Deborah Grider

 program for your medical practice, make certain that you set specific goals. Keep in mind the goal is to improve documentations, coding, and reimbursement. I recommend you begin with these goals in mind when building your program

• Aim to establish a well-organized medical practice
• Produce reliable medical records that can help enhance the quality of care for the patients
• Promote the profitability of the provider
• Develop a query process to clarify coding ad documentation
• Provide guidance and direction to the providers as to documentation expectations
• Audit and monitor continuously
• Stay on top of coding and carrier guidance

There are three general processes that you should take into consideration:


• Evaluate current systems in place for clinical documentation
• Conduct a baseline medical record audit to identify areas that may require:
            • Improvement
• Corrections
• Make physician education, training, and briefing part of assessment process
• Set specific goals and expectations for the providers and the practice
• Keep types of audits separate
• Diagnostic procedures
• Therapeutic procedures
• E&M and consultations
• Focus on level 1-5 visits
• Don’t just target level 4 and 5
• Reimbursement could be missed
• Review bell curve data and practitioner utilization
• Diagnosis coding to support medical necessity and to support ICD-10


• Collaborate via a CDI provider to implement the needed changes in the best way possible wherein everyone can smoothly adjust
• Make everyone aware of the importance of a certain task
• Pre-planning is the initial step where everything needed such as the tools, work spaces, personnel, templates, etc., is prepared for successful implementation
• Carry out a customized program based on the results of the audit
• Provide the necessary education to local practitioners in preparation for the maintenance or sustaining process
• Implement the needed changes, based on the suggestions of a well-planned audit, while every move is closely monitored by a dedicated staff member
• Evaluate the effectiveness of the CDI tasks to identify area that may require further improvements or evaluations

Queries are a valuable piece of CDI implementation. A query is a question posed to the physician to obtain additional clarifying documentation in order to assign a procedure or diagnosis code. Query responses can be documented in the progress note, discharge summary, or a query form that is kept as part of the permanent record. Queries must be: clinically based; fact driven; concise and to the point; and not leading.

Queries should be done whenever there is conflicting, ambiguous, or complete information, or regarding any significant procedure, condition, or reportable event. Queries should not be done to question a provider's clinical judgment.

In addition to developing a query process, the practice must assign a staff person or CDI practitioner to monitor and manage the queries, including deciding a format (e-mail- or software-based, Intranet, etc.) and tracking the number and types of queries per month by practitioner to identify those who might need more help with their coding and documentation.

Maintaining the CDI program is critical to its success. 

The CDI program should be maintained by the local practitioners and administrators. To ensure the sustainability of the program, the provider or consultant should stay closely involved with:

• Monitoring;
• Continuing education;
• Additional audits; and
• Adjustment programs.


Monitor improvements and deficiencies. Educate practitioners who fall below accepted standards set by the practice. Make sure your compliance plan is active along with the CDI program and both are working and breathing documents.

To overcome the CDI challenges just like with any other goals, it should start with proper awareness and motivation. In this case, appropriate physician training and clinically oriented education should be provided. Hire a reliable provider of clinical documentation improvement programs who can collaborate with local practitioners effectively. By having a team of specialists who can impart CDI solutions, the exact needs of the facility will be matched to the appropriate solutions. Invest on training tools and materials that are needed for documentation. This way, physicians and nurses can document properly.

 CDIP, CPC, CPC-I, CPC-H, CPC-P, CPMA, CEMC, CCS-P, is a senior manager for revenue cycle at Blue & Co. LLC. Grider is a nationally recognized author of American Medical Association Publications, including "Principles of ICD-9-CM," "Coding with Modifiers," "Medical Record Auditor," and "Principles of ICD-10-CM and the ICD-10-CM Workbook." She is a healthcare consultant with over 32 years of coding, billing, practice management, and Health Information Management experience. 

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Here are three general processes your practice should take into consideration when building its CDI program for better documentation and coding.

Building a Clinical Documentation Improvement Program

Clinical Documentation Improvement (CDI) is missing from many ICD-10 plans for physicians. The hospitals are thinking about their CDI plan, but not about their employed physicians; and documentation begins and ends with the physician. So if the hospital's clinical documentation is not sufficient, the place to start is not just in the hospital but also the physician practice.

I recommend that every medical practice whether independent or part of a hospital group develop a CDI protocol. What does that really mean? Hospitals can purchase software to assist with data mining to determine what records to review and develop an automated query process. But what can the physician practice do for CDI? CDI will be so important with ICD-10 to ensure your practice is staying on top of the clinical documentation and accurate ICD-10 coding.

One of the interesting things I hear when I speak to physicians is, "We got paid, it must be right." They falsely assume every paid claim is accurate and are not really certain what they need to document to get paid appropriately. What about their billing and coding policies? I ran across a large hospital-owned physician practice which was not one of my clients that was billing preventive visits and problematic visits for every patient they wrote a prescription for. The practice said it forced every patient who scheduled a preventive visit to sign a document that they understood if the physician discussed anything about their medical condition including the need for renewal of prescriptions, a level 3 (99213) visit would be billed in addition to the preventive medicine visit. Is this method of coding and billing correct? I don’t believe it is. Where was administration in all this? How could the coding and billing rules be so misinterpreted and who pays the price?

