After ICD-10, the CDI World has become Data Driven and High Tech

Now that the smoke has cleared from the transition to ICD-10-CM/PCS, the healthcare industry is taking stock of how the transition changed the industry landscape.

In remarks delivered Tuesday at AHIMA’s CDI Summit, Pamela Hess, MA, RHIA, CCS, CDIP, CPC, with himagine solutions, noted in her presentation “The Case for CDI Solutions in a Post ICD-10 Environment,” that healthcare executives are now more interested in healthcare data than ever before.

That’s because, Hess said, their primary concerns are all related to:

  • Demographics
  • Financial strategies
  • Reimbursement
  • Population health

All of those priorities rely on accurate data, which presents greater opportunities for clinical documentation improvement (CDI) programs to assist in ensuring that data is accurate. To help CDI teams develop a strategy to tackle the demand for their services, Hess outlined some of the common documentation issues her organization has identified since the implementation of ICD-10, discussed tools and resources that can be deployed to support CDI, and noted how informatics and analytics can assist CDI efforts.

Post ICD-10 Documentation Trends

Hess said that himagine solutions’ own research revealed that in terms of inpatient coding accuracy, their own coding professionals are consistently exceeding accuracy standards. On the outpatient side, outpatient coding professionals have a 94 percent overall accuracy rate. She noted that overall, PCS coding is still proving to be a struggle because it’s still a challenge to get physicians to document to the level of specificity required to code PCS claims, Hess said.

To deal with these documentation problems, Hess recommended that CDI specialists aim not to bend a physician’s ear for an hour, but to engage them in more meaningful and concise 10 minute segments.

Technology Solutions for CDI

Hess said she was very encouraged by the ever-expanding vendor solutions for assisting CDI. The most effective technologies include:

  • Natural language processing (NLP), which can track dictated portions of documentation and enhance clinical record review
  • Clinical language understanding (CLU), which can help identify key words and phrases with a dictionary of common CDI focused diagnoses, quality indicators, and clinical data
  • Computer-assisted physician documentation (CAPD) technology, which uses CLU

In addition, Hess said the healthcare industry can expect to see mobile CDI query solutions take off in coming years. She even noted that one university is offering a PhD program that combines psychology and informatics—a combination that will link degree holders to the change management professionals that help get new initiatives like CDI up and running.

“If you’ve seen what I have, change is happening. I’ve been in this a long time, and the changes we’ve been seeing in the last few years have been exponential,” Hess said.

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