Clinical documentation improvement programs are an important piece of the preparation for ICD-10 implementation. Documentation details why a person seeks care, what care was provided and may be used as defense in malpractice claims and to support the medical necessity of care.
Each physician’s records must support both the diagnosis and the procedures performed at every visit. In order to receive reimbursement from a third-party, documentation must be clear and concise. Vague documentation may results in questions, error and claim denials.
In the current healthcare environment, CPT coding drives reimbursement and many review are focused on whether the procedure codes are supported within the documentation. With the introduction of ICD-10, there is an increased emphasis placed on diagnoses becoming an important factor in reimbursement decisions.
Chiropractic reviews frequently cite “insufficient documentation” as a basis for denial. Focusing on documentation improvement prior to the implementation of ICD-10 will help to reduce denials or assignment of
unspecified codes. Although there are times when the use of these less-specific codes is appropriate, routine use will result in decreasing reimbursements. Physicians must take the time to document the specifics to ensure accurate code selection.
A patient’s treatment plan is dictated by the diagnosed condition. Failure to properly document and assign ICD-10 codes brings increased risk in reimbursement, not only are the initial CPT codes called into question, but the patient’s entire treatment plan may be denied.
There are several challenges to a clinical documentation improvement program.
- Improving documentation without creating excessing administrative burdens and, physician frustration.
- Identifying the correct details needed, not creating a volume of detail for each visit.
- Preparing the documentation without encroaching on time spent on patient care.
Physicians have the unique challenge to try and fit the new coding and reimbursement system into their daily clinical workflow without adversely impacting patient care. Beginning well in advance of ICD-10 is advised.
There are 4 steps to a Clinical Documentation Improvement (CDI) program.
- Assess. Evaluate the current status of medical records. Does it support the ICD-9 codes used today? Will it support ICD-10 code selection? Does the record support the CPT codes billed? The outcome of the assessment phase indicates areas of potential improvement for both diagnosis and procedure coding.
- Education. Physician education, training and tools are vital to a successful CDI program. Training via classroom, webinar, video, or articles can be used to support providers.
- Implementation. In this step providers and staff work together to support the creation of EHR templates, worksheets and reference tools to make the changes identified in the assessment step.
- Maintain. A CDI program must be maintainable to provide value. The changes made as a result of the previous steps should be monitored and assessed regularly to ensure that documentation continues to reflect the requirements of the payers as well as federal and state regulations.
The focus of a CDI program should be on increasing the accuracy and completeness of documentation regardless of the impact to the bottom line. Don’t focus only on the highest dollar services, but on all procedures performed in the clinic. The most vital role of the CDI program is completely and accurately reporting both diagnosis and procedure codes.
Cornerstone offers Documentation Readiness Assessments and Chart Audits to help you in your CDI program. The Chart Audit looks at ICD and CPT coding. Does the information in the chart support the ICD-9 code and have the elements needed to support the CPT codes billed? The Documentation Readiness Assessment looks specifically at documentation supporting ICD-10 coding. Based on your documentation today, what ICD-10 code could be assigned and what details, if added, could improve that code assignment.