HSMN advises hospitals and clinical practices on how to overcome the problems of transitioning to ICD-10-CM/PCS after a survey of compliance officers and warnings from CMS indicate concerns about using “Repetitive Terminology” or “Smart Phrases” in their EMRs.

The enterprise systems such as Epic offer the possibility for Clinicians to choose phrases that they will typically use over and over again in their clinical documentation. For many Clinicians this is a time saver and rather than rewriting the same phrases used in their particular discipline, this shortcut has been used. Some might call it the “Cut and Paste” Clinical Documentation Syndrome but with many patients and too little time it can seem to be a very legitimate way to proceed.

HSMN has advised its clients that coding in the ICD-10-CM/PCS era requires a level of specificity and capturing of all the variables in diagnostic statements as well as the thousands of elements that are part of developing a code for the procedures.  In the ICD-10 procedure world, Coders actually build the final ICD-10-PCS based on individual character definitions. Therefore, developing “procedural Smart Phrases” would have to be very limited in order to stay within the boundaries of a single character definition.

HSMN advises that before the provider can create or use a “Smart Phrase” in their database, they first have to understand what variables and/or elements will need to be documented to ensure accurate, optimal coding. Therefore, an understanding of ICD-10 and assessing current documentation practices is still critical in transitioning to this new classification system.  In previous articles HSMN has discussed the “The Deconstruction Methodology” in which current, recent or active cases are parsed so that Clinicians can actually see all of the variables in the construct of ICD-9 and how they evolve into ICD-10.

First order is for a partnership to be developed between the “Champion” of a specific discipline (a seasoned attending) and an experienced and trained senior (ICD-10) Coder/Auditor to help shape the clinical documentation.  These Champion teams can then go on to train others in the respective disciplines, especially those who do procedures.  Without these steps, there is a great danger that Clinicians can become dependent on the “Cookie Cutter” and not the substance and logic of ICD-10.

HSMN has also advised its clients to bear in mind that CMS already is greatly concerned about the higher levels of care coded since the inception of the EMR.  The feeling in the Agency (CMS) is that the EMR is perhaps not prompting but rather assisting the Clinical staff in achieving higher levels of coding.  CMS is completely aware of the “Cookie Cutter” documentation approach and strongly cautions that documentation should be unique for each patient encounter to reflect what happened during the encounter and also to acknowledge that no two patients are alike.

HSMN offers a way to stay compliant, but be able to use tools that have been properly shaped once the Clinical and Coding staff completely understands both the substance and logic behind ICD-10-CM/PCS. If you would like to learn more about our philosophy, our approach to consulting and what we can do to help you, please give us a call at (866)-908-4226 or fill out the form on our Contact Page.