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ICD-10 readiness: Will your coders have enough information?

  • Jeff Goldstein, MD, MS FACHE
  • 07/14/2015

User documentation, education and governance remain the top three issues threatening ICD-10 readiness. But another, equally disturbing practice is emerging. Many hospitals and practices have opted to let coding staff select ICD-10 codes based upon physician documentation, placing key decisions in the hands of the coders instead of clinicians. In a recent Healthcare Informatics article, Dr. John Elion noted that certain ICD-10 PCS (procedure coding system) codes require a great degree of detail and granularity. The physician must explicitly detail a procedure and the circumstances associated with the event so that there is no ambiguity as to the correct code. The real concern is not missing information, it is that the physician’s description is not formatted to meet the requirements of ICD-10. When this happens, then it is up to the coder, or clinical documentation improvement (CDI) specialist, to either […]

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ICD-10: Tips for heading into the home stretch

Hospitals and physician practices have been discussing ICD-10 for many years. However, even with a one-year implementation delay, many of them are only now realizing that they are still not ready for the October 1 start date. In the past month, our ICD-10 consulting practice has received more inquiries for assistance than in the past calendar quarter. We expect this pace will continue well into the coming months leading up to October. A significant number of inquiries have come from organizations that have considered ICD-10 to be an IT or HIM issue. In fact, when looking at the scope within a hospital or practice that ICD-10 encompasses, there are more than a dozen areas that should be involved, such as revenue cycle and contingency planning. Ignoring any of these areas can have a detrimental effect on ICD-10 readiness. 3 most […]

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ICD-10 strategies: Document consistently, with the right amount of detail

  • Jeff Goldstein, MD, MS FACHE
  • 05/06/2015

ICD-10 is the largest mandate in U.S. healthcare history, and it will require diligent, comprehensive actions to be fully prepared for the transition. This is the fourth post in a four-part series that explores successful strategies in key areas of ICD-10 readiness: general approach, governance, education and standardization of documentation. “The pen is mightier than the sword,” is a famous line from Edward Bulwer-Lytton’s 1839 play, The Conspiracy. Fast-forward nearly two centuries, we substitute the keyboard for the pen, and the idea is nonetheless the same; documentation is the quintessential element that translates one’s thoughts and actions into a durable record of key events in health care. Unfortunately, the lack of uniform documentation is the Achilles’ heel for ICD-10 readiness across the entire industry. Concise, thorough and comprehensive documentation is not only essential, but it is the required basis for […]