With the ICD-10 delay, experts are urging healthcare organizations to spend the time furthering their efforts toward clinical documentation improvement. After all, better documentation can improve not only reimbursement rates, but also clinical quality measures.
That improvement involves physicians, CDI specialists and coders--and closing the gap between "doctor-speak" and "coder-speak," which can be vastly different, according to an American Health Information Management Association article on physician and CDI specialist perspective. (A separate article focuses on the coder perspective.)
The article urges more documentation training in medical schools and says physician coders in residency programs can be a huge asset, not only in training, but in also shedding light on physician resistance to CDI efforts.
Those efforts rely on physician buy-in, and successful ones present the case from the physician's point of view. Doctors are being required to shoulder more tasks that take time away from seeing patients, so it is important to help them fiercely guard their time for patient care and improve that care, the article says.
Small group sessions of physician peers have been a successful formula for Marty Conroy, director of CDI and ICD-10 education at Temple University Health System.
The CDI team at St. Mary Medical Center has taken a "servant leadership" model focused on things that matter most to physicians--memorable customer service, quality patient care and positive clinical outcomes. Its teams have combined clinical documentation and concurrent Core Measure Quality reviews at the beginning of patient stays--combined functions that can also alert the physician to patient issues.
To engage its physicians, Baptist Health South Florida has dubbed the effort "CDI: Miami." Lorena Chicoye, M.D., Baptist's corporate medical director of managed care, has stressed the importance of making sure physicians understand what the initiative means for them.
"If they don't know the day-to-day impact, they're not going to support you," she said.