A strong CDI program is a key enabler to successful implementation of ICD-10-CM/PCS. Hospitals that currently have CDI programs will need to adjust the focus of CDI efforts to address the specific documentation that is needed for ICD-10-CM/PCS code assignment. In addition, hospitals that do not currently have a CDI program should institute one.

UASI is conducting ICD-10 clinical documentation gap analyses for our clients and we have coded hundreds of hospital inpatient charts in ICD-10-CM/PCS, capturing details on the specificity of clinical documentation currently available.  As a result, we’re gaining perspective on where the priorities are for documentation improvement and helping our clients adjust the focus of their CDI programs to intervene now. You need to do the same in your hospital. All hospitals should perform a comprehensive ICD-10 documentation gap analysis, at least on inpatient cases. But meanwhile, a simple place to start is to review your query language, especially any standard queries.

Look at your most common queries and consider how to adjust the query to address any additional clinical documentation that will be needed to assign ICD-10-CM/PCS codes. Here are a couple examples on conditions that are commonly queried:

Sepsis:

• ICD-9-CM queries for distinctions between sepsis, SIRS, severe sepsis, septicemia and septic shock
• ICD-10-CM queries will need the same distinctions as for ICD-9-CM, but you will also need to know if the sepsis is due to a Foley catheter or vascular catheter

Skin Ulcers:

• ICD-9-CM queries for the type of skin ulcer (pressure, stasis, diabetic, neuropathic) as well as the site and the stage of the ulcer.
• ICD-10-CM queries will also address the type, but the types are more specific (for example non pressure ulcer chronic is a distinct category); sites are also needed, but more specifically; the stage of the ulcer is still needed and the presence or absence of gangrene becomes crucial for correct MS-DRG assignment.

Begin to introduce physicians to these additional documentation elements now and you’ll strengthen your clinical documentation over the coming months, resulting in a smoother transition to ICD-10.           

Mary H. Stanfill - Vice President of Health Information Management Services     

February 13, 2012