Reducing ICD-10 Clinical Documentation Queries

Now that ICD-10 is our reality, practitioners are interested and invested in assisting with their clinical documentation so as to support the appropriate ICD-10-CM diagnosis codes. To capitalize on the momentum attributable to the change, and reduce the volume of Clinical Documentation Improvement (CDI) queries, we have provided a series of "Quick Tips" which allow providers to focus on areas of concern, while assisting with timely claims processing.

Present on Admission

Present on Admission (POA) and Hospital Acquired Conditions (HAC) developed during a hospital visit, are terms that influence hospital reimbursement for inpatients. Payers may reduce or eliminate reimbursement for a variety of HAC's that were not present on admission.  The Emergency Department physicians' and/or hospitalists' documentation is therefore crucial to support whether or not a condition was present at the point of inpatient admission, or acquired during the stay.   SunStone has identified the following CDI "Quick Tips" for situations that arise requiring correct assignment of the POA conditions and HAC:

  • Infections or complications of urinary catheters, dialysis ports and PICC lines
  • Infections of integumentary, genitourinary, respiratory systems
  • Sepsis
  • Staged decubitus ulcers
  • Context of injuries (e.g. falls)
  • Adverse drug effects and reactions 
  • Interpretation of abnormal lab values (e.g. blood glucose, PTT and electrolytes)

Severity of Illness

Severity of Illness (SOI) is a term that indicates the acuity of the pathophysiologic changes that have occurred and provides a basis for evaluating resource consumption, medical necessity and the patient care provided. SOI reflects the patient's level of sickness and disease complications as sicker patients are more expensive to treat, utilize more resources, and have a higher rate of complications. The benefit of ICD-10-CM codes is that they will allow improved support for documentation of SOI.

For example, simply stating "lab reviewed" is inadequate. Laboratory results for ICD-10 may only be coded when the physician specifically indicates that there is a clinical relevance and significance; therefore, clarification when an abnormal lab or symptom is related to a specific disease or condition is vital. For instance, a low bicarbonate is NOT considered inherent with dehydration so it would add additional detail of severity, while an elevated lipase would be considered inherent with pancreatitis and would not be coded separately.  Below are some additional areas where the specificity of documentation will help capture the severity of the patient's condition. 

Document severity levels of key conditions:

Chronic Kidney Disease staging (1-5, ESRD)

Ulcer staging (stage I-IV)

Burn degree, extent of total body surface area and percent of third degree involved

Document the significance of lab findings:

Dehydration with abnormal serum creatinine

Hypoxia or hypercapnia with asthma or acute respiratory failure

Document disease complications:

Primary or secondary diabetes with nerve/kidney/circulatory manifestations

Influenza complicated by pneumonia

Febrile Neutropenia due to chemotherapy, HIV

Angina secondary to uncontrolled hypertension

While organizations successfully geared up for ICD-10, they must now tackle the after affect related to ICD-10 documentation specificity.  For many years, SunStone Consulting has been helping clients implement CDI Solutions which ensure quality documentation initiatives as well as appropriate revenue capture and will continue to offer "Quick Tips" in future editions of HotStone.

If you are interested in discussing SunStone Consulting's ICD-10 CDI Solutions, or wish to conduct training programs, SunStone offers a suite of customized, specialty specific training seminars for staff and physicians.  For more information, please contact Vonda Moon, Principal at