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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