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We are always in search of the fastest and least painful ways to solve our problems, and selecting a computer-assisted coding (CAC) solution is no exception. Some consider it a silver bullet or magic pill. Still, there is never any easy, one-size-fits-all answer. Nowhere is that truer than when it comes to the promise of the benefits of technology in the healthcare industry. Technology is supposed to represent a painless way for us to save time and money, and to solve complex problems.

Technology also is at the heart of many organizations’ efforts to adhere to a host of regulatory, financial and quality requirements. One of the most pressing initiatives currently facing hospitals and healthcare systems  is the transition to ICD-10-CM and ICD-10-PCS. In anticipation of the Oct. 1, 2014 implementation deadline, hospitals and health systems are in the midst of juggling numerous complex project management initiatives to prepare for this significant change.

Once again, technology will and must play a pivotal role in the transition to a new coding language. Unfortunately, however, some organizations may be looking for a quick fix or an easy answer – and this simply does not exist.

CAC increasingly is being seen as a fast and painless way to combat expected dips in coder productivity and to improve coding accuracy. Unfortunately, if CAC were to be implemented without important changes to processes unfolding throughout the entire patient encounter, especially on the front end, a seemingly quick fix only would compound existing problems. In other words, CAC should not be utilized as a work-around, but as one of several technology and process improvement initiatives that can turn ICD-10 preparation from a one-off project into a clinical integration and transformation program across all service lines and clinical functions.

Readying for the Transition: The Missing Link

While hospitals and healthcare systems  are at various stages in the transition to ICD-10, most have undertaken a first step with the initiation of a “gap analysis.” A thorough ICD-10 assessment gap analysis includes the following steps, at a minimum:

  • Identify an ICD-10 executive champion;
  • Convene an ICD-10 interdisciplinary team and identify a team leader;
  • Ensure that all key stakeholders have had ICD-10 awareness briefings;
  • Develop a communication plan;
  • Conduct a systems inventory and a gap analysis to identify systems (and corresponding vendors) that will be affected;
  • Conduct staff awareness sessions;
  • Assess and plan for staff training needs;
  • Create a multi-year budget;
  • Map how ICD-10 fits into other health IT projects; and
  • Evaluate health plan contract implications.

Specific to technology decisions, an initial focus for ICD-10 readiness also involves the assessment of impacted IT systems and the evolving requirements of those systems, plus planning and cost analysis of necessary updates. Along with those assessments comes the difficult challenge of readying interfaces between new and existing IT systems.

While technology challenges are daunting, a greater systemic breakdown in workflow and process communications often represents one of the most frustrating aspects of ICD-10 preparatory efforts. One single technology solution cannot bridge the divide that often exists between various constituencies and functions within an entire hospital or health system. Physicians, coders, documentation specialists, clinical staff and ancillary staff all will be impacted by ICD-10, to varying degrees. But it is the interface between these disparate groups that may determine the success of ICD-10 implementation.

What Comes First?

What should come first during ICD-10 preparations: CAC or improved physician documentation? That one is easy: improved documentation.

There’s no argument that CAC can play a vital role in the ICD-10 transition if organizations are ready with electronic documentation. CAC provides a methodology to assist coding staffs in gathering critical coding information from medical record documents. Many in the industry have suggested that such technology will enable coders to identify specific diagnosis and procedural codes, with little change in physician behavior. We already know that current physician documentation is often insufficient for coders to operate in a timely and accurate manner under ICD-9, leading to patterns of decreased revenue, risk of fraud and the potential for substantial recoveries due to coding errors. This weak link only will be compounded by the transition to ICD-10, especially if hospitals try to justify CAC tools to overcome anticipated lack of physician engagement.



Consider a simple example. In ICD-10-PCS (the procedural coding system), every procedure must have a discrete root operation. Two of those operations are similar, as defined below:

  • Resection: Cutting out or off, without replacement, all of a body part.
  • Excision: Cutting out or off, without replacement, some of a body part.

Physicians often use such terms interchangeably. If a physician states that a procedure is a resection when in fact it is an excision, the CAC will pass on that inaccurate documentation in the form of an inaccurate code. It would be impossible for the CAC system to arrive at the correct procedural code unless these terms are utilized correctly. Even if such errors were identified subsequently by coding staff, such a system seems designed to perpetuate inefficiency.

The Domino Effect

The domino effect is a chain reaction that occurs when a small change causes a similar change, which subsequently can cause more changes. This happens all around us, every day. If you want positive outcomes to result from this effect, make sure the first change sets off the right chain reaction. That’s why when we look at the ICD-10 workflow, we start at the beginning. Who is the primary generator and user of clinical information? That would be the physician.

A predominant finding of many surveys is that most facilities are particularly concerned about physician education and preparation for ICD-10. The current focus is on very high-level education: assisting physicians in beginning to prepare their office staffs for the transition, and to build a collaborative effort.

The healthcare  industry as a whole appears to have developed a health information management (HIM) -centric approach to ICD-10 challenges, putting the hard work squarely on the shoulders of coders and using CAC tools to make up for what is assumed to be a lack of physician interest and engagement. We believe that the only way to implement ICD-10 at an organization successfully is by using a collaborative, cross-functional approach.

There are some risks with taking a HIM-centric approach, as opposed to a collaborative approach. Some of the key supporting reasons for promoting an integrated, multi-disciplinary approach to ICD-10 implementation include:

  • Coders need plenty of time to prepare. Not only must they learn a new coding “language,” but they also must undergo extensive foundational re-education regarding anatomy, physiology, patho-physiology, current medical terminology, etc.
  • Major HIM organizations, such as the American Health Information Management Association (AHIMA), have indicated that the responsibility to provide accurate coding will fall on professional coders. Still, these organizations also promote the multi-disciplinary approach to mitigate any deficiencies in physician documentation. CAC is only one component of a fully integrated, strategic information technology plan, and it should not be championed as the principal solution to assist in the transition to ICD-10.

Using ICD-10 as the “carrot” to motivate physicians to become better documenters might be a losing strategy. Focusing on why improved documentation quality matters to them and their patients, however, rarely fails to win over converts (better patient outcomes, observed to expected mortality rates, improved physician profiling and professional opportunities, etc.). The key is to motivate physicians by transferring knowledge in a peer-to-peer format, and in a way that doesn’t disrupt their workflow. Key ICD-10 physician education steps are:

  • Phase 1: General overview.
  • Phase 2: Specialty- and/or subspecialty-specific ICD-10 content.
  • Phase 3: Physician-to-physician education. In this phase, physician education should convey two important themes: One, if you don’t document it, it didn’t happen. And two, accurate documentation has an important impact on the continuum of care for patients, as well as the physician’s own profile and billing.
  • Phase 4: ICD-10 education becoming part of a hospital/provider learning management system.
  • Phase 5: Specific training for office staff and outpatient-only physicians.

This type of education process enhances the ability of physicians to provide necessary clinical information for rapid, effective, accurate documentation and coding of diagnoses and procedures.

Ensuring Integrity of the Clinical Record

Modern patient safety theorists recognize that errors inevitably occur in virtually every human process, particularly those involving communication. Retrospective correction of clinical documentation errors not only puts hospitals and physicians at risk, but more importantly, it puts patients at risk. For years, hospitals and health systems have been moving toward establishing clinical documentation improvement (CDI) and clarification processes to enhance the integrity of the clinical record, to reduce clinical management errors, and to provide more accurate clinical information for the discharge-related final coding process performed by professional coding staffs.



The notion that ICD-10 is merely a coding issue has fallen to the wayside as facilities, clinicians and HIM professionals continue to acknowledge an absolute need for clinical documentation integrity. As ICD-10 implementation approaches, it is becoming increasingly clear that verifying the integrity of clinical documentation jump-starts the process and provides the foundation for accurate clinical data, quality data reporting and appropriate reimbursement. Clinical documentation improvement efforts focus on the physician at the point of care.

Utilizing the efforts of specific clinicians known as clinical documentation specialists (CDSs), CDI programs clarify diagnoses based on clinical indicators in the medical record. Such a process focuses on concurrent clinical interaction with a physician and a thorough review of clinical parameters in these records. It is at this juncture, where the electronic health record has so many clinical components, that a physician alone would find it virtually impossible to review all relevant nursing, physical therapy, dietary, respiratory therapy and consultant documentation, let alone radiology and pathology interpretations.

A CDI program supported by clinical documentation specialists  provides physicians with a more complete view of all the various elements of the medical record, and it provides additional resources to the physician to facilitate the creation of accurate, compliant documentation while it still matters (that is, while the physician is still treating the patient).

In this way, physicians receive their own clinical support network, making it easier to document more accurately. Another technology consideration is the integration of physician speech recognition software to save further time by capturing the physician narrative via dictation, thus improving the accuracy and completeness of documentation.

Documentation clarifications for physicians, based on clinical parameters found in the medical record, also are part of any good clinical documentation improvement program. While it may appear redundant to present these clinical parameters to the physician at the time of clarification, the process of doing so clearly demonstrates the integrity of the process to external reviewers as well as internal constituents. What may seem obvious to the documenting physician thereby can be made crystal clear to others involved in caring for the patient, including colleagues who share patient care responsibilities on other shifts and on other days of the patient’s stay.

Achieving Efficiencies in Clinical Documentation Improvement

As the evolving electronic health record captures increasing volumes of text-based and discrete data, the process of chart review by the CDS has become more laborious, time-consuming and inefficient. Use of innovative new technology such as clinical language understanding (CLU) and computer-assisted physician documentation (CAPD) solutions facilitates automated chart review. Based on analytic profiles, a physician-wielded CDI tool can generate requests for documentation clarification automatically, with some of those requests to be presented directly to physicians. The CDS may review clarifications sent to physicians in order to avoid redundancy and to complement the CAPD workflow.

Documentation clarifications can arise in a variety of clinical settings, representing, for example, conflicting diagnoses between the attending physician and consultants, incomplete documentation, uncodeable terminology, and/or documentation omissions. These aforementioned solutions are undoubtedly complementary to existing CDI programs, enhancing both the efficiency and the effectiveness of the CDS.

Enter Stage Left: CAC

Once the physician becomes part of the clinical documentation improvement process through education, awareness and collaboration with clinical documentation specialists – coupled with a CAPD that supports a dynamic concurrent clinical documentation process – the stage is set for appropriate application of CAC technologies.

In this setting, a CAC tool can harness the power of concurrent CAPD and CDI processes by automatically reading and translating electronic clinical documentation provided by healthcare practitioners into the appropriate codes. At this point, the data coming into the CAC application already has undergone rigorous scrutiny to ensure that the documentation reflects true severity of illness and the proper diagnoses and procedures. In other words, the CAC output improves in direct proportion to solid, accurate clinical documentation input. The CAC tool now will be more capable of generating suggested ICD-9-CM, ICD-10-CM and ICD-10-PCS medical codes for review and validation, which accelerates code submission to patient billing systems and delivers better results.

In this way, CAC now can deliver on its promise to help health systems:

  • Mitigate the risk of productivity loss by improving coder throughput and accuracy;
  • Accelerate claim submissions and billing processes;
  • Improve cash flow and decrease accounts receivable (AR) days;
  • Uncover issues in clinical documentation;
  • Enable cross-department communication to better understand patient outcomes while sharing best practices; and
  • Improve coder workflow while increasing regulatory compliance.

The CAC solution is not where the process ends, however. It’s always good to have coding and compliance tools to help HIM manage the coding workflow and identify potential areas of noncompliance, also helping reduce claim denials and exposure to fines and penalties for inaccurate coding.

Confront the Real Problem: True Collaboration

The healthcare industry is infamous for maintaining silos of work within a complex environment. These silos negatively impact quality of care, stakeholder satisfaction and reliability of data, resulting in risks of poor clinical care, poor quality metrics, underpayment, allegations of fraud and substantial error recovery.

While the ICD-10 transition comes with a compliance deadline, organizations should make Oct. 1, 2014 a target date for ensuring that clinical documentation at the point of care sets off the appropriate domino effects. Remember, quality documentation is necessary for quality care.

By enabling physicians to describe their clinical impressions (diagnoses) more accurately, supported by a dynamic clinical documentation infrastructure, hospitals and health systems can achieve improvements in quality and quality metrics. Then, and only then, can CAC technology make a good situation even better.

Breaking down institutional silos means solving the coding challenge across the continuum of care, thereby enhancing the collaborative relationship between physicians, documentation specialists, other clinical staff and HIM professionals.

About the Author

Mel Tully MSN, CCDS, CDIP is the Senior Vice President at J. A. Thomas and Associates, a Nuance Company. Mel has extensive experience as a provider in multiple healthcare arenas, a clinical manager in a large academic facility, and as an expert in clinical documentation improvement (CDI). She has played an important role in the development and expansion of advanced CDI for the past 13 years. Mel is a nationally certified Clinical Documentation Specialist through the Association of Clinical Documentation Specialists (ACDIS) and nationally certified by the American Health Information and Management Association (AHIMA) as a Documentation Improvement Practitioner.   

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