Health Information Management

Clinical documentation affects specificity for ICD-10-CM

HIM-HIPAA Insider, November 23, 2015

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With the transition to ICD-10, some documentation issues have required the capture of new information while others involve updated, modified, and otherwise expanded documentation needs. As we gain experience with ICD-10 and more questions are answered, physicians, coding professionals, and other clinical staff must continue training in clinical documentation improvement (CDI) and ICD-10. Now comes the hard work: ensuring consistency and reliability of ICD-10 coded accounts and the analytics that will be the outcome of ICD-10 data.

CDI programs play a vital role in ensuring the documentation in the record reflects the true and accurate story of a patient. CDI programs with compliance oversight keep everyone accountable with proper controls in place, ongoing education, active monitoring of program outcomes, and adherence to compliance in concurrent CDI and retrospective coder queries. If you did not get it right in ICD-9, don't expect to get it right immediately with ICD-10.

This article was originally published in HIM Briefing (formerly Medical Records Briefing).

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