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Clinical Documentation and Coding Integrity

Preventing ICD-10 Revenue Stoppers and Compliance Risks

Health Solutions

May 13, 2016

ICD-10—the tenth revision of the International Classification of Diseases—is here. The U.S. Healthcare System has been preparing for this moment for several turbulent years. Beginning October 1, 2015 the Centers for Medicare and Medicaid Services (CMS) instructed the nation’s providers to commence submitting claims utilizing the new ICD-10 code set. The new system carries with it the potential for profound benefits, including opportunities for enhanced quality and coordination of care and improved revenue. But the shift has triggered waves of anxiety among healthcare providers who have seen claims denied and payments delayed because they did not use and bill the new codes properly.

With more than 100,000 new codes, ICD-10 gives providers, payors and researchers access to a wealth of new clinical data. The codes reflect changes in medical technology and treatment and allow for more thorough and precise descriptions of diagnoses, severity of illness and the intensity of care provided to patients. The new code sets carry the potential to improve a healthcare organization’s ability to document patient quality of care, greatly enhance coordination of care by painting a more accurate and comprehensive clinical picture, provide deeper and more meaningful justification of services provided and present opportunities for providers to receive better reimbursement that more closely reflects true severity of illness and utilization of resources.

But the new system is not without intense challenges. To realize ICD-10’s benefits, physicians need to change the way they document care to ensure each record reflects the right information related to laterality, specificity, severity of illness (SOI), risk of mortality (ROM) and additional information about accompanying diagnoses, approach for procedures, use of medical technology and devices, and other clinical and descriptive information they did not previously need to document so fully. Likewise, coders need to be fluent in the ICD-10 coding methodology in order to pick up the right codes to support accurate billing. Clinical documentation improvement (CDI) specialists and physician advisors need to understand ICD-10 documentation and coding requirements in order to draft queries and develop education to ensure that physicians are documenting in a complete, compliant, and ICD-10 centric manner. And billers, revenue integrity staff and revenue cycle personnel need to understand key requirements and financial implications to ensure financial success under ICD-10.


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