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Building Bridges Between Clinicians and HIM Professionals. Elizabeth Horn AHIMA Student Advisory Council. Why is this Necessary?. Quality Management Improvement ICD-10 Coding System Clinical Documentation Improvement Documentation Anaylsis. 2. ICD-9-CM. 3-5 Characters

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building bridges between clinicians and him professionals
Building Bridges Between Clinicians and HIM Professionals

Elizabeth Horn

AHIMA Student Advisory Council

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

2

icd 9 cm
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

icd 10 cm
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

an illustration
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

effective icd 10 implementation
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

how to be effective
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

success is crucial
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

final thoughts
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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