Successful adoption of ICD-10 isn’t just a coding and billing issue. Improving clinical documentation also can enhance a healthcare organization’s quality scores and revenues. 

 At a Glance

Hospitals can improve clinical documentation under ICD-10 by implementing three strategies:  

  • Bring clinical documentation improvement (CDI)specialists and coders together for daily or weekly communications to improve documentation quality, processes, and outcomes.
  • Encourage CDI specialists to engage in direct, one-on-one conversations with physicians or generate queries, whether paper or EHR-based, to clarify missing or unclear documentation to promote better overall clinical documentation outcomes.
  • Assess ICD-10 hot spots for documentation gaps to mitigate risk of lost revenue under ICD-10.

Setting priorities for process improvement projects in health care is like deciding which pet to rescue from a burning building. Many areas need improving—and they all require time, money, and human resources. Most of the time, regulatory mandates drive prioritization. Such is the case with ICD-10. 

The deadline for nationwide implementation of ICD-10 has been firmly set for Oct. 1, 2014. With little more than one year remaining, healthcare leaders have accepted that achieving ICD-10 readiness is a top priority, and their organizations are finally moving forward with education, preparations, and testing. 

Yet many erroneously believe the move to ICD-10 is only a coding and billing issue. Strong clinical documentation under ICD-10 also can produce profound benefits, which early adopters report can have a positive impact on patients, staff, and the organization’s financial health. Such benefits include a reduced discharged not final billed (DNFB) rate, fewer denied claims, smoother care transitions, and more accurate quality-of-care reporting.

The Growing Importance of Clinical Documentation

Initial testing of ICD-10 transactions demonstrates that implementation of the new code set elevates the importance of clinical documentation. Hospitals without a clinical documentation improvement (CDI) program in place should establish one now, and existing CDI programs should be reinforced well in advance of ICD-10’s October 2014 deadline. 

Although CDI initiatives have been around in acute care hospitals for years, recovery audits, quality reporting, and ICD-10 are driving the need for more detailed clinical documentation. 

 Recovery audits. Through December 2012, recovery audit contractors (RACs) have taken back $1.2 billion in complex denials of paid claims due to medical record issues, with 84 percent of complex denials affecting medical and surgical acute care hospitals deemed either “medically unnecessary” or as having “insufficient documentation” (RACTrac Survey, American Hospital Association, January 2013,). Quarterly, the message has been: “Medical documentation for patients needs to be complete and support all services provided in the setting billed.”

 Quality reporting. Quality outcomes and scorecard reporting demand complete and accurate clinical documentation to assign the most-specific DRG possible. When an organization receives a poor quality score after a patient dies, it is often the result of incomplete or unspecified physician documentation. Healthcare reform’s drive toward a pay-for-quality payment model makes the need for precise documentation even more critical.

 ICD-10. New terms and phrases in ICD-10 will demand changes in physician documentation patterns. Surgical services are at particular risk of lost revenue due to poor documentation as age-old definitions change in ICD-10. Cardiology, orthopedics, obstetrics, and behavioral health are other service lines at risk for documentation-based denials and payment concerns. 

Hospitals can improve clinical documentation under ICD-10 in three primary ways:

  • Bringing coding and CDI together
  • Querying physicians in person
  • Focusing on ICD-10 hot spots

Bring Coding and CDI Together

The majority of CDI specialists are nurses; however, in some organizations, health information management (HIM) coders serve in CDI roles. Both professions bring necessary skills to a CDI team. Nurses know the clinical components of a disease process, while coders understand coding guidelines and reimbursement language.

Bringing CDI specialists and coders together for daily or weekly communications is essential for organizations seeking to rapidly improve documentation quality, processes, and outcomes. As a team, these professionals can discuss cases in real time and determine which physicians should be queried for additional documentation. A combined CDI specialist and coder team effort often yields better documentation in real time and prior to patient discharge—expediting the coding and billing process and reducing the DNFB rate.

CDI specialists and coders also should receive training for ICD-10 together to tighten their relationship and foster deeper knowledge sharing between these two groups of specialists. Having these specialists learn together as a team can expedite the clinical documentation improvements required for ICD-10.

