Documentation Improvement and ICD-10

The way you perform documentation improvement can definitely impact you adjustments to the upcoming changes.

In relation to the revisions done in the medical field, medical institutions must be up to date to the latest documentation improvement programs. The tenth revision for the International Statistical Classification of Diseases and Health Problems or ICD-10 can definitely challenge the standards of a certain hospital. It is therefore necessary to conduct medical record audits and identify the areas that will require improvements and corrections.

Proper coding is important to avoid different legal issues that may cause fines and penalties. The revisions will set additional codes that can be used to classify a particular medical case. These changes will definitely make clinical documentation more challenging especially for hospitals that operate purely on traditional practices.

With the expected policies coming up, what makes it more complex is that medical institutions shouldn’t start with ICD-10 trainings until more than six months prior to implementation.  But to prepare for it, there are other ways possible. One is by conducting effective audits which are seen to be more effective when outsourced to a reliable third party provider. Through these specialized support services, it will be easier to identify the most appropriate clinical documentation improvement program. This will then highlight the roles performed by documentation specialists as new members of the clinical teams. If everything goes well, adjusting to the demands of ICD-10 will be easier.

documentation improvementMedical institutions should start learning the basic concepts related to the upcoming revisions. Physicians should be aware of the goals set to improve the overall practice of clinical documentation.  It is also important to maintain high quality medical records that are detailed enough to support the upcoming revisions. ICD-10 is all about adding more codes to make assignment of patient severity and reporting more detailed. By promoting best practices in the creation of medical records, a medical institution can smoothly adapt to the latest revisions without being interrupted in a major way.

A lot of information has been provided by the World Health Organization online and medical institutions can easily access procedures on how to prepare or implement the revisions brought by ICD-10.  Proper awareness can help a company to become more flexible to change and thus be more future proof. These features are just among the many pre requisites in becoming a high standard medical institution. It may start by seeking the help of providers that can offer support services such as medical record audits and clinical documentation improvement programs.

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