![]() ![]() Without these steps, there is a great danger that Clinicians can become dependent on the “Cookie Cutter” and not the substance and logic of ICD-10. These Champion teams can then go on to train others in the respective disciplines, especially those who do procedures. In previous articles HSMN has discussed the “The Deconstruction Methodology” in which current, recent or active cases are parsed so that Clinicians can actually see all of the variables in the construct of ICD-9 and how they evolve into ICD-10.įirst order is for a partnership to be developed between the “Champion” of a specific discipline (a seasoned attending) and an experienced and trained senior (ICD-10) Coder/Auditor to help shape the clinical documentation. Therefore, an understanding of ICD-10 and assessing current documentation practices is still critical in transitioning to this new classification system. HSMN advises that before the provider can create or use a “Smart Phrase” in their database, they first have to understand what variables and/or elements will need to be documented to ensure accurate, optimal coding. Therefore, developing “procedural Smart Phrases” would have to be very limited in order to stay within the boundaries of a single character definition. In the ICD-10 procedure world, Coders actually build the final ICD-10-PCS based on individual character definitions. HSMN has advised its clients that coding in the ICD-10-CM/PCS era requires a level of specificity and capturing of all the variables in diagnostic statements as well as the thousands of elements that are part of developing a code for the procedures. Some might call it the “Cut and Paste” Clinical Documentation Syndrome but with many patients and too little time it can seem to be a very legitimate way to proceed. For many Clinicians this is a time saver and rather than rewriting the same phrases used in their particular discipline, this shortcut has been used. The enterprise systems such as Epic offer the possibility for Clinicians to choose phrases that they will typically use over and over again in their clinical documentation. HSMN advises hospitals and clinical practices on how to overcome the problems of transitioning to ICD-10-CM/PCS after a survey of compliance officers and warnings from CMS indicate concerns about using “Repetitive Terminology” or “Smart Phrases” in their EMRs.
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