Electronic Documentation Templates Support ICD-10-CM/PCS Implementation

Improving patient care continues to take center stage in the healthcare industry, as demonstrated by an increased emphasis on health IT, electronic health record (EHR) implementation, the American Recovery and Reinvestment Act’s (ARRA) “meaningful use” EHR Incentive Program, and strategic organization-wide planning for ICD-10-CM/PCS.

The implementation of ICD-10-CM/PCS will require organizations to capture detailed information at the point of care. Since ICD-10-CM/PCS provides increased specificity in its code sets, clinical documentation to support that specificity is critical. Specifically, providers don’t need to provide a higher volume of clinical documentation, but rather more precise documentation (i.e., laterality, specificity, anatomic sites, etc.). Proper documentation can be facilitated through the effective use of EHR templates and prompts, and the data repurposed throughout the EHR to support the “collect once, use many times” concept.

The meaningful use EHR standards and certification criteria have enhanced organizations’ ability to capture and exchange standardized, structured clinical content. Templates can also help support the capture of clinical content in a standardized and structured manner. Prompts or clinical decision support rules relevant to clinical specialties will result in meaningful patient data.

Leveraging these data collection tools will improve clinical documentation, leading to a higher quality of care for the patient through a better understanding of complications, better design of clinically robust algorithms, and better tracking of the outcomes of care. Greater detail and specificity offers many advantages, including the ability to discover previously unrecognized relationships in data, and the impact on public health by detecting developing epidemics in the early stages.

Prior to ICD-10 implementation, healthcare organizations will need to create templates and review and update existing templates to facilitate compliance with new documentation requirements. Reviewing and updating existing physician queries is one effective clinical documentation initiative. By employing the features available in custom template design, an organization or physician practice can modify the EHR to better fit their unique workflow needs.

Templates add the advantage of helping to remind providers to ask patients specific questions. The structured note will assist the physician with reminders to ensure his or her documentation is as complete and accurate as appropriate for ICD-10-CM/PCS coding guidelines. In a physician practice, for example, the ability to utilize different templates will allow the provider to simply choose by specialty (i.e., the “check-up” or “diabetes patient” template) at the start of the encounter. Reviewing and updating the physician query form is just one example of the type of template that will require attention.

This practice brief will identify best practices that ensure clinical documentation remains accurate when leveraging data tools like EHR templates and prompts. These best practices are designed to support and guide HIM professionals, providers, physician practice staff, clinicians, and other healthcare stakeholders through an effective transition to ICD-10-CM/PCS documentation requirements that ultimately improve the quality of healthcare.

Defining Templates and Prompts

Templates and prompts can be useful tools to ensure complete EHR documentation at the point of care. A template is an EHR documentation tool utilized for the collection, presentation and organization of clinical data elements. Prompts are a function of a template designed to trigger the provider to specify required or missing documentation.

Careful, thoughtful design and the ongoing review of EHR templates and prompts is essential to successful implementation and use. A collaborative approach that includes health information management services (HIMS), clinical documentation improvement (CDI) and quality staff, providers, and information technology (IT) representatives is recommended when implementing templates and prompts. Utilization of data from the CDI program will place a facility in a better position to design the specific prompts required for the template, resulting in more complete documentation.

To ensure success, templates should be used only where documentation is not optimal.1 Specifically, documentation needs should be identified in support of ICD-10-CM/PCS implementation. Those documentation areas with significant impact may require the design of new templates to capture the new information required. Templates should not be designed to broadly capture information. This can result in faulty template design that captures documentation in a way that makes all patients look the same.

There are advantages and disadvantages to using these tools. Templates and prompts can assist in improving the quality of care delivered and the completeness of documentation.2 Alternatively, providers may feel as though there are additional steps as the electronic prompts force their documentation requirements. Proper education, monitoring, and training will help support the use of these tools.

Customized Template Benefits

The ability to utilize different templates allows a single EHR solution to be flexible. Important benefits of template usage include:

  • Easy, standardized organization of clinical data
  • Single page views of patient data for quick reference
  • Ability to quickly manage an entire patient population
  • Time savings vs. having to browse through multiple patient files/pages
  • Increased percentage of chart completion
  • Standardized data capture, which helps to ensure accurate coding
  • More complete data fields which can lead to fewer under-billed appointments

“EHR 105: EHR and EHR Templates.” EHRapproved.com. 2011. http://www.emrapproved.com/pdf/phs-hitu/emru105_course.pdf.