When I questioned a couple of the physicians in the group they both told me administration told them to do this. A lot of coding and billing errors similar to this could be eliminated with a CDI program in place in the medical practice.

What does CDI really mean? CDI refers to the process of improving documentation to better reflect the severity of the patient encounter. Imagine if physicians were paid based on severity of illness versus relative value units (RVUs)? Do you think their reimbursement would increase or decrease? I would bet it would decrease significantly if payment was based on the current documented diagnoses. The ICD-9 set justifies medical necessity for services rendered and assists with supporting medical necessity for the E&M service level reported. ICD-10 will change or modify how practitioners document and code patient encounters. Clinical documentation is not "all about the money."

Clinical documentation services many purposes including:

• Adherence to medical practice and standards of care
• Medical necessity (diagnosis codes)
• Quality and outcomes measures
• Measures of efficiency and effectiveness
• Medicolegal purposes
• Adherence to Joint Commission standards and other requirements
• Basis and support of reimbursement for services rendered

The fact is when documentation is insufficient, incomplete, or incorrect, insurance companies, RACs, MICs, and others can take back payment with fines and penalties in some instances. By developing a solid CDI program the risks can be significantly reduced. Because documentation issues will be at the forefront with ICD-10 it is important that your ICD-10 steering committee take a good look in developing a CDI program.

ICD-9 to ICD-10 Examples
Pre-eclampsia antepartum with gestational diabetes


ICD-10 clinical documentation will need to specify 1.) trimester; 2.) pre-existing or gestational diabetes, diabetes type; and 3.) other maternal diseases complicating pregnancy (i.e., anemia, obesity, alcohol use, smoking, mental, digestive disorders)

You notice in both of these examples that with a little more detail in the documentation, accurate diagnosis coding can be achieved.

CDI will be important with ICD-10 to ensure your practice is staying on top of the clinical documentation and accurate coding. Here's what you need to know.

Clinical Documentation Improvement Programs and Your Practice

It is now only 37 months before ICD-10-CM becomes a reality. There’s much to do before October 1, 2013, but implementation can be a smooth transition if you take a systematic approach. There are many elements that need to be addressed, but preparing your practice in a step-by-step fashion can keep the transition from becoming overwhelming.

Planning and implementing ICD-10-CM must include communication and significant collaboration on information technology, finance, education, and problem solving. The work necessary to implement ICD-10-CM and the resources required will depend on the size of the practice. A large practice may need to recruit key people from many different departments and areas of the practice to assist with the transition; a small practice might enlist only one or two staff members to assist in the transition.

The transition to Version 5010 of the Electronic Data Transactions (EDI) must be made no later than January 1, 2012 - prior to ICD-10-CM implementation. Version 5010 must be implemented because Version 4010A cannot accommodate the expansion of the code sets that include ICD-10-CM and ICD-10-PCS. You will not be able to send claims or receive reimbursement without the 5010 conversion.

You’ll need the help of your software vendors to make this transition. My advice is to contact them now because level I testing (the vendor’s internal testing) also should be happening now. Make sure the software conversion occurs prior to January 1, 2012, in case there are problems with the conversion that must be fixed prior to the “drop dead” date.

Every practice needs to assign a project team or key person to organize and manage the implementation effort. If you have several people in your practice involved in the ICD-10 transition, form a team and assign projects with completion dates during each step of the process. The transition team or key person is responsible for the initial planning process.

Include at least one physician in the implementation process, as well as your management and coding staff. It’s important to have the physicians involved so they understand the importance of preparation as the transition occurs. Ask the project team to provide periodic progress reports so everyone is aware of the progress, problems, and barriers to implementation in your practice.

After leadership roles have been identified, it’s time to get to work. The first step is preparing a project summary, including an overview description of the regulation, changes to the code set, the anticipated scope of work that needs to be accomplished, and anticipated internal and external work processes. For larger practices this could mean reading the ICD-10 final rule; for smaller practices this could mean reading materials prepared by a professional society. The project summary, along with an outline of project steps, will serve as the roadmap for completing the implementation. This summary should be shared with the physicians in your practice.

A preliminary impact analysis is a good tool for assessing which areas of your practice may be affected most in the early stages of ICD-10-CM implementation. After the analysis is complete, the project team can develop a budget for ICD-10-CM implementation. Vulnerable areas may include:

This information must be shared with the providers so they understand the depth of the changes. It is important in this planning stage to identify who in the medical practice or organization has decision making authority.

Conducting a system audit for ICD-10-CM compatibility is part of the impact assessment. Start by performing a comprehensive audit of all data systems currently using ICD-9-CM, and then analyze the systems that will use ICD-10-CM. Your analysis should answer the following questions:

• How are ICD-9-CM codes currently used in information systems?

