By Dr. Brian Levy, MD, Vice President and Chief Medical Officer with Health Language, part of Wolters Kluwer Health
Finding and selecting the right diagnosis code is critical to both patient care and revenue
cycle management. The downstream negative impact of using an unspecified code can touch everything from decision support to reimbursement, compliance, and reporting. In addition, unspecified codes are not as useful for other clinicians needing to review the records and for patients themselves as they review their own records.
Consider the following four reasons why healthcare organizations need to streamline the clinician diagnosis process to improve workflows, accuracy, and the bottom line:
- The number of clinical codes is increasing
The increase in the number and specificity of ICD-10 codes delivers many opportunities for patient care, along with many challenges to workflow. For example, ICD-10-PCS includes more than 75,000 codes after the October 2016 update and
ICD-10 CM includes about 68,000 codes. With the growing number of various diagnoses, clinicians need a quick and easy way to search through thousands of codes to find the appropriate, billable one. Also, with the frequent amount of updates to diagnosis codes throughout the year, healthcare organizations need to have a system in place to manage all these updates to have the most accurate, up-to-date code sets.
- Unspecified codes can lead to inaccurate reimbursement
When physicians are unable to locate the appropriate code, many default to an unspecified code. The average rate of unspecified code use is 31.5 percent. The CMS grace period for this practice ended in October 2016, and providers still engaging in deficient unspecified coding practices face revenue cycle exposure. Over the long term, further revenue risk may be realized through lower value-based payments.
Choosing the most specific code ensures that optimal reimbursement is realized. For example, consider the DRG shift for major depressive disorder. If documentation supports the choice only of an unspecified code (F32.9, major depressive disorder, single episode, unspecified), the reimbursement for that particular code is $3,921, as opposed to $5,723 for the more specific code F32.3, major depressive disorder, single episode, severe with psychotic features. Even specifying that the depression is mild versus unspecified increases the DRG reimbursement. One US hospital recovered $3M in additional reimbursement by helping providers submit more specific and appropriate codes in place of F32.9.
3. Getting it right the first time streamlines clinical documentation improvement (CDI) workflows and revenue cycle management
Industry data[1] suggests most CDI staff review between 6 and 20 records daily, and between 11 percent and 30 percent of the charts they review result in physician queries. The time spent resolving these queries is substantial and often delays revenue cycle by as much as two weeks—and sometimes even resulting in penalties and potential expulsion of the physician.
Also, potential revenue/productivity loss from use of unspecified codes can be substantial. The table below shows a 10-provider practice with an average volume of 300 patients per day and three diagnosis codes per patient encounter:[2]
| Unspecified Rate |
Potential Denied Claims (denials per day) |
Physician Productivity Risk (minutes per provider per day) |
Cash Flow Risk (dollars per day) |
| 5% |
45 |
13.5 minutes |
$1,125 |
| 10% |
90 |
27 minutes |
$2,250 |
| 20% |
180 |
54 minutes |
$4,500 |
| 30% |
270 |
81 minutes |
$6,750 |
4. Physician satisfaction will improve
When it comes to EMRs, the number one complaint from physicians is that workflow is negatively impacted. Many feel blindsided when promises of streamlined processes do not materialize, and use of technology actually creates more work, such as tedious code lookup or long-winded clinical queries.
The good news is that solutions exist to streamline and improve this process for clinicians to document more specific codes—to reflect what conditions the patients actually have. For instance, Health Language’s Provider Friendly Terminology provides automated mapping of unspecified codes to their related specified code choices. The PFT solution lets physicians look up the specified codes using their own language used in everyday care delivery, and then answer a few clinical questions to choose a more specific code. With the use of this tool, which can be embedded in most EMRs, clinicians can locate the diagnosis they need within their EMR more quickly.
Clinicians are also able to use their own language with the use of Health Language’s over 1 million synonyms, acronyms, abbreviations, and even some common misspellings. For example, clinicians can search for the concept “atrial fibrillation” using familiar clinical terms such as “afib,” or “atrial fib,” and our Provider Friendly Terminology solution will provide the corresponding ICD-10-CM, ICD-9, or SNOMED CT codes. Improved code look-up processes have the potential to improve physician satisfaction by reducing the time and tedious code lookup needed to complete an encounter.
[1] http://www.hcpro.com/content/294678.pdf
[2] https://www.whiteplume.com/icd10/risk-of-unspecified-icd-10-codes
Article link: https://www.healthitoutcomes.com/doc/four-reasons-healthcare-organizations-need-to-simplify-the-documentation-of-the-clinician-diagnosis-process-0001?vm_tId=1990771&user=0009EE33-ABCE-4D02-9B3C-4F32FFAA82BE&utm_source=et_6231164&utm_medium=email&utm_campaign=HCIT_04-04-2017&utm_term=0009EE33-ABCE-4D02-9B3C-4F32FFAA82BE&utm_content=4+Reasons+You+Need+To+Simplify+Documentation+Of+The+Clinician+Diagnosis+Process
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