Building Bridges Between Clinicians and HIM Professionals Elizabeth Horn AHIMA Student Advisory Council

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

3 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

4 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

5 An Illustration Asthma, Acute Exacerbation –ICD-9-CM –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

6 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

7 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

8 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

9 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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