Clinical Documentation Upgrade Critical Before ICD-10 Conversion

For most providers organizations, the news that ICD-10 implementation is likely to be delayed is, at minimum, a big relief.  But don’t let that lull you into a false sense of relief, suggests Priya Patel of tech consulting firm Perficient.  Even if the ICD-10 rollout is delayed — as many hope — until October 2013, it’s still going to happen.

So what can organizations due to reduce that weak feeling in the knees associated with ICD-10?  Well, generally speaking, Patel notes, your organization is already overdue for doing an ICD-10 impact assessment to figure out how to move ahead.

While the whole assessment is important, perhaps the most important element of the ICD-10 preparation process is clinical documentation assessment, Patel says. In fact, “if you choose not to assess your clinical documentation, you will certainly lose!” Patel asserts. Lose what?  Well, clinical and business effectiveness, sure, but also a great deal of money.

Right now, few doctors document efficiently enough to support coders, who are forced to do their work based on their assumptions and often, make mistakes and end up doing things over again.  As things move to ICD-10, these problems are only likely to get worse, as consistency in coding will become even more important.

Unfortunately, that’s not going to happen on its own. In fact, According to Patel, a recent study of 3,000-odd medical records across the country found that only 37 percent of physician documentation in existence would meet standards set by ICD-10.  Most organizations, in other words, will find that the documentation they have on hand is nowhere near as specific as it should be to support ICD-10 coding.

To figure out just how much your physicians need to improve before you transition to ICD-10, it’s critical to assess what clinical documentation gaps your organization faces, Patel says.

Anyone who reads Patel’s article and doesn’t see it as a red-hot wakeup call (deadline move-up or not) they’re crazy. It’s hard to argue that it will take a lot of time and physician training of doctors, coders and hospital staff.   If your clinicians don’t drill down to codes that have the clinical impact for them, and medical coders get much more training on documentation, anatomy and physiology and disases processes, things could get ugly, Patel notes.

About the author

Anne Zieger

Anne Zieger

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

1 Comment

  • Thanks for posting this and highlighting the problems with physician documentation. As a former coder, I can certainly attest to the time wasted, revenue held up and frustrations caused when coders don’t have complete, precise, timely documentation from physicians. The current manual workarounds to deal with this are too numerous and embarrassing to even mention. Thanks again for raising this concern. It is a big one!

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