• Cynthia Reyes, Alissa Greenbaum, Catherine Porto, and John C Russell.
• Department of Surgery, university of new mexico, Albuquerque, New Mexico. Electronic address: Cynthia.Reyes-Ferral@Nemours.org.
• J. Am. Coll. Surg. 2017 Mar 1; 224 (3): 301-309.

BackgroundAccurate clinical documentation (CD) is necessary for many aspects of modern health care, including excellent communication, quality metrics reporting, and legal documentation. New requirements have mandated adoption of ICD-10-CM coding systems, adding another layer of complexity to CD. A clinical documentation improvement (CDI) and ICD-10 training program was created for health care providers in our academic surgery department. We aimed to assess the impact of our CDI curriculum by comparing quality metrics, coding, and reimbursement before and after implementation of our CDI program.Study DesignA CDI/ICD-10 training curriculum was instituted in September 2014 for all members of our university surgery department. The curriculum consisted of didactic lectures, 1-on-1 provider training, case reviews, e-learning modules, and CD queries from nurse CDI staff and hospital coders. Outcomes parameters included monthly documentation completion rates, severity of illness (SOI), risk of mortality (ROM), case-mix index (CMI), all-payer refined diagnosis-related groups (APR-DRG), and Surgical Care Improvement Program (SCIP) metrics. Financial gain from responses to CDI queries was determined retrospectively.ResultsSurgery department delinquent documentation decreased by 85% after CDI implementation. Compliance with SCIP measures improved from 85% to 97%. Significant increases in surgical SOI, ROM, CMI, and APR-DRG (all p < 0.01) were found after CDI/ICD-10 training implementation. Provider responses to CDI queries resulted in an estimated $4,672,786 increase in charges.ConclusionsClinical documentation improvement/ICD-10 training in an academic surgery department is an effective method to improve documentation rates, increase the hospital estimated reimbursement based on more accurate CD, and provide better compliance with surgical quality measures.Copyright © 2016 American College of Surgeons. All rights reserved.

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