ICD-10 & CDI: Three tips to help physicians understand the need for improved documentation

Carl Natale
by Carl Natale

It is often said that healthcare providers need to improve their documentation in order to code properly for ICD-10 compliance.

In a recent conversation, ICD-10 trainer and consultant Kristi Stanton told me that it's going to be a significant issue for ICD-10-PCS coding. Thus it's a huge challenge for hospitals. The impact won't be as big for physicians in medical practices.

Nonetheless, clinical documentation improvement (CDI) is an effort that can help providers of all sizes and forms. But that won't happen if you don't get physicians to become part of the process. If they resist any documentation changes, it won't improve.

How do you get buy in from physicians?

ICD-10 Trainer has a couple tips on educating physicians to make the ICD-10 (&CDI) transition easier.

First, "Don’t dwell on details." Or scare them by talking about complexity and the increase in number of codes.  They don't need to know every single ICD-10 code. Keep them focused on treating patients and documenting the care not memorizing codes.

Second, "Discuss the financial implications." No, ICD-10 isn't going to bring in more money. But not properly coding claims could bring in less money. Physicians need to understand the financial implications of not giving the medical coders enough information. While it is an important point, concentrating on something this negative might not motivate physicians.

Third, explain that "ICD-10-CM will allow greater specificity in reporting illnesses." Physicians understand diagnoses need to be specific. In HealthLeaders Media, Lyman Sornberger, executive director of revenue cycle management for Cleveland Clinic Health System, explains that ICD-10 will require more granular documentation. Sormberger believes that will help physicians make more accurate diagnoses.

These make for a bit of a carrot and stick approach. Actually the stick is sandwiched between a couple carrots. Emphasizing the positive will create better cooperation and enthusiasm.