Improve Clinical Documentation for ICD-10

December 4, 2013

Clinical documentation must be improved to meet the more rigorous ICD-10 specificity requirements. Prepare physicians with an ICD-10 readiness assessment.

With less than a year left before the "go-live" date for ICD-10, industry focus is turning more and more to clinical documentation improvement (CDI), as it will be even more vital to every facility.

Under ICD-10’s more rigorous specificity requirements, physician documentation will need to meet the higher standard as well. If your practice is fully prepared for ICD-10 in every other aspect, but clinical documentation has not improved, accurate coding and proper payment will not be possible.

A recent study of more than 20,000 audits of physicians’ clinical documentation revealed that only 63 percent of current documentation is sufficient for ICD-10’s specificity levels. Keep in mind, the insufficient documentation found in these audits often represented a larger percentage of at-risk revenue. For example, in one larger assessment, findings indicated seven of the most commonly used diagnosis codes accounted for 93 percent of the facility’s revenue.

Here are a few examples of where documentation changes will likely be needed:

Diabetes documentation must include:
• Type of diabetes
• Body system affected
• Complication or manifestation
• If a patient with type 2 diabetes is using insulin, a secondary code for long term insulin use is required

Neoplasms documentation must include:
•Type:
Malignant (Primary, Secondary, Ca in situ)
Benign
Uncertain
Unspecified behavior
• Location(s) (site specific)
• If malignant, any secondary sites should also be determined
• Laterality, in some cases

Asthma documentation must include:
• Severity of disease:
Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
• Acute exacerbation
• Status asthmaticus
• Other types (exercise induced, cough variant, other)

These are only a few examples of the more specific documentation requirements.

To avoid an increase in denied claims under ICD-10, perform an ICD-10 readiness assessment. Here's how:

Start by running a report in your computer system and sorting it by diagnosis code. Next, take your top 10 most commonly used diagnoses and run another report of patients that had those diagnoses appended to them. Pull 10 to 20 charts for your most commonly used diagnosis code. Review the ICD-10-CM guidelines (if there are any) for the chapter in which the diagnosis is located. Then, review the notes for diagnosis only. Look at the history and the assessment, and see how much can be coded under ICD-10-CM.

Based on the documentation, determine how many of these notes:
• Could be coded under ICD-10-CM
• Need more specific information to code
• Had to be coded to an unspecified code

Each provider in your facility should review these findings so they understand what documentation is needed to support this specific diagnosis in ICD-10. Then, move on to the next diagnosis on your top 10 list, and keep evaluating until your list is complete.

The facility should have a target percentage for the assessments and schedule future readiness evaluations, even if the goal is reached along the way.

How often these evaluations take place will depend on the number of providers at your facility, the number of different specialties, the type of specialties (some are seeing more changes in ICD-10 than others), and how providers perform. To ensure a smooth transition and a minimal impact on revenue, these assessments should become part of the regular audit process even after implementation of ICD-10.