Case Management

Mentor moment: Anticipated impact of ICD-10 on CDI programs

Case Management Weekly, November 14, 2012

Within the last few years, the development of clinical documentation improvement (CDI) programs and the CDI specialist profession have dramatically advanced as hospitals recognize the value of clinically accurate medical record documentation to their financial operations and fiscal health.

 The ultimate goal of these CDI programs is to clarify and solidify nonspecific, ambiguous, or inconsistent physician documentation through the concurrent review of medical records. CDI specialists and their coding counterparts understand that the record must speak for itself when a patient is discharged from the hospital. With approximately 68,000 ICD-10-CM diagnosis codes and 72,000 ICD-10-CS procedure codes, which enhance the specificity of reporting, requirements for more complete and accurate clinical documentation will also be necessary. This does not necessarily mean more documentation, but rather increased specificity in the medical record to help facilities report the most clinically accurate codes. 

CDI specialists don’t assign codes, but their efforts to improve physician documentation serve as the foundation for accurate code assignment. The impact of ICD-10 on the CDI profession will be monumental, spanning beyond the traditional reach and realms of most CDI programs today. October 1, 2014, is the date facilities will begin using ICD-10, so time is short to plan your CDI program’s preparation. 

Editor’s note: This article is adapted from The Clinical Documentation Improvement Specialist’s Guide to ICD-10 published by HCPro, Inc.

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