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New Intranet Section Gives Healthcare Coding Tips

One of the key features of healthcare reform is the linking of clinical outcomes with quality reporting and reimbursement. The thoroughness and accuracy of documenting a patient's condition and care — such as complications present at the time of admission, co-morbidities and the rationale behind care decisions — will be more important than ever.

To assist Cedars-Sinai medical staff in more thoroughly documenting patients' medical conditions and care in a way that would translate into more thorough, appropriate coding, a section has been launched on the Intranet as a resource that provides quick, practical documentation advice.

"We want to ensure that the medical staff gets full recognition for the quality of care they provide at the bedside by providing education and resources to ensure that their documentation accurately reflects the true severity of illness and complexity of care provided," said Joe Kim, MD, associate medical director of quality improvement.

The pages, built by Cedars-Sinai's Clinical Documentation Improvement (CDI) team, have been designed primarily for physicians, physician assistants, nurse practitioners and others who need to be prepared for next October's mandatory implementation of the new ICD-10 coding system.

The Intranet section, titled Clinical Documentation Tips, is an easy-to-use resource loaded with practical advice, Kim said. The tips also take into consideration medical vernacular and how to translate it into accurate coding.

"With so much emphasis being placed on documentation in healthcare right now, we have to be more precise, so that what is documented accurately reflects the care we are providing our patients," Kim said. "If you don't document properly, it doesn't get coded. If it's not coded, it didn't happen."

Clinicians who go to Clinical Documentation Tips can see a list of medical terms and conditions, each with tips for documenting the condition and its treatment regimen. There is also a page with general guidelines regarding documentation of core measures of the federal Centers for Medicare and Medicaid Services and the Joint Commission. The content is licensed by the University of Rochester Medical Center, to which Cedars-Sinai pays a small fee.

Cedars-Sinai's Enterprise Information Services team has updated the content to include key phrases and terms exclusive to Cedars-Sinai, said Laura Hardy, Health Information Department supervisor.

The tips are also included in a free app for mobile devices. The app, called "URMC MDtips," is available for Android and Apple operating systems.

The tips are only recommendations to help improve physician documentation to clarify a patient's clinical condition and are not meant to take the place of medical judgment, Kim noted.

Precise documentation of patients' clinical information is critical, because it not only impacts patients' overall healthcare but can affect the medical center's quality data, insurance reimbursements and public-performance records. Under the new rules of the Affordable Care Act, for example, Medicare can refuse reimbursements to healthcare providers who do not meet certain care or documentation criteria.

Teresa Brown, RN, a member of the CDI team, said the target audience for the documentation tips includes any physician affiliated with Cedars-Sinai who has access to its Intranet, as well as physician assistants and nurse practitioners.

"We know physicians have a medical language they like to speak, but sometimes that language doesn't translate into the ICD-9 coding system, or what will become ICD-10 next year," Brown said. "In these situations, we (CDI team nurses) sometimes have to be interpreters to bridge the gap between physicians and the coders. Our goal is to work with our medical staff so that we're all speaking the same language."

Also affecting the work of this group is the mandate from the U.S. Department of Health and Human Services to implement the new ICD-10 coding methodology effective Oct. 1, 2014. The change is significant, resulting in an increase from about 17,000 codes in ICD-9 to just over 140,000 in ICD-10. This increase directly impacts documentation requirements.

Due to the scale of the change, Cedars-Sinai has invested in resources to host a robust ICD-10 provider training plan focused on improving the specificity of physician documentation to reflect an accurate picture of patient illness and its severity. The CDI team is instrumental in training for ICD-10 and will continue to support providers in clarifying the documentation requirements of this new language.

Additionally, the CDI team will work closely with the medical center's 55 full- and part-time coders, who have completed more than 100 hours of training on ICD-10 to ensure preparedness for the transition.

Previously in Medical Staff Pulse:
Physicians and Office Staff — Not Just Coders — Need to Prepare for ICD-10