ICD-10 Readiness Assessments
A crucial step in preparing for ICD-10 is clinical documentation improvement. Providers need help in getting their chart documentation ready to support the new level of specificity in ICD-10. If you randomly pull charts and assess the diagnosis documentation, you could get multiple different diagnoses that cover multiple different guideline issues in ICD-10. Struggling to cover too many things at once would make it difficult and frustrating to discuss with a provider. So, where do you start?
First, run a report in your computer system and sort it by diagnosis code. Next, start with your top ten and run another report listing patients that had those diagnoses appended to them. Pull 10 to 20 charts with your top used diagnosis code. Review the ICD-10-CM guidelines (if there are any) for the chapter in which the diagnosis is located. Then, review the notes for diagnosis ONLY. Look at the history and the assessment and code it under ICD-10-CM. Put together a report based on the diagnosis: how many notes could be coded under ICD-10-CM? How many notes need more specific information to code? How many notes had to be coded to an unspecified code?
Take these findings to each provider and review them to show the specificity in ICD-10-CM and what is needed in the documentation to support the diagnosis. Go through all of the notes and answer all questions. Depending on how well the provider did on the assessment, you may either perform another assessment on the same diagnosis, or move on to the next diagnosis on your “top ten” list. The facility/office should have a target percentage for the assessments that all providers should meet. Reports should be kept on each assessment to show progression of the providers.
Once the assessments begin, they should continue until the implementation date of October 1, 2013. How often they occur depends on the number of providers you have, the number of different specialties, the type of specialties, and how the providers perform. When we start to officially use the code set, then it will become part of the regular audit process.