This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.
By Wil Lo, MD, CDIP, CCA
Clinical documentation improvement (CDI) serves as a cornerstone in this era of patient-centric care, patient safety indicators, quality metrics, utilization management, performance improvement, value-based purchasing, public reporting, facility/physician profiling, and the shifting landscape of prospective and retrospective reimbursement for services rendered. It is exciting to be involved in CDI initiatives in the US. Outside of the US, CDI programs are being implemented, leading to increased demand for CDI specialists and a keen interest in the CDIP credential.
Based on the initiatives of the AHIMA World Congress and conversations with esteemed healthcare professionals from many regions, including South East Asia, the Middle East, and Europe, it is apparent that documentation challenges are rampant. Similar to the US, the documentation issues range from physicians’ inadvertent oversights to egregious disregard for the content and quality of the patient medical record.
Documentation challenges exist, regardless of the code sets. For instance, the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) is used by several countries to report diagnosis codes. ICD-10-AM contains 21,885 codes, whereas ICD-10-CM contains 69,823 codes. Likewise, the Australian Classification of Health Interventions (ACHI) is used by several countries to report inpatient procedure codes. ACHI contains 6,284 codes, compared to 71,924 code combinations present in ICD-10-PCS. The concept of the Australian Refined Diagnosis Related Groups (AR-DRGs) is similar to the MS-DRGs, in which ICD-10-AM codes, ACHI codes and other factors (e.g., age, gender, patient discharge disposition) generate one AR-DRG for each inpatient stay.
Interestingly, although there is a general consensus that ICD-10-AM and ACHI are not as specific or clinically aligned as ICD-10-CM and ICD-10-PCS, the number of AR-DRGs (698) is similar to the number of MS-DRGs (751). An inherent problem exists, due to the fact that ICD-10-AM and ACHI have fewer diagnosis and inpatient procedure codes respectively. Documentation that is too specific and precise may lead to diagnoses and procedures that are not indexed in ICD-10-AM or ACHI. As a result, more general or unspecified codes will be assigned, leading to AR-DRGs that do not reflect the severity of illness or utilization of resources during each patient’s stay. However, in countries outside of the US, lack of proper documentation appears to be the more common culprit and, in a similar fashion, will lead to the incorrect assignment of AR-DRGs.
There is another layer of complexity because the reimbursement models in most of these countries may differ from the US. Some countries utilize ICD-10-AM and ACHI, whereas other countries utilize ICD-10-AM and CPT-4 to assign codes for inpatient stays. Some countries utilize AR-DRGs and others are in the infancy stages to develop a model for prospective payment. Moreover, some countries utilize variations of ICD-10, such as ICD-10-CA, ICD-10-GM, and ICD-10-TM. It is evident that the code sets and reimbursement models may vary from country to country. However, the common theme is that improper documentation practices exist in facilities throughout the world and CDI programs are being implemented to address this issue.
Healthcare leaders from various regions in the world have discussed their plans to implement CDI programs and create CDI specialist positions in their facilities. These leaders cite patient care and safety as the compelling reasons to create CDI initiatives. These leaders have the foresight to realize that their respective countries are in the early stages of adopting a prospective payment or reimbursement model, so the concepts of AR-DRGs, case mix index, public reporting and facility/physician profiling will be addressed in the distant future. Also, these leaders recognize the versatility of the AHIMA CDIP credential as a global standard of proficiency in documentation practices and have suggested that the AHIMA CDIP credential should be a prerequisite for employment as a CDI specialist in their respective facilities.
Wil Lo (firstname.lastname@example.org) is a CDI physician consultant.