We’ve all heard by now the frightening statistics on the drop in coder productivity when Canada switched from ICD-9 to ICD-10.  According to the American Health Information Management Association (AHIMA), in April of 2002 Canadian medical coders completed 4.62 inpatient charts per hour using the Canadian version of ICD-9.  At the start of ICD-10 in July 2002, that number dropped to 2.15, and only rebounded to 3.75 in April 2003.

It’s clear that our industry has put a strong emphasis on training and preparing coders for the switch, with dual coding recommended as a critical way to foresee and plan for the ‘problem’ codes ahead of time.  But, what about instituting dual clinical documentation improvement (CDI) to identify documentation gaps and arm clinical documentation specialists (CDSs) with the information and tools needed to better support providers as they address ICD-10 documentation issues?

Implementing a dual-documentation approach for the upcoming transition is a way for CDI teams to get the most out of their clinical documentation efforts and take clarifications ‘up a notch.’  Concurrent clinical documentation, and the important role CDSs play in this strategy, will continue to have a large impact as organizations make strides to educate and deliver better documentation to support core measures, quality outcomes, reimbursements and now, ICD-10.

Hospitals can’t rely on a post-discharge query process if they want to avoid drops in coder productivity, which is why CDI directors should be actively initiating a dual CDI program now.  Outlined below is a simple walk-through that demonstrates the importance of implementing a dual-CDI program:

Practice indexing both in ICD-9 and ICD-10.  While the diagnosis-related groups (DRG), complication or comorbidities (CC), and major complications or comorbidities (MCC) may stay the same, the specificity required in ICD-10 will be much greater than is currently needed for ICD-9.  For instance, in ICD-10, when a physician documents atrial fibrillation, details on the type – such as chronic, paroxysmal, permanent or persistent – will be needed.  Additionally, the documentation must also state if the condition occurred intra or post-operatively, during a cardiac procedure, and either with or without associated-shock or acute pulmonary insufficiency.  Making sure these specifics are addressed is one of the keys to success.

Clarify both in ICD-9 and ICD-10.  When a CDS determines that clinical indicators and treatment support a clarification, he or she should index the ICD-10 code and include the ICD-10 specificity in the clarification as well.  Clarifying in ICD-10 will not only enhance skills and knowledge, but also familiarize physicians with the additional diagnosis specificity required in ICD-10.  For example, a straight-forward ICD-9 clarification for acute respiratory failure becomes acute respiratory failure with hypercapnia, or hypoxia, or both when it is documented properly for ICD-10 compliance.

Implement a dual CDI program.
  Some hospitals are using automated systems that allow CDSs to toggle between ICD-9 and ICD-10.  A dual-CDI program will enable both HIM directors and CDI clinical leadership to quickly identify the areas that need additional emphasis in training, while simultaneously providing CDSs with practice sessions necessary to build confidence for the October 2014 transition.

Although indexing for medical diagnoses under ICD-10 will not differ greatly from current practice, indexing for procedures under the new system will be very different.  Having time to practice, index, and pose physician clarifications under ICD-10 is essential to successfully preparing CDS teams for the transition.  Integrating dual-coding practices now and making sure dual-CDI strategy is a hospital priority will help safeguard your organization’s bottom-line.

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Mel Tully

About Mel Tully

Melinda (Mel) Tully is the vice president of clinical services and education for Nuance Healthcare, overseeing the development and expansion of clinical documentation programs and clinical education best practices. Mel joined Nuance in 1998 and has more than 25 years of experience in multiple healthcare arenas as a provider, clinical manager in a large academic facility, and as an expert in clinical documentation improvement (CDI). Mel attended Emory University, where she earned her Master’s degree in Nursing. She has been certified through the Association of Clinical Documentation Specialists (ACDIS) as a clinical documentation specialist, as well as by the American Health Information and Management Association (AHIMA) as a documentation improvement practitioner.