Strategies for complete ICD-10 documentation: Communication and physician queries

Communication is a major portion of the documentation and coding conundrum. Creating avenues for information exchange with the physician community is essential to the success of clinical documentation improvement (CDI) and the capture of coded data. Physicians take a variety of courses (e.g., pathology, physiology, disease manifestations, etiology, and process) throughout their academic medical education. However, their education does not address the importance or the details of documenting medical terminology with specific information that corresponds to ICD-9 and ICD-10 codes. Physician profiles and scorecards have been linked to ICD-9-CM codes; physician awareness of this and future linkage to ICD-10 is necessary.

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