Clinical documentation improvement for ICD-10 and a clinical assessment of how it is supported by the electronic health record is of critical importance.

The ICD-10 Clinical Documentation Gap Analysis is the initial component of a comprehensive analysis of documentation requirements related to successful coding under ICD-10.

The intent is to provide a rapid insight into current ICD-9 documentation and coding practices for a selected sample of high value, high volume and high complexity areas that will be impacted in the transition to ICD-10.

  1. Based on a gap analysis of ICD-10 clinical documentation, and a thorough understanding of organizational needs, an ICD-10 CDI (Clinical Documentation Improvement) strategy will be created.
  2. Part of the approach will focus on alignment between the Health Information Management (HIM) department, coders, nursing, and physicians, and is driven by the analysis in the initial phase.  This includes both shielding physicians from unnecessary complexity, and engaging with them using our clinical team, explaining the benefits of coder-physician collaboration, and securing results in improved coding.
  3. We will blend the findings of the ICD-10 gap analysis and:
    • Prioritize chart reviews based on analytics, so we are finding the charts and related providers where the highest investment must be made to ensure risk reduction and maximized reimbursement while ensuring the best possible patient care and documentation of medical necessity.
    • Use the ICD-9 and ICD-10 analytics and reports to identify educational opportunities for physicians and areas for improvement.
    • Use the ICD-10 clinical documentation is driven by the ICD-10 roadmap workshop to help enlist the assistance of the case managers, or work with physicians that are the largest admitters

The components will help improve revenue cycle management by ensuring that clinical documentation supports Medicare Standards, such as medical necessity as prescribed in Medicare Local Coverage Determinations also known as Medicare LCDs.   Proper documentation of the patient condition is essential.  Additionally, clinical documentation quality improvement will help improve reimbursement by commercial payers by meeting their Standards for medically necessary care as provided for in their coverage determinations and medical policies.

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