Clinical Documentation Improvement: Why it's needed before ICD-10 implementation

Carl Natale
by Carl Natale

One of the reasons why ICD-10 implementation will be a major change for hospitals and medical practices is documentation.

Clinicians will need to improve documentation so diagnoses and procedures can be coded to the highest level of specificity. There are other reasons why clinical documentation improvement (CDI) is needed. Priya Patel does a thorough examination of how and why clinical documentation deserves improvement. She focuses on the medical record:

"The medical record is the most important source of information within a healthcare organization.  It is used not only for providing patient care but also for assessing the effectiveness and quality of that care, as well as for billing and reimbursement, research and to set healthcare policies as needed."

This breaks down to two major motivations for CDI:

  • Patient care: Complete and accurate medical records are needed to ensure the patient gets the right treatment.
  • Cash flow: Medical claims are rejected and down-coded because there is not enough documentation to support a diagnosis.

Patel then refers to Caroline Piselli's five key steps to improving clinical documentation:

  1. "Assess documentation for ICD-10 readiness."
  2. "Analyze the impact on claims. "
  3. "Implement early clinician education."
  4. "Establish a concurrent documentation review program. "
  5. "Streamline clinical documentation workflow."

To make this happen, hospitals can hire CDI consultants or full-time specialists. But for the smaller healthcare providers, there may not be the money to invest in such a person. Even if they factor in the return realized when fewer medical claims are rejected or down-coded.  Lisa Eramo writes about the scope of CDI in healthcare facilities and suggests that existing staff can be trained to implement CDI.

One of the options is computer assisted coding (CAC) paired with natural language processing (NLP). Jason Pollatsek explains how the technologies can scan physicians' notes to help identify where CDI can help:

"By applying natural language processing solutions to the analysis of physician documentation, practices and health organizations can determine now how their documentation would fare under the rigors of the ICD-10 system and can apply training to close those gaps based on the identification of real data deficiencies."

CDI will be an important part of most ICD-10 implementation project. But it also can be applied now with ICD-9 coding to realize improved patient care and cash flow. This means it's worth doing no matter what is decided about the ICD-10 deadline.