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 relatively 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 the analysis the initial stage of ICD-10 clinical documentation gap analysis, and a thorough understanding of organizational needs, an ICD-10 CDI (Clinical Documentation Improvement) strategy will be created.
  2. The effort requires achieving alignment between the HIM department, coders, nursing, and physicians, and is driven by the analysis in the initial phase.  This includes shielding physicians from un-necessary complexity, 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:
    • Use the ICD-9 and ICD-10 coder and case manager observations 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 to focus on trends across the board, or work with physicians that are the largest admitters
    • Prioritized 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.
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