Dear Physicians: Your ICD-10-ready EHR should look like this

Carl Natale
by Carl Natale

As my colleague J. Thomas Ward, M.D., FACEP, said in an earlier article, there are four unique approaches vendors may use to generate ICD-10-CM codes.

Guest post by Hank HikspoorsI believe the fourth approach, “ICD-10 clinical content, feedback and code generation,” is the best-case scenario for both physicians and coders, as well as for the overall goals of a hospital.

Physicians, below are checklists of qualities you should look for in your current or prospective electronic health record (EHR).

Clinical content

When it comes to clinical content, ask your vendor what steps they have taken to incorporate ICD-10-CM. The cream of the crop will have spent a significant amount of groundwork on building specific ICD-10-CM clinical content tailored for the physician. Qualities to look for:

  • Helps ease the transition by translating ICD-10-CM jargon into appropriate clinical content.
  • Does not place the burden on the physician of having to learn the deep-dive terminology and categorization of ICD-10-CM.
  • Complements existing workflow.
  • Easy to use, enables quick and efficient documentation without free texting
  • Promotes the required level of detail necessary to generate the most specific ICD-10-CM code and help prevent claim delays and rejections.

Feedback features

Real-time feedback features will be one of the most important factors to research on ICD-10 ready software. Find an EHR that gives you multi-level visual feedback when documentation is specific and complete enough for proper reimbursement. The following features (or something similar) are highly recommended:

  • Indicators such as exclamation marks that visually show you when pertinent details are missing from a coding / billing perspective.
  • Next-level indicators for further alert of incomplete documentation, such as color-coded groupings.
  • Visual signs of completed ICD-10-CM specific documentation such as check marks.
  • An overview tab that provides feedback based on both complete and incomplete documentation.
  • An overview of any deficiencies and coding reports with the detailed diagnosis and ICD-9-CM / ICD-10-CM codes.

Final note…

The right EHR can have a positive impact for your hospital’s patient care, physician workflow, risk mitigation and financial return. Make sure decision makers have a complete understanding from prospective vendors on EHR features that have been added or changed for ICD-10-CM.

Hank Hikspoors, MBA, directs ongoing product development efforts for T-System Inc.’s emergency department information system, supporting eight million patients per day. Hikspoors is a veteran engineering executive with more than 20 years of innovation in agile and lean processes, product development, product management and software architecture. Experienced in both the healthcare and telecommunications fields, he currently holds a U.S. patent for “Method, System and Computer-Readable Medium For Resource-Based Route Selection” and has a patent pending for T-System’s ICD-10 documentation feedback schema. Hikspoors has presented on various topics at the University of Visakhapatnam and is an active HIMSS Texas-chapter member.