Improving Physician-CDI Engagement for Smooth Transition to ICD-10 Documentation

Many healthcare establishments are faced with the challenges of ICD-10 documentation and medical coding. One of the major reasons for this is the fact that the clinical documentation initiative (CDI) is typically perceived by physicians as having little net benefit for their individual practice or their patients. However, detailed clinical documentation is all the more important as ICD-10 involves a larger number of codes and proper documentation holds the key to proper reimbursement.

Efficient CDI Essential for ICD-10 Documentation

Clinical documentation is something hospitals and healthcare practices need, but many physicians aren’t yet convinced that it is helping them administer better care to their patients or making their job easier. They only think of it as a requirement for the hospital database and the coding which, however, is vital. They don’t find it a sufficient return on investment or reward for the time they spend on it. Though there is some truth in this reasoning, physician engagement with CDI is vital for the facility and for smooth transitioning to ICD-10.

Making Physicians Engage with CDI

CDI plays a crucial role in the accurate representation of healthcare services provided through complete and accurate reporting of diagnoses and procedures. The healthcare establishment can take steps to prompt physicians to embrace CDIs:

• One of the foremost steps should be getting real-time information to the physicians in the presence of the patient, when they start entering the documentation. Doctors must feel the documented data actually helps them in their treatment, and so rather than consigning the documented data to the database, it must be analyzed and processed in real time and filtered back to the physicians to use during diagnosis and treatment as part of immediate care. Of course, software is capable of providing such instant processing of data and the technical and database team of the hospital or practice should be able to develop it.
• Physicians must be provided with CDI training so that they integrate the CDI into their daily workflow. Clinicians do not have exposure to a CDI in their medical training so they need to be given greater support in terms of a CDI education program. With ICD-10 documentation to be implemented in October 2015, it is high time that individualized CDI training is provided to stimulate physician engagement.
• Speaking about ICD-10, this is another area that instills fear in physicians. But such fear is unnecessary. The code conversion has already been carried out by CMS and the GEMS (General Equivalent Mappings) conversion tool provides the subluxation diagnosis codes. All these help practices in converting their existing code list. ICD-10 medical coding also increases the need for better documentation since it requires greater granularity.

More Engagement between Physicians and Administrative Staff

To facilitate all these measures, there must an active relationship and engagement between the CDI staff and physicians. This is particularly important when considering the fact that coders are often at odds with doctors thanks to the latter’s ignorance in proper coding. Coding rules aren’t always in compliance with what the physician thinks of the particular clinical situation. That’s why a strong working relationship is essential between the medical and administrative staff, built on mutual respect. This will help the administrative staffing train physicians better in coding documentation practices.

Before all this, of course, is the process of enrollment where the administrative staff actively seeks physician input in introducing any CDI. It reduces the chance of doctors offering any resistance and their opinions being overruled.

Implementing these measures would make CDI more user-friendly and encourage physicians to view it as integral to their profession. With ICD-10 implementation looming, these steps are just what the doctor ordered, literally!

OSI is a leading healthcare BPO company based in Tulsa, Oklahoma, focused on providing reliable medical billing and coding services.