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HIM Education: Prepare for Healthcare’s Future

Gearing Up for Change: Target Your Physician Documentation

Published August 21, 2014 8:21 AM by HIM Professionals

By James P. Fee, MD, CCS, CCDS, AHIMA Approved ICD-10-CMS/PCS Trainer, Associate Director, Huff DRG Review

Plan-Do-Study-Act. These are the four steps for any educational or quality improvement endeavor-the same process required to ready your physicians' clinical documentation for ICD-10. The challenge is getting physicians educated, engaged, and involved.


Plan an assessment of your current physician documentation by specialty using physician advisors in collaboration with coding and clinical documentation specialists. Keep the focus on known ICD-10 documentation requirements to clearly identify existing gaps.


Analyze physician documentation before final billing with these four objectives in mind:

  • Identify documentation gaps for ICD-10
  • Correlate lost dollars under ICD-10
  • Examine impact of current documentation regarding quality metrics with ICD-10 translation
  • Compile clinical topics where physician education will have greatest impact

Physicians are data-driven. Careful study of the data derived from this pre-bill review yields a plan of action for documentation improvement that is physician centric.


Study your pre-bill review data. Given the complexities of ICD-10, especially the procedural coding system, establish specialty physician advisors as team members. Maximize your impact through a methodical approach.

  • Organize findings by specialty and clinical topic to align with the physicians' approach.
  • Streamline data and concisely outline "what's missing" within their documentation.
  • Involve the specialty physician advisors to enhance clinical validity and peer "buy-in".
  • Develop a trend analysis to continually modify your focus allowing for longitudinal documentation improvement.


Implement change through customized education utilizing your data analysis. Keep physician education concise, clinically focused and specific for each specialty. Use a carefully selected and comprehensively trained physician advisor for maximum impact and medical staff engagement. Ongoing engagement by the physician advisor through daily pre-bill reviews fosters long-term effectiveness with the medical staff.

Once physician advisors are in place, begin your physician education program for ICD-10. Here are four important guidelines to follow:

  • Begin training your physicians on their documentation needs for ICD-10
  • Target physician education on "what's missing" for each specialty and share ongoing pre-bill review data to demonstrate improvement
  • Leverage physicians' drive for competition every step of the way with data reflecting their quality and efficiency scores.
  • Combine ongoing training and daily CDI rounds with regular pre-bill reviews, committee reporting and mentoring sessions

Benefits Extend Beyond ICD-10

ICD-10 is as much a documentation issue as a coding issue. Better physician documentation for ICD-10 drives powerful improvements within other executive indicators.

  • Quality metrics
  • Case mix index (CMI)
  • Severity of illness (SOI)
  • Risk of mortality (ROM)
  • Return on investment (ROI)

The rewards of better clinical documentation are truly endless. Pre-bill reviews in conjunction with the right physician advisor team propel ICD-10 change and establish a firm foundation for long-lasting clinical documentation improvement.


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