Computer-assisted coding at the Cleveland Clinic: a strategic solution. Addressing clinical documentation improvement, ICD-10-CM/PCS implementation, and more.

摘要

HEALTHCARE REFORM, ELECTRONIC health records (EHRs), pay for performance, and ICD-10-CM/PCS are just some of the influences changing the landscape of health information management (HIM) quality and finance. Administrative data is used to measure patient care and clinical performance for hospitals and providers. In order for the administrative and coded data to be valid, the care provided to the patient needs to be documented with accuracy and completeness. Documentation requirements will increase with the conversion to ICD-10-CM/PCS.