Streamlining Workflow Processes

There may be ways to streamline the workflow process to mitigate some of the potential productivity losses that are expected to come with ICD-10-CM/PCS implementation. Designing workflows now may reduce the need for coding staff to initiate physician queries for missing or additional information in order to code a patient record. Deloitte published an article that discusses the importance of developing and executing strategies that include physician engagement and adoption of technology-driven templates and code selection tools. The article states,

“the development of enhanced electronic health record (EHR) templates to support clinical documentation needs can help ease provider adoption of the new code set. Finally, many organizations are considering the inclusion of the following ‘top five’ elements in their EHR templates: laterality, devices, episode of care, trimester, and root procedure.”3

Increased documentation initiatives may include creating or evaluating the volume of physician queries initiated monthly. Determining the “vital” documentation opportunities now will allow organizations to begin providing focused education and training.

In the outpatient setting “there are many advantages to creating templates in the EHR, there are also benefits to utilizing an EHR with integrated practice management, billing, and documentation tools. But to take full advantage of the EHR’s efficacy, a practice should look to the variety of methods for customization.”4 Leveraging the use of tailored elements in a custom template design is a popular method for customizing the EHR. The unique features developed through the customization of EHRs allows practices to create an EHR best suited to their specific needs. Some studies have found that an involved customization is important in order for the adoption of any EHR to be successful for a given practice.5

When discussing the improvements that will need to be made in preparation for ICD-10, Mike Davis, managing editor for the Advisory Board Company, stated in a HIMSS article that the “answer will call for the creation of discrete encoded data to support the ICD-10 coding process.”6 Dictation and transcription services are currently able to produce much of the physician documentation through new technology solutions, such as natural language processing (NLP), which work to mine text from the transcribed documents. Additionally, clinical vocabulary solutions can help code the resulting discrete data to a medical terminology such as SNOMED CT and pass the patient data to computer-assisted coding (CAC) applications, which can assist with coding quality and efficiency.

These workflow enhancements will need to be considered as facilities move toward structured template documentation for physicians. Beverly Dellinger, RN, clinical applications analyst at Wellspan Health, adds, “When clinical documentation workflows are adequately analyzed and weak points properly identified, the implementation of templates can add value by making the documentation process comprehensive, standardized, and produce timely display of documentation results.”

Documentation Considerations for ICD-10-CM/PCS

Physician documentation needs to be more granular to support the specificity in ICD-10-CM. The table “Documentation Considerations for ICD-10-CM” on page 68 discusses various concepts and provides considerations for documentation which should be captured using templates and prompts.

Documentation from the operative report will be critical in the selection of the appropriate ICD-10-PCS code. In order to make a code assignment, the following will need to be included in physician documentation:

  • Body system upon which the affected body part belongs (central nervous system, endocrine system, etc.)
  • Type of operation—describe clinically the procedure performed to the extent necessary for a coder to accurately translate the clinical description of the procedure to the appropriate root operation (i.e., resection, excision, etc.)
  • Specific part of the body and laterality where the procedure was performed (i.e., appendix, liver, etc.)
  • The approach taken to accomplish the procedure (i.e., open, laparoscopic, etc.)
  • The type of device (if any) that remains in the body upon completion of the procedure (i.e., grafts, implants, etc.)

Documentation areas for consideration when selecting a code include:

  • Selection of the root operation is dependent on properly determining the objective of the procedure—what will be accomplished through the procedure? A thorough explanation of the purpose of the procedure is necessary. For example, the terms “excision” and “resection” were used somewhat interchangeably in ICD-9-CM. In ICD-10-PCS, however, these terms represent completely different procedures.
  • Does the operative report state the specific site of the procedure? The body part selections and laterality are much more specific in ICD-10-PCS. Documentation must specify what body part was affected by the procedure. Some of the specific body parts identifiable in ICD-10-PCS are the anterior tibial artery, abdominal sympathetic nerve, and the thorax muscle, left.
  • Devices that remain in the body after the completion of the procedure must be documented. These include devices such as drains, non-autologous tissue substitutes, radioactive elements, and infusion pumps.
  • Qualifiers are represented as the seventh character in an ICD-10-PCS code. These will vary depending on the ICD-10-PCS code. Some examples include the types of pacemakers, graft materials, and hip prostheses. Qualifiers can also represent anatomical locations which are relevant to that particular procedure.7
Documentation Considerations for ICD-10-CM
ICD-10-CM Concepts Considerations ICD-10-CM Concepts Considerations
Injury
  • More specific documentation of the site of an injury, such as a fracture
  • Laterality of injury
  • Episode of care 7th character
    • Initial encounter for care of fracture
    • Subsequent encounter for fracture with routine healing
    • Subsequent encounter for fracture with delayed healing
    • Subsequent encounter for fracture nonunion
    • Subsequent encounter for fracture with malunion
    • Sequela
  • Categories S52, S72, and S82 are impacted by the Gustilo Fracture Classification
    • Fractures delineate displaced or nondisplaced as well as type of fracture, such as comminuted, spiral, segmental, etc.

