Health Systems Management Network, Inc. Creates a Program for Resolving the Conflict Between Integrated Care and Clinical Documentation in the ICD-10-CM Transition

Wellington, FL — (SBWIRE) — 06/13/2013 — In a recent article written by Cathy Idema, BSN, MPH, FAAHCC, Ms. Idema discusses the conflicts which exist between clinical decision making and the demands of the clinical documentation in the ICD-10-CM transition era beginning in 2014.<--break->   Based on research done over a period of 30 years on clinical documentation and work with hundreds of clinicians, HSMN introduces a new program based on data from its extensive work with them in every possible setting.
The program is called “The 2014 Clinical Documentation Paradigm”. There is no black box nor is there software or a magic bullet. This is a process/program bringing the medical staff to an intersection where integrated patient care meets integrated clinical documentation.
The program begins with an analysis of the current clinical documentation using patient specific criteria which are applied to every clinical discipline: what is the working diagnosis, what are the interventions; which are working and which are not? What is the status of patient problem list?
These are some of the criteria applied to the communication provided by each team member. Does a picture of the patient emerge clearly? Do we understand the management plan and each participant’s role in addressing the patient problem list?
The next step parses or deconstructs the clinical documentation in a way that allows for a judgment as to whether it will support a clean claim for the actual services rendered. Was the documentation able to be translated into current and correct coding? If not, the parsing is used as a teaching tool to link the clinical decision making to the correct supporting documentation.
“In 30 years of experience, we’ve often heard two phrases spoken by clinicians: ‘Cookbook medicine’ (related to both clinical documentation and clinical pathways) and ‘Coders never went to medical school’” said an executive at HSMN.
“In our process the physician becomes a teacher and the coder becomes the technician on clinical documentation. In our process we use live cases because it keeps everyone’s attention especially in a teaching hospital.”
The “live” case is reconstructed in ICD-10-CM/PCS language and coding and then presented by the lead clinician and lead coder. This entire process requires time with clinicians in all disciplines in order that a greater understanding is gained of what they do clinically. The coder is made a part of the team so that they can follow cases and have a better sense early on about the final diagnoses and procedure.
HSMN has worked with hundreds of physicians to successfully create a program and knowledge transfer to the hospital/practice staff. The lead people become the trainers in each clinical discipline. HSMN believes that only through knowledge transfer over a period of a few months with many cases being parsed can the clinical staff become comfortable and successful with ICD-10-CM Clinical Documentation requirements. This is the new Paradigm.