When clinicians document diagnoses at a lower level than ICD-10 supports, the patient’s medical record may lack details that can benefit the care team and future providers – and financial claims may be submitted for unnecessarily low amounts. A clinical decision support (CDS) system designed for ICD-10 awareness can help by delivering ICD-10-specific clinical documentation improvement (CDI).
CDS systems are in a unique position to strengthen documentation at the moment it’s recorded into the electronic medical record (EMR). CDS rides on top of the EMR system, with a primary purpose of aligning clinical decision-making with evidence-based best practices. It can also align clinical documentation with ICD-10 best practices by reading EMR entries as they are being recorded and alerting clinicians of opportunities to use more specific ICD codes.
The result, greater documentation precision – which was the entire point of the transition to ICD-10 – without requiring clinicians to master and memorize the greatly expanded code set. In addition to adding specificity to the patient’s medical record, this CDI enables a provider organization’s billing function to submit cleaner, more complete claims for a higher level of reimbursement.
CDS Capabilities Required for ICD-10 CDI
For the CDS system to assist accurately with CDI, it must have a complete clinical picture of the patient for whom care is being documented. This requires the ability to read and interpret all details in the patient’s EMR – unstructured free-text notes as well as structured documentation – and to gather information from external information systems, such as those in labs and imaging departments.
The CDS system must also be capable of reading clinical documentation as it is being recorded, immediately analyzing it relative to its knowledge of the patient and ICD-10 best practices, and issuing accurate documentation suggestions to the clinician in real time. Armed with the necessary information and capabilities, the CDS system can issue a pop-up suggestion within the EMR screen when conditions indicate the need to document at a higher level of detail or reimbursable code, which the clinician can capture with one click.
SEE ALSO: Physician Preparedness for ICD-10
Examples of ICD-10 CDI From CDS Alerts
CDS improvements to clinical documentation fall into two general categories: a higher level of detail regarding the condition being diagnosed, and a more complete accounting for:
- Greater detail in documenting a condition. The far greater number of codes in ICD-10 than in ICD-9 enables greater specificity for virtually any condition being documented. Femur fractures, for example, have a host of new codes for such aspects as laterality, anatomic part of the femur, initial visit or subsequent visit and comminution (multiple breaks creating fragments). If a clinician documents laterality and an anatomic part of the femur but mentions fragmentation only in a free-text note, the CDS system will recognize comminution and suggest the corresponding code adjustment. The higher level of detail makes the episode of care eligible for a higher rate of reimbursement – due to greater level of complexity to treat the fracture – than would have been the case without the CDS-driven documentation improvement.
- More complete documentation of comorbidities. If a patient is admitted with pneumonia, a clinician could choose a code that, while billable, would be reimbursed to the hospital only at the base amount. By automatically informing the clinician of a more complete and accurate diagnosis – for example, taking into account malnutrition in the patient’s history – documentation can support billing at a much higher level of reimbursement. Similarly, if the clinician documents that a patient has gall bladder disease, and also notes abdominal tenderness and rebound, the system can suggest documenting the abdominal tenderness and rebound with the code for peritonitis, the specific term required by coding rules to signify the condition as a major comorbidity.
CDS as Productivity Enhancer
These are just a few examples of the many ways a CDS system can deliver ICD-10 CDI, and they all add up to alleviating the need for clinicians to personally master ICD-10 complexity. The days when a physician could locate a code by opening a book and flipping a page or two are gone. ICD-10 is a perfect opportunity for gains in both accuracy and productivity through point-of-care automation.
If the CDS system also generates reports that show which documentation suggestions were ignored, it can help the billing department close ICD-10 gaps that remain during the billing cycle. Such reports can also guide clinician ICD-10 education and policy/procedure improvements to help the organization adjust more completely to ICD-10.
Broadening the Value of CDS
CDS systems elevate the EMR from its role of merely recording and data repository mechanism to serve as a real-time clinical advisory system that can streamline processes, improve patient safety, save time and reduce cost. ICD-10 CDI is yet one more way in which CDS systems provide a complete clinical view of the patient and intelligent analysis of best practices and can deliver clinical and operational benefits.
Dr. Allan Strongwater is senior vice president, medical informatics, at medCPU.