Tip Tuesday: Balance productivity and specificity

Productivity has been a huge concern for both CDI specialists and coders. With the added specify in ICD-10, facilities need to strike a balance between getting claims out the door and capturing the full clinical picture is key, says ACDIS Advisory Board member Judy Schade, RN, MSN, CCM, CCDS, CDI specialist at Mayo Clinic Hospital in Arizona.

In an effort to increase or maintain post-implementation productivity, some facilities let the smaller diagnoses and procedures, and query opportunities, go, says Schade. For example, some are not going after certain secondary diagnoses if it doesn’t affect the reimbursement. This could be a bad habit to get in to, she warns, because you won’t be able to capture the whole clinical picture or support resource use.

Now, nearly six months after ICD-10-CM/PCS implementation, here’s an opportunity for everybody to step back and realize that the data does matter, Schade says.

“We shouldn’t be neglecting to document or code something simply because the reimbursement won’t change. There are so many other factors that can be affected if the documentation isn’t as accurate as possible. The goal should be to be proactive, not reactive,” she says. “We have to stay on top of these things now, not wait until someone says this is a problem,” she says. “Pay attention now, or pay penalties later.”

Bottom line, hospitals should strive for complete and accurate documentation that leads to complete and accurate coding that shows the true clinical picture of the patient, says Schade.

“This is about representing the quality of care that we give our patients,” says Schade. “It’s important to get this right.”