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Providers should be aware of all the EMR components that must be updated to meet ICD-10’s increased documentation requirements.

Navigating health reform

ICD-10 Requires Changes to EMR Documentation and Capture Tools

  • 10/29/2015

The ICD-10 implementation is here. If your organization has not completed preparations, there is no time to waste. Organizations should evaluate all documentation in their electronic medical record (EMR) systems and work with vendors to upgrade the EMR documentation content and process as soon as possible.

Work with vendors

For many organizations, the only support they receive from EMR vendors comes from the ICD-9 to ICD-10 mapping tools (i.e., the crosswalk) the vendor provides and the training on how to use the crosswalk to correlate ICD-9 codes to ICD-10 codes. The process relies on educating the providers to choose the correct ICD-10 codes from those available in the crosswalk when they have multiple options. Providers must realize, however, that there are many other EMR components that need to be updated to meet the increased documentation specificity requirements in order to migrate to ICD-10.

Providers should speak with their EMR vendors to understand how they have updated their EMR database structure because many pre-ICD-10 databases don’t have structured fields to record data for the new required fields. This conversation should include whether the fields are discreet or structured. For billing purposes, providers should also verify with their vendor that fields required by their specialty can be captured as structured fields within the EMR database.

Understanding payer requirements to approve procedures

Government and commercial payers routinely require clinical information, including supporting diagnoses, to approve or pre-authorize a significant number of surgeries, procedures, or diagnostic studies. Providers may find that approvals now need more specific documentation. Many ICD-9 diagnosis codes now have several corresponding ICD-10 diagnosis codes that go into greater specificity.

The figure below demonstrates the specificity of ICD-10 compared to ICD-9 and highlights the importance of the inclusion of structured data for all decision points.

ICD 9 vs ICD 10 Code Options Diagram

From a payer’s perspective, some of these more specific ICD-10 codes may support a procedure, while others may not. Approval policies are generally available from payers, so providers should research the requirements for their common procedures and adjust their templates to capture the information required for payer approval. If templates are not adjusted, providers may face a significant increase in denials and a decrease in income.

Best practices incorporated into EMRs

As the sophistication of EMRs increases, more support tools for documentation, clinical decision, and best practices will be incorporated into the design of EMRs or “attached” to EMRs to provide greater consistency and focused clinical guidance.

Many tools use diagnosis information as part of their internal algorithms, and vendors are increasingly expanding their clinical rules engines. Many EMR vendors are incorporating voice recognition (VR) to activate components of documentation templates. Providers are using combined VR and natural language processing (NLP) tools in a number of ways in order to:

  • Reduce errors in reports
  • Assist with clinical and peer reviews
  • Find appropriate treatment plans based on identified diagnoses if the recommended treatment plans are not initially chosen

Changes to diagnosis codes and increased specificity may require changes to existing VR-NLP algorithms. Because the VR-NLP and other support tools are tightly tied to EMR templates, providers should evaluate templates and work with vendors to make the required changes.

Revisions to EMR documentation

Providers routinely use patient portals to meet “meaningful use” communication requirements and streamline patient intake. Patient questionnaires available through these portals collect a significant amount of information, including details that accurately diagnose patients and assign corresponding ICD-10 diagnosis codes. These questionnaires help ensure that the correct updated templates are selected for the visit or procedure. It is imperative that questionnaires are updated to collect data with the appropriate amount of detail.

Most EMR documentation capture tools have sections that include the reason for the visit, a review of systems, the examination, and the treatment or care plan. Each part of the template should be evaluated to determine if it needs to be updated. For instance, the “reason for the visit” section should capture information such as laterality, specific body location, and whether the issue is chronic or acute.

Templates should also be modified to capture the information needed for the care plan component. Information entered about the patient prior to the care plan templates will impact the selection of order sets and specific care plan sub-templates.

Long-term care (LTC) facilities have unique reporting requirements and should make sure all resident assessment instruments (RAI), intake forms, and documentation templates are updated to reflect the increased specificity of the ICD-10 diagnosis codes. Information captured on the RAI must support and flow to a “Therapy Evaluation and Plan of Care” or the “Section I Active Diagnoses” of the minimum data set (MDS 3.0). In addition to ICD-10 changes, LTC facilities’ documentation will need to support the new UB-04 form for billing multiple third party payers that went into effect October 1.

Procedure templates often use information collected previously and recorded in the EMR. Information required for completing procedure templates and for payer approval of the desired procedures must to be built into the intake questionnaire and procedure consult templates. Providers should map the information requirements for all components of services provided, as well as identify when the information was or will be collected to ensure that templates are adjusted appropriately.

Talk to your vendor

Providers should speak with their EMR vendors to understand how they have updated their EMR database structure, because many pre-ICD-10 databases don’t have structured fields to record data for the new required fields. This conversation should include whether the fields are discreet or structured. For billing purposes, providers should also verify with their vendor that fields required by their specialty can be captured as structured fields within the EMR database.

How we can help

CLA can help with the transition to ICD-10 in several ways. We provide staff education, clinical documentation improvement reviews, assistance with modifications to documentation elements, and organizational readiness assessments. Most organizations will start to see the impact from ICD-10 on their payments in late October or November. We can assess the financial impact of this important transition on your organization and help facilitate discussions with your banker for lines of credit.