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.
CMS has finalized changes to packaged services and E/M CPT® codes for clinic visits with the much-anticipated November 27, 2013 release of the 2014 outpatient prospective payment system (OPPS) final rule.
The road to ICD-10 has been a long one, and we still have many miles ahead of us. Organizations have invested a significant amount of time and money into this venture, and even though October 1 is rapidly approaching, there’s still work to be done before and after implementation.
The U.S. healthcare system is and will continue to be dependent on clinical codes and is thus equally dependent on accurate and complete clinical documentation.
Medical Records Briefing (MRB) recently asked HIM, clinical documentation improvement (CDI), and coding professionals about their ICD-10 implementation efforts for our first quarterly benchmarking survey of the year.
