to success:

1. Emphasize to physicians that "docutemptation" — the use of copy/paste, checking off boxes and other shortcut maneuvers — cause more trouble than time saved.

2. Talk to the physicians' wallets. If physicians understand they are leaving revenue on the table with insufficient documentation, ears will perk up.

3. Track as many data elements as possible during documentation audits.

4. Ensure documentation improvement is part of the hospital's credentialing process.

5. Don't be afraid to be repetitive. Repetition is the gold standard of practice, he said.

More Articles on Clinical Documentation Improvement:

7 Projects Hospital CFOs Should Focus on in the Final Months of 2012

7 Areas That Will Influence the Finances of Safety-Net Hospitals

How Clinical Documentation Improvement Could Improve the Revenue Cycle

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