There is significant value in Clinical Documentation Improvement (CDI) in and of itself, according to Sue Bowman, senior director, coding policy and compliance at the American Health Information Management Association (AHIMA) and Nelly Leon-Chisen, director of coding and classification at the American Hospital association (AHA). Their comments were delivered this week at AHIMA’s annual Clinical Documentation Improvement Summit in Washington, D.C. Both said that, paired with the greater specificity of ICD-10, CDI can promote better patient care and lead to more accurate captures of acuity, severity and risk of mortality.
Bowman and Leon-Chisen noted the important effect ICD-10-CM/PCS has on CDI, as well as other external forces such as healthcare reform, electronic healthcare record adoption and pay-for-performance standards. Quality documentation and data are foundational to national healthcare initiatives aimed at improving care and lowering costs, including meaningful use, accountable care organizations, and value-based purchasing. A good clinical documentation improvement program can ease the transition to ICD-10, they said.
EHR documentation prompts and templates can be used to facilitate complete and accurate documentation, including capture of increased specificity needed for ICD-10 codes, accordfing to the speakers. “These templates will let physicians spend more time on patient care and less time on clinical documentation,” Bowman said. “EHR templates will ease the ICD-10 transition for all involved and provide greater coding accuracy, productivity and coder and physician satisfaction.”
The pair also shared strategies for healthcare organizations looking to initiate CDI programs. They emphasized the overarching goal is not a greater volume of clinical documentation but better and more efficient documentation. Strategies include:
- Identify documentation improvement opportunities that could affect various initiatives including ICD-10, Meaningful Use, value-based purchasing, present on admission and hospital acquired condition reporting.
- Determine the best solution for addressing each documentation gap – one size doesn’t fit all.
- Prioritize - start with ‘low hanging fruit’ or issues with greatest potential to make a difference.
- Educate medical staff.
- Demonstrate to physicians the value of high-quality documentation.