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ICD-10 implementation success to date has been a result of collaboration and leveraging technology and education. Just as we experienced with planning for the successful implementation of ICD-10, we have learned that it takes a team of healthcare colleagues working together and sharing expertise across the continuum of patient care to sustain quality and accuracy

Focusing on clinical documentation integrity has raised the awareness of collaboration among hospital teams, especially in light of limited resources, high demand for physician-provided information on patients, and multiple balls being in the air at the same time. We must tip the silos over and embrace our willingness to learn from each other and work together.

What I mean by this is that the focus on ICD-10 has shown us the connection of clinical documentation integrity to accurate facility and physician coding, profiling, appropriate severity of illness and risk of mortality scores, improved patient safety indicator ratings, proper reimbursement, and decreased denials.

Electronic health records (EHRs) have provided us with simultaneous access, but that also blinded some healthcare professionals from identifying the tremendous opportunities to look at the information that is being collected, right in front of us.

Coding, clinical documentation improvement (CDI), utilization review (UR), case management, quality, risk management, charge capture: these are all critical areas associated with unique areas of responsibility, but they all have clinical documentation integrity in common. We all want to raise the bar of the clinical documentation integrity being achieved.

The time is now to examine skills sets, timing, and performance among each of the disciplines that require accurate clinical documentation to provide value to their organization. Continuous quality improvement in the clinical documentation value chain is critical; such a value chain is a group of activities that are performed in order to deliver a valuable product or service for the organization. The clinical documentation value chain consists of your physician documentation, CDI, and coding and compliance processes. Your goal should be to develop a future-state documentation, CDI, and coding and compliance value chain that is focused on the integrity of the clinical documentation. The ideal structure will cut across the entire continuum of care and utilize complete and electronic physician documentation and substantiated/validated ICD-10 code selection.

The preferred skills set for coders, CDI and UR specialists should include the tools that allow such staff members to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. These critical players should exhibit sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions or procedures, thus creating an opportunity to reexamine who does what and when. Follow the continuum of care of a patient and identify the key requirements with the best fit/timing.

So, what can you do to utilize both technology and a physician-focused approach to addressing the need for clinical documentation integrity?

First, look for a technology solution(s) that brings together all of the processes and sub-processes that make up the entire value chain and begin to erase the dividing lines between the value elements. This way, accurate coding, billing, quality reporting, and compliance become a natural result of the clinical documentation process. 

Plan to integrate your physician dictation and speech recognition solutions into your EHR strategy. A clinically driven approach to CDI creates complete and compliant documentation that drives more accurate reimbursement, compliance, and quality reporting on a real-time basis.

As you create the future-state design, follow the critical path of your clinical documentation integrity value chain from pre-admission though the close of the encounter and final billing. You are looking for an end-to-end value chain running from patient care to payment. This will enable you to find new opportunities and creative approaches to streamlining workflows and crafting new ways to leverage your technology investments. We must insist on integrity in the value chain’s processes and technology solutions that are connected intimately into the EHR workflow, where they will influence clinical documentation as it is created.

The ideal clinical documentation integrity value chain will cut across the entire continuum of care and will utilize complete and electronic physician documentation.

In Summary:

  • The future-state clinical documentation integrity value chain is a cross-functional approach that leverages your EHR’s investment and utilizes technology across the continuum of care.
  • Your strategy for continued success with clinical documentation that supports your  ICD-10 coding is multi-pronged and should include a) physician-generated clinical documentation; b) a clinical documentation improvement program; and c) coding compliance processes and solutions, including a defined core clinical documentation record set for coding compliance 
  • Success requires focusing on the beginning of the process and ensuring that your physicians are engaged and empowered with the tools necessary to help them capture high-quality documentation from the beginning, in their preferred workflows, and keeping the process tightly integrated with the EHRs.
  • A clinically focused CDI approach engages your physicians with evidence-based strategies, education, and technology support, giving them the tools to help ensure that documentation is clear and accurate from the moment the patient enters the hospital – thus enabling better communication between caregivers, especially at critical transitions of care, and that documentation better reflects the true severity of illness and risk of mortality of each patient.

Although there should definitely be synergy between coding, CDI, quality management, charge capture, and case management, I think each group has a defined purpose, and we must not lose sight of that. This is what makes blended coding and CDI or CDI/CM models so tricky: one person cannot be responsible for everything. But we do still have opportunities to be creative and innovative with our people, processes, and technology.


Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS

Bonnie Cassidy is the president of Cassidy & Associates LLC. She was the former president of AHIMA and received the 2015 Distinguished Member Award from the Georgia branch.

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