For years we have heard that EHRs improve the quality of clinical documentation in the medical record. While this is absolutely true in terms of legibility, it may not be so true otherwise.
Coding productivity will decrease at least initially with the switch to ICD-10-CM/PCS. Coders will also need complete, accurate documentation to take advantage of the new code set's increased specificity. So HIM and coding managers need to know how productive their coders are and the extent of their clinical knowledge base, as well as how accurately and completely physicians are documenting.
Jean Stone, RHIT, CCS, has never met some of the coders who report directly to her. She has, however, spoken with them by phone, and in some cases, she has seen their wedding or other photographs. This is because nearly all members of her department work remotely.
When Carolyn Taggett, RHIT, director of health information services at Northern Maine Medical Center in Fort Kent, found that it sometimes took weeks for coders to receive answers to their physician queries, she decided there had to be a better way.
Facilities that feel they have a strong inpatient admission screening process but still have a high observation rate may need to look closely at their data.
Even with today's tight budgets, there are ways to brighten the faces of staff members. We asked a variety of experts for their ideas. Here's what they had to say.