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The expectation is that ICD-10-CM/PCS will improve the data being collected, which in turn will allow data-driven outcomes to improve the delivery and quality of healthcare.

Although clinical documentation is the foundation of the health record, sometimes there are gaps within the documentation or within the translation of the documentation into current ICD-9-CM codes. Many healthcare organizations have turned to clinical documentation improvement (CDI) programs to assist with achieving quality clinical documentation, especially in anticipation of ICD-10.

How do we define quality clinical documentation in today’s healthcare environment? Back in the beginning, clinical documentation improvement was specifically about achieving the documentation needed to support the correct DRG and reflect appropriate reimbursement. Proactive CDI programs evolved to offer support with some of the core measure data collection efforts and present on admission (POA) indicators. The documentation was then “packaged up” and sent off to the Health Information Management (HIM) department to be coded with ICD-9-CM codes. Each entity working within its own silo, with specific department goals and outcomes, was considered normal and acceptable protocol.

Jumping to 2013, CDI efforts to achieve quality clinical documentation need to not only support MS-DRG assignment, but also a plethora of quality initiatives stemming from the Meaningful Use (electronic health record incentive program), Value-Based Purchasing, the Inpatient Quality Reporting Program, the Hospital Readmissions Reduction Program, and a host of other federal quality initiatives. In addition, we cannot omit the transition to ICD-10-CM/PCS that will also require more specific documentation. From an HIM coding perspective, the expectation is accurate coding. Coding accuracy includes the correct MS-DRG assignment, accurate reporting of the present on admission (POA) indicators, reporting of the correct discharge disposition, not over-reporting or under-reporting codes that reflect complications, patient safety indicators and/or hospital-acquired conditions, with the ability to withstand excessive outside audit scrutiny, including the Recovery Audit Contractors. By the way, a note to the professional coders: Hospital administration would like you to do all of the above and still drop the bill within three days. Can we afford to continue to work in silos?

In order to achieve what one could consider data-driven outcomes in today’s demanding and complex healthcare environment, all entities within the healthcare organization need to work in collaboration.

Clinical documentation is the foundation of the health record and, simply stated, requires accurate reflection of all conditions and treatment for a patient in order to appropriately reflect the severity of illness and risk of mortality that will justify level and quality of care provided. This information must then be translated appropriately with the correct codes for reporting in ICD-9-CM. This desired outcome can only successfully take place with communication and processes adopted to “check and balance” all of the moving pieces.

For example, all or select patient safety indicators (PSI) could be flagged when coded and a process put into place to hold a record, prior to billing, for review from clinical documentation, coding, and quality to verify completeness of the documentation and appropriateness of code assignment.

To demonstrate, let’s take a look at Patient Safety Indicator (PSI) #3, Pressure Ulcer Rate, which includes cases meeting the inclusion and exclusion rules for the denominator with an ICD-9-CM code of pressure ulcer in any secondary diagnosis field and ICD-9-CM code of pressure ulcer stage III or IV (or unstageable) in any secondary diagnosis field. A POA indicator of YES is an exclusion. Any diagnosis of hemiplegia, paraplegia, or quadriplegia is also an exclusion for PSI #3. The patient developed a stage III pressure ulcer after a lengthy hospital stay, which was already assigned to the highest level MS-DRG. The pressure ulcer had POA indicator of NO, but patient had other major co-morbidities (MCC). This patient had a history of a previous CVA with hemiplegia that was documented in a nursing note but not found anywhere else in the record. The Clinical Documentation Specialist did not pose this question to the physician because there were already other major co-morbidities documented. The coder did not hold up the record for additional documentation because it wouldn’t change the MS-DRG and that bill needed to be dropped. The quality department wasn’t notified of the final coded PSI until after the bill was already released.

Without education, communication, and collaboration from all entities, PSI #3 was erroneously reported for this case and will negatively affect quality reporting for this facility. With a process in place to flag any case when a PSI code is assigned, a second review could have prevented this case from being reported inappropriately. Ideally, this collaboration should take place concurrently in order to acquire appropriate documentation from provider prior to discharge.

As the complexity of documentation, coding, and quality requirements increases, so must the clinical, coding, analytical, and communication skills of those professionals working within this field. Continuing education is essential to all CDI and coding programs. With the transition to ICD-10-CM/PCS and increased emphasis on data-driven outcomes, healthcare organizations must acknowledge this common goal and work together to achieve the most accurate outcome results, driven by quality clinical documentation.

About the Author

Lisa Roat, RHIT, CCS, CCDS, is the manager of HIM product development and compliance for J.A. Thomas & Associates, a Nuance Company. She is an AHIMA-approved ICD-10 CM/PCS Trainer.

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References: Agency for Healthcare Research and Quality. AHRQ Quality Indicator, Version 4.4, March 2012 Technical Specifications. http://www.qualityindicators.ahrq.gov/Modules/PSI_TechSpec.aspx


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