HIMagine That! Collaborating on ICD-10 Documentation

August 19th, 2015 / By Sue Belley, RHIA, Donna Smith, RHIA

Donna and Sue are joined this month by fellow 3M HIS blogger Jill Devrick.

Donna: Hi Sue. How was the AHIMA-AHDI summit? Didn’t you give a presentation?

Sue: The summit was really good, and yes, Jill Devrick and I gave a presentation on how CDI professionals and Healthcare Documentation Specialists can work together to improve the content of the medical record in light of the transition to ICD-10.

Donna: So tell me more…

Sue: You know what, let’s get Jill on the line and we can both tell you about it…

Donna: Good idea!

Sue: Hi, Jill! I have Donna on the phone. She asked me about our AHIMA-AHDI Summit presentation and I thought it would make sense to get you on the line too.

Jill: Hey, Donna! Sure – I ‘m happy to talk about it. Earlier this year, I asked Sue if she thought that Healthcare Documentation Specialists could assist in capturing accurate, complete medical record documentation as we transition to ICD-10. Right away she said, “It takes a village to deliver a well-documented medical record,” so we started talking. She threw out some ideas and we fleshed out our presentation right then and there.

Sue: Well, I was intrigued by her question. Since CDI professionals are going to be very busy working with physicians to ensure their documentation supports ICD-10 coding, I thought there was a definite opportunity for Healthcare Documentation Specialists to lend a hand.

Donna: So how can these two groups work together, Jill?

Jill: In our presentation, Sue gave an example of a CABG procedure with harvesting of a saphenous vein graft. She explained that in ICD-9, the harvesting procedure was not coded, but in ICD-10-PCS it is. She told us that the surgeon needs to document the laterality of the vein harvest and whether it is the lesser or greater saphenous vein.

Sue: My thought was that the Healthcare Documentation Specialist who handles the transcribed operative report for this procedure could verify immediately if this information was recorded, and if not, flag it for the surgeon to include before signing off on the report. Handling this upstream during the operative report completion process would save the CDI professional from having to query for this information and would ensure that it is documented before the operative report is even sent to the EHR.

Jill: That’s right – Healthcare Documentation Specialists and surgeons are used to working together to ensure well-documented operative reports.

Donna: Did you consider operative report templates?

Jill: Yes, we talked about the fact that Healthcare Documentation Specialists would be an asset to the template building process since they’re so knowledgeable about what needs to be included in documents such as operative reports or history and physical reports, to name a few. They’ve been working with physicians for years to create these documents and are a wealth of knowledge.

Sue: We gave an example of creating a templated document for hip replacements – making sure to capture documentation of the type of implant – you know, ceramic, metal, etc. – and whether it is a cemented or uncemented implant.

Donna: I like the fact that you were thinking about how the two groups could collaborate to capture the documentation that will be needed to support ICD-10 coding, because Sue’s right . . . it takes a village!

Sue Belley, RHIA, and Donna Smith, RHIA, are project managers with the consulting services business of 3M Health Information Systems.


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