ICD-10 is here, and you are ready. Yes.  But, what about your physicians?

Systems are tested, billing processes are updated, coders have done their homework, contingency plans are in place…I won’t bore by repeating the ICD-10 mantra that has been pushed out to you for years. But don’t stop reading quite yet, please.

This post is about clinical documentation… which could very well become some hospitals’ undoing. We know that many physicians are not ready for ICD-10. Yet they are the linchpin of your hospital’s ICD-10 transition going forward. Despite how thorough preparations have been, if your physicians do not document with sufficient detail, they will stall your transition and immediately begin threatening your cash flow. We have some last-minute thoughts and suggestions.

In an August study conducted by Navicure and Porter Research, 31% of respondents cited “increased clinical documentation updates/coding requirements” as their biggest challenge. From an anecdotal perspective, many consulting colleagues and I continue to talk almost daily with smaller hospitals that have provided little or no training to their physicians. Or, if the hospitals have offered training, many physicians have participated very little. As of today, these hospitals are at financial risk.

Why are these hospitals and physicians in such a vulnerable position?

• Undoubtedly, the biggest issue for physicians is that ICD-10 was not developed to improve day-to-day clinical care for individual patients. Immediate medical care does not rely on documenting in greater specificity. So, ICD-10 doesn’t help a physician focus on his or her daily care-giving job that required many years of training and experience — and which was intended to provide value and professional satisfaction.  The physician experiences no benefit from ICD-10 right now.
• For the physician, there will be ICD-10 benefits, but they will be long term, based on the aggregation of more precise health-related data that our new ICD-10 world will make possible. Reimbursement policies are expected to be more fair. More complete and accurate data will positively impact outcomes, efficacy, and costs of new medical technologies. This greatly improved data will help to better identify patients who need disease management and to tailor disease management programs for them. It will also strongly impact healthcare research and population health management, including facilitating international quality of care comparisons. Best practices, including health disaster recovery (think Ebola, SARS, etc) will be greatly improved, and shared globally. We may be in for a very exciting time in healthcare advances!
• On the other hand, your busy physicians will be experiencing a downside, especially in upcoming months: “lost” time. Estimates indicate that documenting at the detail level needed for ICD-10 will take 20% more time for physicians. ICD-10 coding represents an explosion of data requirements that physicians must accommodate when documenting. To make things worse, physician productivity is predicted to take a 10%+ hit due to increases in queries from coders — a lesson learned from other countries that have taken the leap to ICD-10. Queries are already unpopular with physicians; ICD-10 will move them into the massive headache realm…at least until physicians become comfortable with this SOP change.
• While it may seem quirky to non-clinicians, it is a time-worn fact that many physicians aren’t willing to be trained by someone who is not one of theirs. If the trainer isn’t a clinician, he or she is seen to have insufficient credibility to be taken seriously.  Hospitals that have been wise enough to develop physician champions have had a leg up in overcoming this obstacle. This approach — where it has been diligent — has worked to smooth the way towards needed documentation changes. But, it is a sophisticated (and sometimes expensive) change management strategy for smaller hospitals; many do not have the expertise (or the right physicians) to go this route.

How can you minimize negative fall-out from these documentation risks?

• Without question, if your physicians haven’t received adequate training, they need it. Immediately. We know hospitals who would not / could not invest in physician training, as recently as a week ago. When your coders begin ham-stringing your physicians with hundreds of queries, or your claims start being rejected and the revenue slows down, you have a choice. Either invest in the proper training, and require your physicians to engage, or in the long run, your organization may go out of business. There are many physician training options — online, with ICD-10 training consultants, and more. Insisting on getting a physician trainer at this point could be a luxury; they are a small species, and can be expensive. (Call us and we’ll offer suggestions, without selling ourselves.)
• Teach your coders to help your physicians. Coders can only code from the information your physicians give them.  If not documented, a diagnosis or procedure may as well have never happened when it’s time for billing. With insufficient documentation, your coders will either have to query your physicians, which results in a delay in billing — or worse, your coders will not know about specific services, and they will never be coded or billed.
  Queries aren’t pleasant for any physicians now, but this inconvenience is going to go sky high if they aren’t prepared. Coder support will make a big difference. We recommend that you examine how your coders’ current queries  are written and make them as physician-friendly as possible, especially considering this new, more stressful environment.
• If a coder needs to write a query, three principles should be applied.  Per AHIMA,  here are some suggestions.
  •  Write in clear, concise and precise language.  Some coders prefer to write their own queries. Others prefer standardized queries based on templates. Create a standard, and decrease physician confusion! If you use query templates, these need to be converted to ICD-10-CM/PCS coding language.
  • Be non-leading. Don’t ask if the patient has a certain condition. Ask if the details in the documentation support a more specific or different diagnosis than what is initially documented. Multiple choice questions would not be considered leading questions as long as the options are medically reasonable. Whatever the format, queries should be individualized and addressed to a specific physician. The coder needs to provide name and contact info with each query.
    • Use ICD-10 coding manuals and other industry references.
    • Teams should consist of:
      • Clinical documentation specialists
      • Medical coders
      • Physicians
    • Plan to break it all into manageable chunks each week.
  • Before sending a query, make sure the information isn’t somewhere else in the medical record. Seriously, why make the care-giver do this work? Give the physicians enough information so they don’t have to look up the medical records themselves. Include the condition or diagnosis that the medical record already cites, any data in the record or supporting documentation that pertains to the question being asked, and the actual question.

The Journal of AHIMA suggests writing a query when clinical documentation is:

• Conflicting, imprecise, incomplete, illegible, ambiguous or inconsistent
• Describes clinical indicators that don’t clearly support the underlying diagnosis
• Includes clinical indicators, evaluation, and/or treatment that does not seem related to any medical condition or procedure
• Does not support or validate a diagnosis
• Does not support the present on admission indicator

Physicians love details, and will respond to feedback.  Queries will actually function as positive feedback to physicians about the quality of their documentation. Moreover, If you can tell physicians that 8% of all charts are being returned (versus 3% under ICD-9) and 30% of those returns are for additional information regarding hypertension, and that they can save time by addressing X,Y or Z in their documentation,  they will listen. You can and should collect and communicate this kind of data…through newsletters, reports…meetings. These will be appreciated and will make a difference in productivity and your hospital’s bottom line.

Our consultants are currently performing specialized ICD-10 cost and savings audits for hospital clients. If you would like to discuss the above post or these services, please contact us. We will connect you with an ICD-10 consultant within 24 hours.