Query Physicians in Person

The physician query is a well-known process initiated by the CDI specialist or HIM coder to ask clinicians to document additional information within the patient chart. Physician queries take the form of paper-based notes placed on the patient chart, messages delivered via an electronic query system, electronic flags within an electronic health record (EHR), or verbal discussions. Sixty-three percent of queries are still paper-based (often involving what also is commonly called a CDI clarification form), while 20 percent are electronic (“2010 Physician Query Benchmarking Report,” Association of Clinical Documentation Improvement Specialists [ACDIS], January 2011). The remainder are verbal queries or a hybrid combination of formats. 

According to ACDIS, most facilities report a 71 to 80 percent physician response rate to queries. The faster physicians respond to a query, the quicker a case can be coded and billed. 

Unanswered or delayed queries prolong coding, delay billing, and lead to an increased DNFB rate. The onus is on CDI and coding staff to submit effective and easily understood queries, promptly present them to physicians, and, with the backing of medical staff leadership, obtain prompt physician response. 

Another tactic—one-on-one communication—is increasingly being used to facilitate more complete documentation. Paper or electronic queries are replaced by live, in-person conversations that plant seeds for better documentation in the future. Instead of receiving a notice with another box to be checked, physicians sit down with CDI specialists to discuss the correct documentation of a particular disease process, diagnosis, or procedure. 

With one-on-one conversations, CDI specialists and coders receive an immediate response to their questions and have the opportunity to educate physicians on why the query is important. Rapport is built between physicians and CDI specialists, with the result that documentation becomes stronger and the CDI specialist is viewed as a documentation resource instead of an administrative hindrance.

Providing high-quality care and getting paid for that care are sometimes two different issues, according to William Walker, MD, FACP, chief quality and safety officer, Sisters of Mercy Healthcare System. Walker, who spoke at the 2011 American Health Information Management Association (AHIMA) convention, told participants that when organizations insist on precise clinical documentation and coding from the start, they benefit from clean claims and accurate quality scores.

Without the appropriate documentation, medical records will have to be placed on hold in order to obtain the documentation, which will cause an increase in DNFB and timely reimbursement. Also, there could be inappropriate reimbursement because the documentation could not be obtained and therefore a code for the particular diagnosis or procedure could not be applied. Obtaining appropriate documentation can alleviate negative reimbursement while quantifying positive reimbursement. 

Direct and timely conversations between CDI specialists and physicians yield better clinical documentation and are another tool for organizations to rapidly improve revenue and quality score outcomes. 

Focus Efforts on ICD-10 Hot Spots

Early adopters of ICD-10 already have identified several “hot spots” for documentation-based issues in coding, billing, and payment under ICD-10. As mentioned earlier, areas such as surgery, cardiology, orthopedics, obstetrics, and behavioral health will all see substantive verbiage and coding changes under ICD-10—warranting extra CDI efforts. Diagnoses and procedures in three areas in particular—blood transfusions, head injuries and comas, and carotid stents—warrant more granular documentation to substantiate correct coding and billing and therefore require a more-focused CDI approach. 

 Blood transfusions. According to the American Red Cross, more than 30 million blood components are transfused each year in the United States. Every two seconds, someone in the United States needs blood, and demand is rising. Costs to transfuse a patient include not only acquisition costs, but also labor, supplies, blood administration, and transfusion-related adverse events. 

Blood transfusions are essentially organ transplants, and in ICD-10, the coding of them is far more specific. Coding for the transfusion of packed red blood cells (PRCs) in ICD-9 is relatively simple: It consists of one code. However, ICD-10 requires that coders specify not only whether the red blood cells transfused were frozen, but also what specific site (peripheral or central vein or artery) and approach was used for the transfusion. Physicians and CDI and coding staff now must consider a total of eight codes for each transfusion event.

Finally, under ICD-10, the physician also must acknowledge that the transfusion was performed. Most transfusions today are documented only within nursing notes and blood bank data.

 Head injuries and comas. According to the Centers for Disease Control and Prevention, every year, at least 1.7 million traumatic brain injuries occur, ranging in severity from mild (a brief change in consciousness) to severe (full-blown coma). The Glasgow Coma Scale scores three assessment areas: eye opening, verbal response, and motor response. In ICD-9, these scores were not coded. 

