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Bridge Building for Clinical-HIM Collaboration

Explore the importance of collaboration between clinicians and HIM professionals for effective ICD coding and clinical documentation improvement. Learn key strategies and potential pitfalls to ensure successful implementation of ICD-10.

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Bridge Building for Clinical-HIM Collaboration

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  1. Building Bridges Between Clinicians and HIM Professionals Elizabeth Horn AHIMA Student Advisory Council

  2. Why is this Necessary? • Quality Management Improvement • ICD-10 Coding System • Clinical Documentation Improvement • Documentation Anaylsis 2

  3. ICD-9-CM • 3-5 Characters • First Character is either a number or E or V • Characters 2-5 are numbers • Decimal after 3rd character 3

  4. ICD-10-CM • 3-7 Characters • Character 1 is alpha and all letters are used with the exception of U • 2 Numeric • 3-7 either alpha or numeric • Placeholder “X” • (Degree of Change Similar in PCS) 4

  5. An Illustration • Asthma, Acute Exacerbation • ICD-9-CM • 493.92 • ICD-10-CM ME Verify • J45.21 Mild, Intermittent with acute exacerbation • J45.41 Moderate, Persistent with acture exacerbation • J45.51 Severe, Persistent, with Acute Exacerbation 5

  6. Effective ICD-10 Implementation • Relationship but improve because of: • Increased standards for diagnosis and procedural specificity • Required System Changes • Improvement of Clinical documentation • Retrospective Audits of physicians • Education of HIM and Clinical Staff 6

  7. How to be Effective • Education is Key! • Includes Early Intervention (ie. Residents, New Medical Students) • Communication between HIM, Clinical Staff and Administration • Confidence and Cooperation • Role Assignment and Understanding • Bridge Barriers and Overcome Resistance to Change 7

  8. Success is Crucial • Consequences of Poor Implementation and Communication between HIM and Clinical Staff may potentially lead to” • Increased delays and/or rejection in payment • Coding Backlogs • Compliance • Loss Profit • High Stress Work Environment 8

  9. Final Thoughts • As an HIM Professional always possess the confidence to communication with clinicians when documentation errors, concerns or questions arise • You play an Important Part! Education and Effective Leadership in the facility starts with you! If no one is shooting for improvement than what is holding you back? 9

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