• Which vendor software applications are being used?

• How are codes entered? Are they manually entered or imported from another system or software?

• Can the system handle alphanumeric structure? It must be able to.

• Can the codes, code descriptions, and supported documentation be obtained in a machine-readable format?

• Does the code format include a decimal?

• Can the current system house both ICD-9-CM and ICD-10-CM codes simultaneously?

After you perform a comprehensive audit of the IT systems, perform an analysis of necessary changes to be implemented for the transition to ICD-10-CM. Identify which forms and reports will need to be reformatted or revised. Evaluate whether each system’s storage capacity is sufficient to support both ICD-9-CM and ICD-10-CM during the transition, or if the capacity will need to be increased. Also consider how long ICD-9-CM will be accessible, which staff will need to access ICD-9-CM, and how long the legacy data will need to be available.

Contact system vendors during this phase to determine whether they can support legacy and new coding systems, and for how long. This is an ideal time to identify costs for upgrading software and storage capacity, as well as contract issues with the vendor. Other potential vendor costs may include hardware upgrades, customization, staffing, and overtime.

Determine if upgrades are included in the current contract or if there will be additional costs to upgrade. Coordinate with the vendor to create the timeline for testing and installation of the new or upgraded software or system. Other IT system considerations might include a conversion to an EHR during this transition, if the organization hasn’t previously converted.

Because ICD-10-CM is more robust (with up to seven digits of specificity), assess whether documentation currently in your medical records will support the level of specificity necessary for ICD-10-CM.

The organization should have an experienced auditor conduct audits either internally or externally. Random samples should be evaluated and various types of medical records should be reviewed. A clinical documentation assessment tool should be used to conduct this audit to be sure current documentation adequately supports ICD-10.

When an audit has been conducted and analyzed, the practice will have a good assessment of any deficiencies, and can develop a priority list of diagnoses requiring more detail. The audit also helps identify providers who will benefit from focused training using ICD-10-CM.

Everyone in the medical practice will need some form of training. Physicians, nonphysician providers (NPPs), coders, and billing staff will need more extensive training than ancillary staff (nurses, MAs, managers, etc.).

• How much training on ICD-10-CM will be necessary?

• How many training days will be required?

• Will there be lost revenue if the practitioners need to be out of the office for training?

• How much training does each staff person need?

Some studies indicate that less than 16 hours of training is necessary on ICD-10-CM. The reality is that physicians will need approximately 16 to 20 hours of training, coders will need 40 to 60 hours of training, and other staff might need approximately six to 10 hours of training.

Because reimbursement is tied to procedural and diagnosis coding, your practice’s finances will be affected greatly by the transition. For example, after the implementation date, if an insurance carrier cannot accept ICD-10-CM codes, your practice probably will not be paid by that insurer. Make sure you know which of your payers have fully transitioned to ICD-10-CM and which have not, so you can do your billing accordingly to ensure you get paid.

Review the current reporting for procedures and services using ICD-9-CM and compare them to ICD-10-CM codes. Professional services are paid based on the procedure code, but the diagnosis code supports medical necessity - the driving factor in payment for all medical procedures and services.

Reports tied to diagnosis codes, such as the accounts receivable analysis, pending claims reports, analysis by provider type, and collection reports also will be affected. Assess which reports will be affected by the ICD-10-CM transition and what changes will need to be made.

The impact of the ICD-10-CM transition on your practice will not end on the October 1, 2013. Pended or denied claims are expensive, and generally are dealt with through a manual process. Any increase in the number of claims not processed or paid will first decrease provider cash flow, then increase both provider workload and plan workload to process the denials. To reduce the risk of reduced cash flow, providers and staff need to know and understand the changes in documentation and coverage requirements well ahead of time to adapt in time for implementation.

It is a fact that people’s productivity decreases short term when they are in training or learning a new skill. These slowdowns result in loss of productivity, including charge capture and reimbursement, and can affect the financial health of a practice. Anticipate a decrease in productivity by measuring and analyzing the impact of the transition prior to beginning the training process. Planning ahead also allows you to try a staggered training approach, where one group of providers and staff is trained at a time, helping to limit the impact on productivity.

Analyzing all areas affected by ICD-10-CM and making operational changes within your practice to accommodate the new code set will ensure a smoother transition to ICD-10-CM. Thirty-seven months may seem like a long time away, but successful implementation depends on planning ahead and allowing time for resolving issues with vendors, equipment, documentation, and training. Getting started now means less stress later in the process.

Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, CPMA, COBGC, CEMC, CDERC, CPCD, CCS-P, 

is the AAPC’s president, and the former AAPC National Advisory Board president. Grider is the author of “ICD-10-CM Implementation Guide, Make the Transition Manageable,” and she also was responsible for the AAPC’s curriculum development for ICD-10. She can be reached via 

This article originally appeared in the September 2010 issue of 

Advance preparation is your key to successfully managing the ICD-10 conversion. Here’s what your practice needs to know and do to get ready.

Author | Deborah Grider

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