With the additional year's delay, practices are justifiably concerned about investing significant organizational resources in a mandate that has now been postponed several times. One approach that practices can take is to identify actions that require minimal financial outlay, yet could benefit the organization's ICD-10 efforts. The additional 12 months provides an opportunity to engage in clinical documentation improvement, or CDI, a key action item in a successful transition to ICD-10.
CDI can provide a number of benefits for practices beyond simply getting ready for ICD-10. More complete documentation of the clinical encounter can enhance billing accuracy, guard against payment audits, augment a patient's medical record, and improve transitions of care for patients by giving downstream providers a more complete record.
Accurate documentation of the patient encounter is critical to outpatient billing. Coders can only code from the information provided in the medical record. Should the record not contain the necessary elements, coders may not be able to identify the most appropriate code. ICD-10 is far more granular than the current code set and includes elements that may not be captured now by clinicians, such as laterality, encounter type (initial, subsequent, sequel, routine healing, delayed healing), anatomic details, severity and disease relationships.
If the patient encounter documentation is not complete, the coding staff may need to “chase” the clinician for the appropriate information. This, in turn, can delay claim submission. In situations where there is a significant time lapse between the patient encounter and the coding of the claim, it might be next to impossible for the clinician to accurately recall the relevant details required to assign a more granular ICD-10 code.
Medical practices' CDI efforts can include a number of tests that can be an effective barometer of how the organization will fare after the compliance date. These tests can include: