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Let me start out by explaining how difficult it is to come up with the antonym to synergy. I searched multiple thesauruses and websites and finally found the term dysergy, which is probably etymologically correct. Why the search? As I have assisted hospitals and their medical staffs in preparation for ICD-10, it strikes me that ICD-10 implementation should work in close synergy with clinical documentation improvement programs. I didn’t have any problems finding synonyms for synergy. Here are a few:

alliance, assistance, coalition, combined effort, esprit de corps, federation, harmony, help, joint effort, partnership, pulling together, symbiosis, team effort, teaming, unity, working together

Yet, as I look ahead to October 1, 2014, I have mixed perspectives on the interaction between clinical documentation improvement programs and ICD-10 implementation. Many have postulated that clinical documentation specialists will be drawn in as supplemental resources to deal with multiple challenges of ICD-10 implementation as they manifest themselves at unprepared hospitals.

What will be the impact of ICD-10 at unprepared hospitals? Could, in fact, the relationship be one best categorized as “dysergy,” which I’ll define as the opposite of all those synonyms listed above?

Consider the following scenarios:

Hospital A has had a clinical documentation improvement program for several years. The medical staff considers the CDSs to be “coders on the floor,” tying to get more money for the hospital by harassing doctors into using the terminology that the coders want for revenue cycle purposes. The physicians rarely see the CDSs, who now work in isolated cubicles sending clarifications through the EMR.

Hospital B has also had a clinical documentation improvement program for several years. Medical leadership has strongly endorsed the CDI program because of its focus on providing real-time clinical accuracy for the medical record. The CDS staff routinely rounds with physicians, providing concurrent feedback and assistance to the clinical team. Physicians have a much better relationship with coders (who they used to blame for just about everything) as well. The physicians are aware that their clinical profiles now much more accurately reflect the clinical condition of the patient and quality metrics have improved. In fact, the general consensus is that the documentation program saves them time by eliminating the need for most post-discharge queries and assists with patient handoffs and preparation for discharge summaries, enhancing the accuracy of coding.

Now superimpose the implementation of ICD-10. Assume that the hospitals provide limited specialty-specific ICD-10 education. A few months before October 1, 2014, HIM decides to transition into ICD-10 with select specialties, knowing that their computer-assisted coding (CAC) software will provide the coders with all the detail they need. Physicians continue to document poorly, as they have previously. What HIM discovers is that the CAC solution cannot logically process deficient documentation, and coders begin to scramble. This is particularly true of procedural coding under ICD-10-PCS. The physicians don’t know what detail they need to provide, CAC can’t invent missing detail, and coders begin to deluge physicians with queries. Physicians are resistant to the queries and the CDI team is called in to intervene, taking them off their regular duties, and the level of documentation drops further. These “coders on the floor” become targets for highly agitated physicians. I would suggest that the revenue cycle impact is going to be profound, and many parties will be highly dissatisfied.

Hospital B is a little better off. If the CDI team is knowledgeable about ICD-10, its members can certainly assist where opportunities exist for documentation improvement. CDS staff on rounds with physicians can also collaborate with HIM to share information with physicians and concurrently assist in obtaining specific documentation necessary under ICD-10. The fundamental difference in the dynamic between physicians and documentation specialists at Hospital A versus Hospital B is the well-established collaborative relationship. In many ways, building a documentation program with a highly clinical focus allows the CDS to function as a facilitator through the challenging times of the transition to ICD-10.

Additionally, hospital leadership should recognize the importance of providing specific front-end guidance to all physicians regarding specific ICD-10 challenges related to their specialty or subspecialty practice. This approach will preempt much of the antagonistic dialogue that will occur if physicians receive no education and are then criticized for inadequate documentation. As one group of surgeons recently stated: “We are glad to cooperate with the hospital in the transition to ICD-10. We just wish they would tell us what they want us to do, rather than just blaming us when it doesn’t work.” I concur with their sentiment.

With the delay in implementation of ICD-10 until 2014, we have the opportunity to change the perception of those CDI programs viewed as only focused on hospital revenue.

If you have one of those programs, it is time to recast your clinical documentation program around the theme of clinical collaboration with the medical staff.

About the Author

Paul Weygandt MD, JD, MPH, MBA, CPE, CCS, is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Dr. Weygandt is vice president of physician services for J.A. Thomas & Associates and is a partner in the firm.

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