Many healthcare organizations as part of their ICD-10 preparation work have used clinical documentation improvement software to enhance the specification of physician documentation, which aids in selecting the appropriate code to maximize reimbursement.
But having better documentation goes way beyond payment benefits by directly improving diagnoses, which improves care quality, says Katherine Lusk, chief health information management and exchange officer at Children’s Health in Dallas. Lusk made the comments during an interview at the AHIMA Convention in New Orleans on Monday.
The organization was the first pilot site for 3M Health’s new 360 Encompass MD CDI software that identifies nuances in documentation and prompts the provider to be more specific.
For instance, a physician may simply note that a child suffers from malnutrition, but the CDI will prompt for a severity level. Or, while congestive heart failure is common in children with cardiac conditions, the software will prompt to specify if CHF is present in the left or right ventricle, which gives a better understanding of a patient’s overall health status. Another example: While the diagnosis may be pneumonia, the CDI will prompt whether it is community acquired and is bacteria or viral.
With more documentation specificity, “We know the true burden of illness on resource consumption for each child,” says Lusk. Consequently, “ICD-10 done right can increase revenue, but you also get a richness of data to manage a population,” she noted.
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