ICD-10 and EHR Fuel Clinical Documentation Improvements

Scott Mace, for HealthLeaders Media , March 18, 2014

"So SNOMED is tremendously powerful, particularly as you want to think about ways to use the structured information to provide better care. It allows you to do things like clinical decision support," he says.

"Continuous documentation improvement works with the doctor to advise them to add language to let their diagnosis tell the story," says Robert Leviton, MD, chief medical information officer and physician advisor at Bronx (N.Y.) Lebanon Hospital Center, a 972-licensed-bed healthcare system.

"CDI allows us to query the doctor about their patient's condition when they cannot document all of their concerns in the EMR because they are very busy and must see the next patient in their roster of patients," Leviton says. "We obtain more detailed diagnostic information. We are able to identify the severity of illness and the risk of mortality so that a patient's assessment, plans of care, and their principle diagnoses can be reported more accurately to impact reporting to regulatory agencies, assist research, and provide specific information to healthcare plans impacting our hospital's revenue cycle management."

CDI technology embedded in EMRs is beneficial in that it can provide guidance to achieve diagnostic specificity required by ICD-10 coding, Leviton says.

"Doctors are not coders," he says. "They know how to care for patients and determine the best diagnoses. We are structuring our ICD-10 solution to have the doctor select a root diagnosis and then also provide coding qualifications to achieve the most accurate diagnosis. If the doctor selects ankle fracture, for example, we will provide coding qualifiers. Is it the left, right, or bilateral ankle? Is there a component of delayed healing, or nonunion healing? What's the encounter—is it an initial or subsequent one? Each detail adds to the ICD-10 diagnosis meeting the required detail of the coding system," says Leviton.

As physicians are prompted to answer these questions, EMR software, in the background, picks the codes that best match the physicians' answers. CDI coding specialists can then refine or ask for even more specificity from physicians to further optimize this coding, Leviton says.

SNOMED coding facilitates sharing of problem lists, procedures, and diagnoses in ways that reduce the differing number of terms physicians use for the same things, says George Hickman, executive vice president and chief information officer of the 734-staffed-bed Albany (N.Y.) Medical Center, an academic health sciences center.

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