Guiding Physicians to More Complete Documentation for Coding Accuracy

Physicians have been aware of the ICD-9 documentation “mountain” for years, and Clinical Documentation Improvement programs were created out of the need for more complete documentation. So the real question is: “How do we conquer the documentation challenges of ICD-10, which is more like climbing Mount Everest?” CDI specialists are not “Sherpas”. They might hand the physician a “map” or point them in the right direction but, unlike a Sherpa, they don’t “carry the pack,” or do the “heavy lifting”.

VitalWare™ introduces Sherpa, the Physician Documentation Ontology™ (PDO) engine, a cutting edge, patent pending, proprietary, concept-based ontology engine for medical documentation. The PDO engine was developed to be consumed as a web service or a deployed database for integration into EMRs, EHRs, coding, and other information systems. Sherpa assists in bridging the gaps between what the physician says or documents and what the coder needs to ensure accurate, specific and complete code assignment for an accurate bill. The PDO engine project was authored by VitalWare’s clinical and coding experts over the last 3 years to enhance and simplify the documentation process for physicians and their allied health professionals. Sherpa guides the physician by grouping medical concepts into clinically relevant “categories” and presents them during the patient encounter. Categories are organized according to clinical significance. Once all ontology concepts for a particular condition have been selected, the corresponding code and the selected medical concepts are available for inclusion in an Electronic Health Record or other repository. Medical documentation has been the lifeblood of the patient care process for centuries. By the 14th century, it was clear to many that categorizing medical conditions and methods of treatment was the best and only way to identify and study the relationship between process and outcome. Documentation and medical coding are intricately tied together in almost all aspects of healthcare, from patient care to research to the electronic health record to payment. Medical coding cannot be accurate and complete without the necessary documentation about the patient’s condition and treatment. The challenge is knowing what specifics must be documented in order to code correctly.

PDO Example with caption_logo and copyright

Additional PDO examples:
Torn Meniscus

As the industry moves from ICD-9 to ICD-10 the path becomes even more challenging. ICD-10 will introduce additional vocabulary and specificity that will need to be documented in the patient record in order to ensure all provided care is accurately and completely represented by the assigned codes.  Medical concepts may be known by several different terms, abbreviations, eponyms or acronyms. Sherpa is designed to link these “alias” terms to their corresponding medical concept, so initial searches yield equivalent terminology. The PDO engine embodies the full-spectrum of documentation concepts necessary to ensure complete documentation enabling accurate selection of medical codes based on those concepts.

Clavicle Fracture graph

Sherpa guides the physician to the most complete and accurate documentation whether it be for ICD-9 or ICD-10. If the physician documentation is explicit enough for ICD-10 coding, hospitals can’t help but see improved ICD-9 coding during the transition.

Features Benefits
Concept-based Physician Documentation Ontology Over 3 years in development associating all appropriate abbreviations, terms, aliases, eponyms, synonyms and acronyms
Simple and enhanced documentation process For both physicians and their allied health professionals
Identification of correct ICD-10 terminology Continually trains clinicians on updated ICD-10 terms and terminology
Easy search options All “alias” terms link to corresponding medical concepts so initial searches yield equivalent terminology results
Robust term/alias search Quickly limits the more than 150,000 ICD-10 code options
Proprietary clinical relevance algorithm Presents clinician with appropriate categorization criteria, weighted according to significance
Displays ICD-10 full descriptions Familiarizes clinicians with new vocabulary and the specificity requirements of ICD-10 codes
Concept related interdependencies Clinicians know (what has not yet been said) requirements based on previously documented concepts
Delivered as a web service database service or system Allows for flexibility in delivering robust documentation functionality in EMR, EHR, coding, or other information systems

VitalWare’s web services enable our partners to request and integrate data from the PDO engine to receive documentation requirements organized by category. Additional requests continue to limit the selection and display remaining requirements until complete, accurate results are achieved.