Source: Simmons, Cortnie, “The Musculoskeletal System and ICD-10-CM.” ICD-Ten: Top Emerging News. April 2011

Under dosing

  • New concept for ICD-10-CM that refers to taking less of a medication than is prescribed by a provider or a manufacturer’s instruction
  • May be classified as due to financial hardship or the age-related debility of a patient

Source: Leon-Chisen, Nelly. ICD-10-CM and ICD-10-PCS Coding Handbook. Chicago, IL: AHA Press, 2012. p. 501

External Causes of Mortality

  • Episode of care 7th character
    • Initial encounter
    • Subsequent encounter
    • Sequela
  • New category for reporting medical devices associated with adverse incidents in diagnostic and therapeutic use

Source: Kostick, Karen. “Coding for External Causes of Mortality in ICD-10-CM.” Journal of AHIMA 82, no. 7 (July 2011): 56-58

Obstetrics

  • Episode of care
    • First, second, or third trimester of pregnancy
  • 7th character to be assigned with multiple gestations; identifies fetus to which the code applies
  • Twin pregnancy may be classified as monoamniotic/monochorionic

Source: Barta, Ann. “Obstetric Coding in ICD-10-CM/PCS.” Journal of AHIMA 81, no. 6 (June 2010): 68-70

Circulatory System

  • Acute myocardial infarction (AMI) time frame is four weeks or less
  • Certain AMI codes classify the responsible artery
  • Subsequent AMIs require historical time frame (within 4 weeks)
  • Angina terminology changes such as “with arteriosclerotic heart disease with documented spasm”

Source: Barta, Ann. “The Circulatory System and ICD-10-CM/PCS.” Journal of AHIMA 82, no. 5 (May 2011): 62-64

Neoplasms

  • Laterality classification is available for some neoplasms
  • Significant changes in terms describing forms of lymphoma and leukemia
  • Significant changes in terms describing polycythemia vera
  • Additional codes for liver cell carcinoma

Source: Bielby, Judy. “Coding Neoplasms in ICD-10-CM.” Journal of AHIMA 82, no. 10 (October 2011): 72-74

Lack of Specificity Prevalent

Educating providers on clinical documentation is as crucial as it is delicate. Physicians need a range of human and technological support to guide them to the documentation needed for the increased specificity of ICD-10-CM/PCS. There are multiple reasons that the documentation in the record may not be specific enough. Providers can perceive their documentation as clear in its intent. However, they may be missing critical documentation needed for coding. One should note that physicians are taught medicine during their education; documentation is not necessarily a part of their medical curriculum. For example, the physician may state that “the patient was grunting,” often meaning the patient was in acute respiratory failure. However, a coder cannot assume a diagnosis using such a general term. There is a difference in acuity by stating the disease more specifically.

Ensuring clear and concise documentation while the patient is still in the hospital is crucial to ensuring high quality care. Utilizing templates and clinical documentation specialists can provide the specificity needed to bridge the gap between the physician documentation and coding.

Stephanie Hays, medical coding quality consultant at Vanderbilt University Medical Center, based in Nashville, Tennessee, says her facility’s CDI program, in collaboration with the informatics department, is involved with a project that evaluates clinical documentation templates and then incorporates prompts that capture details required in ICD-10-CM/PCS. “The project will reduce the need to query providers by collecting required details up front, within their existing tools and templates,” Hays says. “Improved templates will allow providers to remain focused on patient care during the challenging transition to ICD-10.”

HIM’s Role in Template Design

While an interdisciplinary team is generally formed whenever electronic, template-based provider documentation is considered, HIM professionals are critical to the selection process when looking to develop or revise electronic templates in preparation for ICD-10-CM/PCS and should be involved in the template development and management process. The heightened specificity of ICD-10-CM/PCS will require clinicians to become more precise in their documentation, and the electronic templates and their associated alerts and reminders must support this change. HIM professionals should be involved with the design process to ensure well-written templates are developed that focus on documentation specificity. This specificity has the potential to enhance computer-assisted coding accuracy and coder productivity. Refer to “Appendix A” in the online version of this practice brief for more information on policy considerations.

As part of the design process, guidelines for the data entered into each field must be determined, as well as guidelines for allowing a comment area for “yes” and “no” answers. Quality initiatives should also be incorporated. Included with the proposed template, a standardized form signed by the requestor and the department head or service chief must be submitted to the workgroup or committee responsible for the implementation of the template. The request form should include the purpose of the template, proposed implementation timeline, and individuals responsible for testing the usability, training, and dissemination of the new or revised template. Refer to “Appendix B” online for a sample request form.

