International impact of clinical documentation

March 9, 2020 / By Felisha Bochantin

Illnesses do not discriminate by country, region or origin and the delivery of medicine remains universal. Illness are found everywhere around the globe; it only stands to reason that providers should also look beyond the borders of the U.S.-centric patient population when treating patients. This sounds simple, but with different languages and documentation standards in play it becomes challenging. Standardization is necessary to the integration of diagnostic language into an understandable dialect for all healthcare providers.

The World Health Organization (WHO) is leading the way, bringing standardization into realization with the International Classification of Diseases, Tenth Revision (ICD-10). This system is managed by WHO to monitor diseases and provide a look at population health in numerous countries. This classification system takes diagnoses and translates them into an alpha-numeric code. This provides the consistency needed to integrate complex medical language. The codes within this complex classification have transformed over the years to not only be used for statistical analysis, but to guide the reimbursement systems for several countries. (WHO, “Clinical Documentation an Era of Increasing Transparency”, World Health Organization, 2020)

The United States has figured out that much of the diagnostic documentation recorded by physicians is not detailed enough enable the assignment of detailed ICD-10 codes. This discovery has led to the inception of clinical documentation improvement (CDI) programs. CDI professionals are trained in the specific verbiage needed to translate diagnostic terms into the appropriate ICD-10 codes. CDI initiatives have become valuable resource for physicians to ensure their documentation is of the same excellence as the care they provide. (AHIMA, “Convergence of CDI” 2020)

CDI programs have been associated with positive outcomes in the U.S. The success has been evident in fostering appropriate reimbursement, accurate quality scores and a reduction in insurance payment denials. Statistical analysis also benefits from accurate ICD-10 code assignment, which provides data that has limitless reporting capabilities.

CDI improves the completeness, quality and specificity of documentation. This is necessary no matter where health care is delivered. The same types of initiatives which have driven CDI in the U.S. are underway in many countries and regions around the world. These include initiatives focused on improving the quality and safety of care, improving the health of populations and reducing the per capita costs of care. Healthcare delivery system transformation, privatization of care, contracting for care and even types of value-based purchasing are emerging.  CDI also supports diagnostic specificity. The level of specificity for an ICD-10 code is determined by the number of characters assigned. The first three characters are considered the category of a diagnosis. The characters that follow the category provide further details about the diagnosis. (AHIMA, “Convergence of CDI” 2020)

With the permission of the WHO, several countries have modified the ICD-10 codes into systems that can provide even greater detail. The U.S., Canada, Australia, and Saudi Arabia are a few countries leading the way in using the ICD-10 system to provide further details about the diseases that plague their patient populations. An example provided by the WHO shows how a femur fracture would look in ICD-10-CM, the clinical modification of ICD-10 in the U.S. You can take the level of detail in the documentation a step further by documenting “initial encounter for a non-displaced spiral fracture of the right femur shaft,” and expanding the ICD-10 code to S72.344A. This code goes beyond the location and offers the type, laterality and encounter information. This information can now be used to support medical necessity of payment, quality reporting and statistical analysis. (WHO, “Clinical Documentation an Era of Increasing Transparency”, World Health Organization, 2020)

Growing CDI efforts in Saudi Arabia:

In the Kingdom of Saudi Arabia, there is a movement toward privatization of health insurance and widespread use of AR-DRGs (Australian Refined – Diagnosis Related Groups) for inpatient reimbursement. With respect to health insurance, facilities will be required to demonstrate medical necessity of procedures by properly documenting the diagnoses. Insurance companies will utilize severity of illness, risk of mortality, intensity of service and length of stay as criteria to determine the level of reimbursement. The institution of CDI programs will help each facility meet the standards set by the payers. In the Kingdom of Saudi Arabia and throughout the world, CDI implementation is viewed with optimism.

Regardless of the country in which care was delivered or the code set was utilized, the only way to analyze for reliability is through high-quality clinical documentation. Within the medical sector outside the U.S., we see vastly different clinical coding systems and sets in use, but documentation is necessary regardless of coding sets used in order to get consistently reliable and usable data.

Felisha Bochantin is an International Population Health Clinical Analyst with 3M Health Information Systems.


Impact Of Clinical Documentation

World Health Organization. “International Classification of Diseases (ICD)

AHIMA HIM Educational Forum