Clinical Documentation Improvement Consulting Practices & Coding for ICD-10-CM Transition

Many of Health Systems Management Network’s (HSMN) clients have asked what systems they should buy to transition to the ICD-10-CM /PCS coding in 2014.  HSMN’s answer and one which we have given over a period of 30 years is “It’s the Clinical Documentation Mr. CFO”.   Every hospital’s clinical staff, and particularly individual clinical disciplines, have their own cultures, traditions and clinical training which often are at odds with clinical documentation requirements.  The clinical mind, the one bringing together all of the clinical data that makes clinical decisions is the number one computer system that matters.

Clinical Documentation Articles

We have advised our client hospitals and their medical staffs to audit their own clinical documentation practices because the best set of specifications for whatever systems are going to be introduced to the hospital are the ones determined by Clinical PracticeHow does the CFO or CEO get an entire staff to agree on a system?  Our experience has been to collect the clinical practice documentation from every clinical department and do an audit of both the clinical documentation and the final claim in order to determine how close the supporting documentation matched the final claim discharge diagnosis and the basis for payment.   The first part of this exercise tells the organization how well they are doing or not doing under the current ICD-9-CM with specificity and accuracy through Parsing and Documentation Deconstruction.  The second phase is to Reconstruct active cases into ICD-10-CM.

These exercises engage the medical staff in looking at how they practice, how they document and how well they will do under ICD-10-CM.  In some hospitals a performance metric is assigned by the clinical department to see how many of a clinicians encounters are denied or rejected on both the hospital and professional fee side.

Hospitals tell us at HSMN that they have already invested a great deal of money in coder training and systems and are reluctant to do anything that will confuse the medical staff.  HSMN has been very successful in working with the medical staff who are the key to success in the new coding environment. It must be mentioned that the exercises described above involve partnering with the coding staff who have much to learn about the content of clinical practice.  HSMN is well known in the industry for pioneering “Role Modeling” for these exercises which are then transferred to the hospital and its staff.   There is no black box that can fix poor clinical documentation practices.  Improvements have to be internalized and champions on the medical staff or practice leaders must take ownership of this process on a continuing basis.

Please call us so that we can share with you ways in which we have helped many client hospitals and practices improve clinical documentation and coding.  Contact our offices by calling  866-908-4226  or email for a consultation on how HSMN can be of service to your organization. This initial teleconference consultation is without cost.