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.
To accurately interpret and code physician documentation, the HIM department must employ a quality clinical documentation improvement (CDI) program and an effective query process. Building upon these programs is integral to the success of the HIM department, especially where ICD-10 is concerned, said Deborah Lantz, RHIA, during HCPro's audio conference "Auditing Documentation for ICD-10: Steps to Take Now to Prepare Physicians and Staff." Lantz is the director of HIM at St. Charles Hospital in Port Jefferson, N.Y., and an AHIMA-certified ICD-10 trainer.
It's no secret that ICD-10-CM allows for more specific coding of many diseases and conditions. However, your physician's current clinical documentation may not have enough detail to allow coders to take advantage of this increased specificity.
Time is of the essence. With less than a year until the ICD-10 deadline, there are many items that organizations need to cross off their checklists as we get ready to go live. Unfortunately, organizations aren't all in the same place when it comes to ICD-10 readiness.
Using a credentialed coder with computer-assisted coding (CAC) can increase coder productivity and lead to more accurate inpatient coding than using CAC alone, according to a study conducted by the AHIMA Foundation in collaboration with Cleveland Clinic and 3M Health Information Systems.
Coding for sepsis is often easier said than done. Obstacles range from difficulty distinguishing between documentation for sepsis and related conditions to trouble with physician queries.
CMS released a number of proposed changes to the outpatient prospective payment system (OPPS) July 8. The 2014 OPPS proposed rule (available at http://tinyurl.com/oyu33jx) is shorter than normal at 718 pages, but the proposed changes are significant and probably the most sweeping since the inception of OPPS, says Jugna Shah, MPH, president and founder of Nimitt Consulting in Washington, D.C.
Medical Records Briefing catches up on computer-assisted coding (CAC) with Deloris Farthing, RHIA, CHDA, director of HIM for Hays (Kan.) Medical Center.
If the October 1, 2014, implementation date for ICD-10-CM and ICD-10-PCS is not altered by the time this is published, there will be 18 months left until the transition.
