Intersection of ICD-10 And Meaningful Use: Clinical Documentation Improvement

As hospitals, health systems and payers navigate the new risk-bearing landscape, synergies exist when clinical documentation improvement strategies are expanded to address both meaningful use (MU) SNOMED CT requirements and ICD-10. While the magnitude of the ICD-10 transition itself and the ongoing rumors of additional delays may tempt some organizations to pause in their pursuit of readiness, the bottom line is that advantages to clinical documentation can be realized even before the transition by using SNOMED CT within electronic health records.

When fully leveraged, healthcare organizations can realize significant benefits — improved capture of diagnosis and severity of illness, reporting, access to decision support and outcomes research to name a few. Financial analytics can also be applied to identify documentation changes that could result in improvements in capturing the appropriate case mix index and severity of illness.

As multiple federal initiatives converge to support greater health information exchange, one challenge that has to be overcome today regardless of the ICD-10 changeover date is semantic interoperability.  Lack of a common clinical vocabulary diminishes the accurate and timely sharing of critical patient data across disparate systems...