Revenue Cycle Management Blog | GroupOne Health Source

How Medical Transcription is Bridging the ICD-10 Documentation Gap

Written by Kaitlyn Houseman | March 8, 2016

It's been several months since the ICD-10 transition deadline, but that doesn't mean that every practice and hospital is fluent in ICD-10 just yet. With the number of codes increasing considerably from ICD-9 to ICD-10, and with longer codes that include far more specificity, it will take time for ICD-10 codes to become free-flowing and automatic, even among experienced coders.

Because ICD-10 requires complete, precise documentation, and because coding professionals can only apply codes correctly when documentation is accurate, an increasing number of facilities are outsourcing the medical transcription.

Medical transcription is absolutely essential because some electronic medical record systems (EMRs) can't capture every tiny detail of documentation. This can be especially true if an EMR is difficult to use and physicians are in a hurry. 

Transcription can improve physician documentation, and when used along with other tools like computer-assisted coding, it can improve accuracy of ICD-10 codes for more complete and accurate billing.

Hospitals Becoming More Interested in Transcription

There has been a sharp escalation in hospitals outsourcing medical transcription according to a new report by HIMSS analytics

Outsourced transcription has more than doubled among hospitals since 2010 and is expected to grow even more in 2016.

"I was recently looking at outsourced transcription – there were 1000 or so hospitals doing that in 2010, and it's up to about 2100 hospitals now," said Schuchardt. "Transcription is hard to do, it's low-margin and it requires a lot of effort."-Matt Schuchardt, HIMSS Analytics' director of market intelligence solutions sale

Third party agencies deliver short-turnaround transcribed medical records after review and quality checks. Then, the transcribed documents are sent back to clinicians and are reviewed by clinical documentation improvement specialists to check for gaps or inconsistencies. 

The more competently clinical notes are transcribed, the more detail is available to coding professionals, and the more accurate your claims will be. With ICD-10, getting the code right means making sure clinician notes are transcribed at a greater level of specificity and accuracy than was necessary under ICD-9, and transcription services can greatly assist with this.

Also: [ Why Your ICD-10 Transition Might Not Be a Long Term Success ]

What a Transcription Service Does

A transcription service (or in-house scribe) can bridge the gap between physician notes and ICD-10 codes by providing the level of detail that ICD-10 coding now demands. In fact, better documentation is perhaps the number one facilitator when it comes to accurate billing under ICD-10.

Clinicians have been dictating notes for years, and now outsourcing and technology assist with getting those notes into a coherent document that makes medical records more complete and helps coding professionals perform at an optimal level.

More detailed transcription may require an up-front investment of time, but it should result in a positive return on investment as more claims are coded correctly and fewer are rejected. A combination of in-house editing and entry of outsourced transcripts can keep turnaround time to a minimum.

How a Transcriptionist Can Accelerate ICD-10 Fluency

Computer-assisted coding tools are great, but they can only do so much, particularly when clinician documentation is vague, unclear, or incomplete. These systems can only code what's documented, so if documentation is inadequate, computer-assisted coding tools won't help much.

Developing fluency in ICD-10 requires clinicians to provide more granular documentation than what was required under ICD-9. Because dictation is an easier and faster method to complete physicians’ documentation process, physicians are able to provide that granular documentation needed for ICD-10 while freeing up time to see more patients.

Also: [ Is Transcription the Solution to Physician EMR Documentation Challenges? ]

Outsourcing Medical Transcription as a Solution

Since today's EMRs don't support handwritten notes, digital transcription of clinical notes is especially important. But finding a professional and accurate medical transcription service isn't always easy. Especially when adding transcription technology and processes into your existing workflows can seem complicated.

Outsourcing the medical transcription for your practice can be an easier route depending on your existing resources and time. With GroupOne it's easy. You send us your files whether it be by telephone or a hand-held digital recorder and get them the next day. We also offer STAT turnaround if requested and guarantee an on time delivery of your transcribed files with multiple methods of retrieval. 

With the adjustment to ICD-10 continuing apace, transcription is being seen as an important step in giving coding professionals and billing teams all the information they need to code and bill correctly. When well-integrated into workflows and EMR systems, transcription can ultimately improve care quality and increase revenues due to more accurate and complete coding.