The requesting party should submit the formatted template following standardized guidelines approved by the appropriate organizational authority. The use of guidelines will add standardization and clarity when establishing templates. The guidelines should include:

  • Requirements of indentation
  • Punctuation
  • Capitalization
  • Headers
  • Indication of a required field
  • Verification of spelling of terms
  • Usage of abbreviations or reference to a legend of abbreviations
  • Review for proper grammar and word tense

Default values must be used with great caution to avoid inaccurate information. Coding nomenclature should not be included in a template. Note titles should be mapped to a standardized format for consistency and ease of retrievable documentation. A review process must be established and maintained on a regular basis to keep up a master list of templates, and to ensure that the template is being used, that information is still relevant, and to identify needed updates. Templates and note titles no longer used should be deactivated but not deleted so a historical library is maintained for templates existing prior to the classification system update to ICD-10-CM/PCS. Refer to “Appendix C” online for more information.

Talking with Physicians About Templates

Templates developed using evidence-based medicine should be designed to capture free text as well as structured data to accommodate the multiple specialties and subspecialties of medicine. In this way the user will be able to identify common data elements with the option of adding significant clinical findings for an individual patient.

With the implementation of EHRs, clinicians are now accustomed to the direct entry of clinical data into electronic systems. As a result, dictation for transcription of clinical notes and reports has decreased. However, the formats designed by the physicians, medical scribes, and medical transcriptionists for transcribed reports may be a good starting point for the creation of clinical templates in the EHR. The well-designed template will recognize that EHRs are primarily data-centric rather than document-centric.8

Working through the health record quality review committee, clinicians can ensure data elements supporting evidence-based medicine and quality care are captured in the EHR. This clinician-to-clinician approach, as well as identifying a physician champion for each clinical service, will be an effective way to design and educate clinicians on the use of templates for the EHR. Physician champions have been trained and can solicit cooperation from their peers. Physicians need to know that the accuracy of their documentation goes hand-in-hand with their physician profile performance reporting, benchmarking data, as well as profiling for patient care. Improved documentation of diagnoses and procedures that specifically affect ICD-10 code assignment will accurately capture severity, acuity, and risk of mortality data. “Motivating physicians to improve their documentation requires getting physicians to understand that proper documentation aligns with a better understanding of the patient’s history and current status, and this information aligns with better quality care,” says Thomas Payne, MD, in a Healthcare Financial Management Association report.9

Vendors and Patients Must Be Considered

Changes in regulations governing documentation, core measures, physician queries, medical necessity, and the implementation of ICD-10-CM/PCS all speak to the need for accurate, thorough, and precise documentation. The desire to meet the meaningful use requirements is expediting the adoption of EHR systems by hospitals and providers nationwide.

Vendors must have knowledge of the multiple requirements and uses of documentation. This will enable them to provide improved products and services to their customer base.

Templates are an ideal documentation tool to facilitate required documentation. However, care must be taken to ensure that the templates are not too prescriptive and are not complicated and time-consuming to use. To this end, physician participation must take place throughout the template development period.

The patient audience is equally important. Patients are increasingly experiencing visits where physicians face a computer and work their way through the EHR during the encounter instead of engaging in face-to-face conversation. The careful design of templates and effective physician training may help reduce patient perception that a physician is focused on the computer rather than the individual.

Daily progress note documentation is the responsibility of the medical staff. The documentation should include required elements and updated diagnoses and procedures when applicable. The collaboration between vendor and hospital client base should result in documentation tools that:

  • Reduce the amount of duplicative documentation by physicians
  • Contain key fields that will assist with accurate and specific code assignments
  • Automatically reproduce data on a coding worksheet to assist with coding
  • Populate a discharge summary with diagnoses and procedures from progress notes, post-procedure notes, consultations, operative reports, and other specified documentation
  • Include required fields for Joint Commission requirements and medical staff rules and regulations for specific documents (i.e., post-procedure notes, discharge summaries, etc.)

Vendors traditionally provide a basic EHR system that includes limited design workflows and templates. Ultimately, it is the responsibility of the healthcare provider to enhance and maintain additional workflows and templates. EHR vendors should have an understanding of the importance of documentation for primary and secondary data use, such as:

  • Medical necessity
  • Continuing care
  • Patient safety
  • Regulatory requirements
  • Coding
  • Quality measurement and reporting

Templates assist with standardization of essential elements in clinical documentation. This standardization will, in turn, result in the timely display of results, expedited chart searching, coordination of care among healthcare providers, and improved patient outcomes.10

Now is the time for healthcare facilities to merge meaningful use and ICD-10-CM/PCS planning initiatives and develop templates, prompts, and overall systems that facilitate and encourage documentation needed for patient care, severity of illness, intensity of services, coding, and reimbursement.

