Improving Clinical Documentation
But whether or not you are one of the skeptics who believe that ICD-10 will never happen, there is an important step that you can, in fact you should, take that will benefit you today, and in your future ICD-10 operations. Improving your clinical documentation is a step that will provide important benefits immediately.
Improving clinical documentation has been shown to improve the accuracy of ICD-9 coding and potentially increase payments to providers by identifying more complex cases. It can also serve to more accurately reflect the quality measures which are being used today to adjust payments and make decisions on health plan physician panels and coverage. And, perhaps most important, improved documentation quality will provide a protective shield against health plan audits and questions as to the accuracy of claims submitted for payment.
Targeting Improvement Areas
So, with ICD-10 here, what are some of the steps you can take to improve your documentation now to both gain the above benefits and prepare for ICD-10? The first step would be to understand any documentation priorities and weaknesses you currently have. You may already know some of these from your personal experience or that of your colleagues – those times when you are taking some shortcuts. However, a much better way would be to focus on areas that might already have been pointed out to you by your health plans. Are there specific conditions where you are consistently being asked to provide additional documentation? Are there specific conditions that are consistently being denied for lack of medical necessity? Have you gotten audited by a health plan, or do you know of others who have? Those results can help guide you in your documentation improvements. These are conditions on which to focus some of your clinical documentation improvements.
To help prepare for ICD-10, we also suggest you look at some of the codes for the specific condition that you deal with the most. Note the specificity changes for those codes. Do you need to include laterality? What about the severity of the condition (e.g. mild, moderate, or severe asthma)? What are the specific sites of the body that must be identified to accurately and specifically code the condition in ICD-10?