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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?. 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

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  1. 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 2

  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 • 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

  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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