Appendices

Three appendices are available in the online version of this practice brief in the AHIMA Body of Knowledge at www.ahima.org:

Notes

  1. Russo, Ruthann. Clinical Documentation Improvement: Achieving Excellence. Chicago, IL: AHIMA Press, 2010, p. 153.
  2. Klauer, Kevin. Emergency Physicians Monthly. Published July 19, 2010.
  3. Deloitte. “Navigating the ICD-10 transition: Implementation imperative for hospitals and medical groups.” 2012, p. 5. http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/us_hcp_NavigatingICD10_041312.pdf.
  4. “EHR 105: EHR and EHR Templates.” EHRapproved.com. 2011. http://www.emrapproved.com/pdf/phs-hitu/emru105_course.pdf.
  5. Bennett, Kevin J., and Christian Steen. “Electronic Medical Record Customization and the Impact Upon Chart Completion Rates.” Family Medicine. May 2010. http://www.stfm.org/fmhub/fm2010/May/Kevin338.pdf.
  6. Davis, Mike. “ICD-10 Will Drive Enterprise Improvement Opportunities.” HIMSS. http://www.himss.org/asp/ContentRedirector.asp?ContentID=75664.
  7. Leon-Chisen, Nelly. ICD-10-CM and ICD-10-PCS Coding Handbook. Chicago, IL: AHA Press, 2012, p. 501.
  8. Kallem, Crystal; Burrington-Brown, Jill; Angela K Dinh. “Data Elements for EHR Documentation.” Journal of AHIMA 78, no. 7 (July-August 2007): web extra.
  9. HFMA. “Educational Report: Will Your Data Support Value-Based Payment?” May 2012. p. 5. http://www.hfma.org/hfma.org/datareadinessforvalue/.
  10. Dellinger, B. Personal interview. June 19, 2012.

References

Doty, Laura, and Marion G. Kruse. “Preparing for ICD-10 While in an ICD-9 World: The Importance of Clinical Documentation and Coding Integrity (CDCI™) Programs Being Early Adopters of ICD-10.” AHIMA Convention Proceedings, 2011.

Capanna, Alaina and Valerie Watzlaf. “Clinical Documentation Improvement and Use of Templates and Standards.” AHIMA Convention Proceedings, 2011.

“EHR and EHR Templates.” EMRapproved.com. August 2, 2012. http://www.emrapproved.com/emr-ehr-templates.php.

Kenneth, N., and J.D. Rashbaum. “EHR templates: Time-saver or patient safety risk?” Medical Economics. Jan. 10, 2012. http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=755244.

Authors

Jill S. Clark, MBA, RHIA, CHDA
Theresa A. Eichelmann, RHIA
Jan C. Fuller, RHIA, MBA, CPHIMS
Stephanie Hays, CDIP, RN, CPHQ
Becky B. Lobdell, MBA, RHIA
Nita Mangat
Maria Muscarella, RHIA
Kathleen Peterson, MS, RHIA, CCS
Carole Uknes, RHIA, CCS-P, MHA
Diana M. Warner, MS, RHIA, CHPS, FAHIMA

Acknowledgements

Sue Bowman, RHIA, CCS
Linda Darvill, RHIT
Beverly Dellinger, RN
Julie Dooling, RHIT
Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P
Kathy Giannangelo, MA, RHIA, CCS, CPHIMS, FAHIMA
Mary Beth Haugen, MS, RHIA
Pamela Heller, RHIA, CCS-P
Doreen Koch, RHIT
Priscilla Komara
Betty Lanzrath, MA, RHIA
Tammy R. Love, RHIA, CCS, CDIP
Jennifer McCollum, RHIA, CCS
Mary Reeves, RHIA
Theresa Rihanek, MHA, RHIA, CCS
Angela Dinh Rose, MHA, RHIA, CHPS
Allison Viola, MBA, RHIA
Jane Walters, MA, RHIA
Traci Waugh, RHIA
Lou Ann Wiedemann, MS, RHIA, FAHIMA, CPEH


The information contained in this practice brief reflects the consensus opinion of the professionals who developed it. It has not been validated through scientific research.


Article citation:
AHIMA. "Electronic Documentation Templates Support ICD-10-CM/PCS Implementation." Journal of AHIMA 83, no.10 (October 2012): 66-71.