2 Tactics for ICD-10 & VBP Clinical Documentation

2. Beef up your clinical documentation integrity program. Under the second year of VBP, risk-adjusted measures such as mortality kick in. This ups the requirement for documentation.

"How do we know physicians are providing specific enough information to give [an organization] credit for the severity of the patient's [diagnosis]?" asks Susan Wallace, MEd, RHIA, CCS, CCDS, director of compliance for inpatient reviews and an AHIMA-certified ICD-10-CM/PCS trainer for the Shawnee, OK–based Administrative Consultant Service, LLC.

"[CMS] will look at those mortality measures over three years, which means hospitals need to work on [documentation] now or it could potentially hurt [the organization]," she says.

Wallace says organizations need to be sure their clinical documentation improvement programs are up to snuff in order to accurately gauge where clinicians may need to improve to meet the ICD-10 requirements.

"Once you have the data, it gives you a sense of the shape your [organization] is in.… You can set up specific initiatives to get the information you need to get your scores up," she adds.

A clinical documentation improvement (CDI) program can be created using an expert coder trained in documentation, though the individual would need to analyze numerous files—a lengthy process. Alternately, organizations can apply technology to help with the review process.