Now that it looks like ICD-10 implementation will be postponed only one year, the already hot-topic of computer-assisted coding will get even more attention. Hospitals obviously need to ensure they have a strategy in place to deal with ICD-10 and the highly anticipated, but often misunderstood, ramifications of ensuring appropriate reimbursement under the new coding standard. Most hospitals I’ve come across have an “ICD-10 Committee” working overtime to determine what the right strategies, solutions and processes are for their organization.
With all of this focus on how to add intelligence and automation to the coding workflow, and mainly the output of that workflow, there has been a lack of attention given to inputs that feed the coding workflow: physician clinical documentation. ICD-10 at its root is a documentation problem. The best computer-assisted coding solution in the world is still dependent on the content of the documentation that it analyzes for the quality of codes that it produces. If key information is missing, you’ll never achieve appropriate reimbursement or accurate profiling and reporting.
If you believe that documentation is as important as I believe it is, then why aren’t there as many intelligent “computer-assistance” applications for physicians to aid them in their documentation as there are to assist coders with coding? There is a huge market for clinical documentation improvement (CDI) services and solutions that address coding and documentation accuracy under ICD-9. The problems and issues addressed by these CDI services and solutions today aren’t going anywhere with ICD-10 and will only increase.
Part of the problem is the complexity and level of personalization in the clinical documentation workflows of physicians. This has led to a chronic lack of focus on physicians and their needs, which are often unvoiced. The gap between how physicians document, and the specificity in diagnosis terms required for coding purposes isn’t going away, so what is the answer?
I anticipate that over the course of the next year we’re going to see a huge increase in the number of vendors offering documentation improvement solutions and “computer-assistance” products for physicians. A lot of these will probably miss the mark due to a lack of truly understanding the needs of physicians. The truly impactful solutions will successfully bridge the gap between documentation and coding, bringing truly customized, intelligent solutions that speak to the physician in their own language.