Why Accurate Clinical Documentation Makes all the Difference

As of the date of this post, we still don’t know when we will begin using ICD-10. Regardless, it is imperative that everyone understand how they can influence and support workflow processes within your organization today.

It doesn’t matter if we’re using ICD-9 or ICD-10, detailed and complete clinical documentation is so important. We can all agree the assignment of a diagnosis or procedure code begins with the physician, non-physician provider and other care delivery staff who provide care, as well as documenting the clinical care.

The importance of detailed and complete clinical documentation practices can’t be over-emphasized.

It is essential that current clinical documentation support not only the ICD-9 coding and medical necessity requirements, but also the specificity that ICD-10 will bring. Physicians, non-physician providers and care delivery personnel are vital to maintaining coding accuracy and productivity, but there are others than are also part of the process.

Consider the impact on a hospital’s work processes, accounts receivable, and cash flow if accurate diagnosis codes aren’t obtained at the time of patient intake…what will happen?

1. The health information management (HIM) coders will need to investigate the correct codes—a process that will slow productivity.

2. The claim may be denied because of the incomplete or incorrect code.

3. Patient accounts, finance, reimbursement and/or denial management will need to investigate and take action, resulting in further delays and rework.

So, for those of you that are sitting back and waiting for CMS to confirm the ICD-10 implementation deadline, may I suggest you take time now to review and analyze your patient intake process.

Do this, by identifying specific workflow improvement opportunities to reduce unnecessary rework and denials now. Engage patient access staff in a targeted project to become a safety net, and proactively reduce / eliminate diagnosis code related rework, rejections and denials.

Ready, set, go!


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