March 31, 2014

A Win-Win: Now is the Time Providers Need to Accept There Is Value in Change

By

Take a deep breath – we now have the implementation of ICD-10 delayed one more year from Oct. 1, 2014. Will you be ready when Oct. 1, 2015 arrives? Take the time now to learn what you need to be documenting in your specialty by adding details of granularity. If your documentation provides specific details, the level of acuity and intensity with complexity of care provided should support the services. Make time to conduct reviews of your information recorded. Does your documentation support your selection of diagnosis codes, as well as the medical necessity for all aspects of care provided?

Benefits of improved documentation, now and in the future, include:

  1. Improved level of acuity and intensity, with complexity of services reported

  2. Improved provider profiles for patient care

  3. Improved timely reimbursement

  4. Decreases in the number of claims in adjudication (held claims/denied claims)

  5. Decreases in the amount of re-work for the billing/coding staff

With the healthcare industry in flux due to the change from the outdated system of ICD-9 codes to the complexity of ICD-10 coding system, we need to continue on this path. Why? It’s simple.

Providers who do not embrace documentation improvement are not demonstrating the level of acuity and intensity necessary for the complexity of services provided. Without changes, their data will continue to be inaccurate, affecting provider profiles and reimbursement issues such as claim denials, held claims for review of documentation, or reduced reimbursement.

At present, some providers continue to document patient information with little improvement in noting the level of acuity, intensity, or complexity of the services provided. What does this mean?

There is no change in specificity of documentation requirements between ICD-9-CM and ICD-10-CM for congestive heart failure, for example. Without the necessary details of the medical condition, the only supported code in either coding system indicates an “unspecified” condition.

The diagnosis of congestive heart failure under ICD-9-CM would be recorded as an unspecified heart failure with ICD-9-CM code 428.0. This also yields an unspecified code in ICD-10-CM, due to the lack of provider documentation details otherwise known as specificity with granularity. Without the specificity/granularity, the level of acuity and intensity/complexity of services are underreported. An interesting fact is that congestive heart failure documentation details are identical for supporting specificity/granularity in ICD-10-CM. There is no change, and thus no documentation improvement!

The level of documentation for congestive heart failure has been an issue for coders, who have queried many providers. The coders specifically have been asking for clarification or additional information that would allow for more accurate code selection, supporting a higher level of acuity and intensity with complexity of services. Unfortunately, among many the documentation has not improved. The following details need to be included to avoid unspecified codes:

  • Is the heart failure:
    • Acute (type)?
      • Location
      • Diastolic
      • Systolic
    • Chronic (type)?
      • Location
        • Diastolic
        • Systolic
    • Acute on chronic (type)?
      • Location
        • Diastolic
        • Systolic
    • Acute combined systolic & diastolic (Includes type & location)?
    • Chronic combined systolic & diastolic?
    • Unspecified systolic (lacks type)?
    • Unspecified diastolic (lacks type)?
    • Unspecified combined systolic & diastolic (lacks type)?
    • Unspecified heart failure (lacks type and location)?

Value-added documented information yields the story of the patient’s medical care, completely told through the translation of data affecting outcomes for the patient, the third-party payer, and the provider.

Now is the time to be proactive for positive outcomes to give credit where credit is due.

About the Author

Gretchen Dixon, MBA, RN, is a consultant at Hayes Management Consulting. She is a Certified Healthcare Compliance Officer, Certified Coding Specialist and internal auditor with more than 20 years of experience in the healthcare industry with an emphasis on clinical documentation improvement, compliance, revenue cycle and coding.

Contact the Author

To comment on this article please go to

Gretchen Dixon MBA, RN, CCS, CPCO, AHIMA-Approved ICD-10-CM/PCS Trainer and Ambassador,

Gretchen Dixon, MBA, RN, is a consultant at Hayes Management Consulting. She is a Certified Healthcare Compliance Officer, Certified Coding Specialist and internal auditor with more than 20 years of experience in the healthcare industry with an emphasis on clinical documentation improvement, compliance, revenue cycle and coding.

Latest from Gretchen Dixon MBA, RN, CCS, CPCO, AHIMA-Approved ICD-10-CM/PCS Trainer and Ambassador,