ICD-10 is much more than just a change in the way coders operate within the confines of their office. It’s a documentation issue that affects nearly every aspect of the clinical chart, says Mel Tully, MSN, CCDS, CDIP and Vice President of Clinical Services and Education at Nuance. While computer assisted coding (CAC) can help coders make better choices before submitting claims, it relies entirely on strong, detailed, appropriate documentation provided by the physician. Without better notes and a comprehensive documentation improvement program, CAC is nothing more than a fancy way of coming up empty.
How do computer assisted coding and clinical documentation work together?
Obviously, the CAC program will code what it’s presented with, so you want people to have good, accurate documentation to feed into it. We’ve been very steady with our recommendations to clients that the first priority is to make sure you have a really robust clinical documentation improvement (CDI) program. Regardless of whether you’re using CAC or not, you still need to have that very accurate, relevant clinical documentation integrity in the chart so you get the most benefit from your CAC.
When I envision the very best combination of CAC and documentation in the medical record, the dream team would be that you have your computer assisted physician documentation, you have your CAC and you have a team of documentation specialists all working together. The CAC is driven by natural language processing, and it has the ability to identify the codes and be very accurate when it presents codes to the coders.
Oftentimes, certain things may flag the necessity for a further dive into the clinical documentation. So if the CAC has said, “I’ve found documentation for pneumonia,” and I wanted to make sure the documentation is accurate enough, I’d go look at that chart and see if there were clinical indicators that suggested a higher severity or more specific type of pneumonia, and use that to guide the physician towards more complete documentation of that patient’s case.
What do physicians need to do in order to get their documentation to an acceptable level for ICD-10?
Educating physicians on clinical documentation has always been a challenge, and moving into ICD-10 is going to be an even bigger challenge. Physicians really just need to depend on their CDI team. I always use the analogy that when you have your taxes done, there’s no way you’re ever going to remember those thousands and thousands of tax codes, right? You depend on your CPA or your tax advisor to do that. So when you talk to physicians about improving their documentation, you can give them tip sheets and you can give them information, but the best thing you can do is have the CDI team in place and provide technology such as computer assisted physician documentation.
I’ve been doing CDI for 15 years and physicians still don’t provide all the details needed to ensure appropriate, thorough documentation. Unless they’re being prompted and given a tool or person to help guide them, they will always document pneumonia as pneumonia. There are many, many other ways to document it and even today, physicians still need guidance on how best to capture the specific details needed to accurately reflect the severity of the care provided.
When we talk about physician education, I’m a big proponent of physician-to-physician education. That’s one of the ways that physicians respond the best. Moving into ICD-10, it’s very important to provide education that’s specific to their specialty. They don’t want to know all about documentation for oncology if they’re a cardiologist. They want to know what they need for their cardiology practice so physician-to-physician focused education is best.
How are providers integrating CAC into their ICD-10 implementation plans?
I think they’re very carefully and thoughtfully considering the technology to support them because of the anticipated drop in productivity. It is known that coder productivity will drop as much as 50%, some people say. But then you need to take a step back and say, “Well yes, CAC is going to help with productivity, but it’s not going to provide the specificity of the codes or the documentation that’s needed.” That’s why you circle back and need to put your CDI process in place first and foremost.
I think hospitals are looking for ways to really hang on to that revenue and also be able to drop their claims with the most accurate codes possible. There was a huge flurry in the industry with everyone thinking that CAC was going to be the perfect solution. It’s a great tool, but you’ve got to seed it with the correct information. Some hospitals are still scrambling to launch their ICD-10 readiness education. I still hear instances where they haven’t done anything. We started almost two years ago with a slow drip of ICD-10 education because you don’t want to hit people with a fire hose approach.
What is your advice for providers looking to take advantage of CAC for their ICD-10 transitions?
CAC isn’t a complicated tool to use. I would say that if you’re considering CAC, consider it within the picture of what your CDI program looks like. If you put a CAC in, it’ll improve productivity for coding, but right now your priority should be to improving your clinical documentation first and absolutely start with ICD-10 education. People think that ICD-10 is a coding issue. That notion isn’t true. ICD-10 is a clinical documentation issue.
I just can’t stress enough that documentation integrity is the most important thing. You don’t develop a documentation improvement program overnight. Right now, providers need to make sure they have that and the team to support the program in place in order to make the transition to ICD-10 successfully.
