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.
The staff at St. Francis Hospital-the Heart Center in Roslyn, NY, recognize that ICD-10 is more than a one-person job, which is why Elizabeth Heller, RHIA, HIM director, and Adelaide M. La Rosa, RN, BSN, CCDS, clinical documentation improvement (CDI) program director, are cochairing efforts.
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.
