The accurate and complete assignment of diagnosis codes is contingent upon having good clinical information documented in the patient’s medical record. How information is obtained and where information is obtained from drives the accuracy of the diagnosis information. In the absence of a definitive clinical finding by a provider, the patient’s sign/symptoms must be used for code assignment. Where does this information come from? Is it accurately captured 100% of the time? This is particularly problematic for specialties that rely on clinical information from other providers. Whenever I query an audience about the accuracy of orders and referring physician clinical information I have never had one individual state that this information was accurate 100% of the time. This is a problem today in an ICD-9 environment that will be amplified by the implementation of ICD-10-CM.
It is important to remember that ICD-10-CM is not only a software update or something that only the coders have to worry about. What about the scheduling and registration staff, clinicians, billing staff and edit/denials department? All of the individuals in these areas will be impacted by ICD-10.
So why should individuals outside of the coding and HIM environment care about ICD-10? Every organization needs to ensure appropriate reimbursement to justify equipment and staffing as well as accurate billing practices to remain compliant. Anyone participating in the clinical data gathering process has to ensure that complete data is present at every step in the process. Given the great increase in the number of codes, and the granularity of these codes, insufficient clinical data will result in more physician queries and problems with diagnosis code assignment. Most organizations need look no further than their process problems today to identify their areas of concern for ICD-10.
Every facility is organized differently and there is not one right or wrong way to do things. Sometimes you just have to work within the system that you have. The scheduling/ordering function will play an even more important role in ensuring detailed clinical information is provided by the referring physician to ancillary areas such as radiology and pathology. This is critical today but any problems you have today will be amplified when ICD-10 is implemented.
The next line of defense is the registration staff. I would argue that bad data should not reach clinical staff for any type of scheduled outpatient service. Inpatient and ER services are different challenges unto themselves. If clinical staff are frequently receiving incorrect or incomplete patient data then you have a process problem that must be addressed. All providers must provide detailed documentation to support the diagnosis codes that are assigned for both the professional and facility billing. Finally, for some areas the referring providers may be the outside influence but their data is what starts the whole process and must be complete and accurate to ensure that the patient is treated accurately and appropriately.
There are a lot of systems within a healthcare organization and the majority of them contain diagnosis information that may eventually get turned into codes. Think about your order entry systems, order forms, scheduling systems, registration, radiology information system (RIS) and others. Errors in data and flawed processes result in inefficiencies and inaccurate claim submission. Identifying problems in an ICD-9 environment and implementing necessary changes will help with the transition to ICD-10 by ensuring data accuracy and more efficient process flows.
Melody W. Mulaik, is the President of Coding Strategies, Inc. (CSI) located in Atlanta, GA. She is a frequent speaker and author who is nationally recognized for her ICD-10 implementation and coding and compliance expertise.