ICD-10 requires the coder to assign not only a code for the specific injury with the consciousness level, but also a code from the coma subcategory to complete the coma scale. The coma scale should be documented in the medical record and assigned a corresponding code. Coma documentation now should be assessed with ICD-10 requirements in mind, and physicians should be educated accordingly. 

Finally, some payers have already notified providers that unspecified codes will not be paid under ICD-9. This trend is expected to continue and worsen under ICD-10 when payers will either pay at the lowest-weighted DRG or deny the claim in its entirety. 

 Carotid stents. Documentation matters in carotid stenting. Although cardiologists are accustomed to fully documenting this procedure, other specialists are not. Interventional radiologists and surgeons that perform carotid stenting must be specific in documenting the type of stent (drug-eluting versus non-drug-eluting) and the specific approach used. Each of these pieces of documentation leads to the correct code assignment and payment in ICD-10. 

Shifts in DRGs pose another challenge, especially given that the list of DRG “shifts” that will occur under ICD-10 is growing. CDI programs should address DRG shift areas with documentation assessments, education, and auditing prior to the ICD-10 deadline. Shifts will change DRG assignment under ICD-10, resulting in revenue variations. 

One example is Major Depression. Under ICD-9, the principal diagnosis of Major Depression, unspecified, groups to MS-DRG 885. Under ICD-10, Major Depression groups to MS-DRG 881, which is a lower-weighted MS-DRG. Two distinct types of patients—those diagnosed with major depression and those diagnosed with unspecified depression—will be captured with the same ICD-10 code, even though these conditions are different and involve different symptoms. Additional examples of known DRG shifts are listed in the exhibit below. 



Make CDI a Priority

Clinical documentation is at the heart of a clean move to ICD-10. The data, words, phrases, and terms used to describe diseases diagnosed, procedures performed, and services rendered must be spot-on to support ICD-10’s granularity requirements. Hospitals and health systems should begin preparing for ICD-10 in 2013 by assessing their current clinical documentation for ICD-10 gaps; educating CDI specialists, coders, and physicians on the need for improved clinical documentation; and conducting documentation audits. 

If a hospital isn’t performing CDI initiatives correctly in ICD-9, the entire organization will fail under ICD-10. Conversely, if an organization’s physicians have demonstrated strong documentation skills under ICD-9, the transition to ICD-10 will be much easier for everyone involved. Now is the time to prioritize CDI to close potential revenue gaps under ICD-10 and support accurate quality reporting under this new system. 

 Kimberly Janet Carr, RHIT, CCS, is clinical documentation manager, HRS, Baltimore, Md., and a member of HFMA’s Northeastern New York Chapter.

sidebar 1 

 Eight Benefits of Strong Clinical Documentation

  • Reduced discharged not final billed (DNFB) rate
  • Fewer denied claims
  • Stronger physician communication
  • Smoother care-to-care transitions
  • Expedited denial management
  • Accurate quality-of-care reporting
  • Easily demonstrated medical necessity
  • Productive and accurate clinical coding

sidebar 2

 Qualities of an Effective CDI Program 

Key stakeholders for an effective clinical documentation improvement (CDI) program include representatives from financial services, revenue cycle, quality, health information management (HIM), and physician leadership. A physician adviser to the program is recommended. Typically, CDI programs report to the case management, HIM, or quality departments or to the organization’s CFO department. 

No particular model for developing a CDI program is more effective than another, so organizations should establish programs based on their particular needs. Placing CDI ownership with the department having the closest physician relationships is best practice, whether it be case management, HIM, or quality. 

Finally, the Association for Clinical Documentation Improvement Specialists (ACDIS) and the American Health Information Management Association (AHIMA) offer resources, conferences, and certification programs. According to AHIMA’s 2010 CDI Toolkit (“Clinical Documentation Improvement Toolkit,” ), the goals of an effective CDI program are to: 

  • Identify and clarify missing, conflicting, or nonspecific physician documentation related to diagnoses and procedures
  • Support accurate diagnostic and procedural coding, DRG assignment, severity of illness, and expected risk of mortality, leading to appropriate reimbursement
  • Promote health record completion during the patient‘s course of care
  • Improve communication between physicians and other members of the healthcare team
  • Provide education
  • Improve documentation to reflect quality and outcome scores
  • Improve coders’ clinical knowledge


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