May 2, 2011

Coding Without Encoders? It’s Happening Again

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If you're making a checklist of things you'll need as you prepare for the transition from ICD-9-CM to ICD-10-CM/PCS, you can scratch off encoders because moving ahead to 2013, in some ways, is pretty much like stepping back into the past. And taking a step farther back in time you'll see why it could be goodbye encoders, hello code books.

In 1979, when the United States implemented ICD-9-CM, there were no encoders. All coding books were purchased through the government printing office, and they were all hardbound. Those active in what then was known as the medical record community and those who were involved in public health and the collection of health statistics were the only ones who understood the full impact of the transition to this new, improved, more detailed classification system.

Prior to 1979, there were multiple coding systems being used for hospital inpatients. The Eighth Revision of the International Classification of Diseases,  - Adapted for use in the United States (ICDA-8), was used to report diagnoses and procedure information for Medicare patients. The most widely used secondary system was the H-ICDA-8, which was developed by the Commission on Professional and Hospital Activities (CPHA) to be used in conjunction with the data collection system Professional Activity Study (PAS). Hospitals that participated in PAS completed paper abstracts of patient information, including the coding of the diagnoses and procedures, using the H-ICDA-8 classification system. This meant that staff pulled double duty, as the Medicare population required that the same diagnoses and procedures be coded using ICDA-8.

I-9: The National Landmark

In the foreword of the ICD-9-CM, Kerr L. White, M.D., chairman of the U.S. National Committee on Vital and Health Statistics stated that “the publication of ICD-9-CM constitutes both a national and an international landmark. In the former case, it means that one classification of diseases, injuries, impairments symptoms and causes of death will supplant the two or even three or four classification schemes that have confounded and confused clinical and statistical comparisons in the United States for a decade.”

A “national and international landmark,” the conversion to ICD-9-CM impacted a relatively small population when compared to the pending implementation of ICD-10-CM/PCS. The HIM community was as concerned about staff training as we are today, but the impact of becoming proficient in the new system was not the same then, because there was no reimbursement attached to the coding. Also, the number of coders who needed training was much smaller, and were all reporting to the HIM directors. There was no coding happening anywhere other than the HIM departments. The biggest concern, other than getting staff trained, was how were they going to manage having three coding books on their desks? My, how the times have changed.

Everywhere a Coder

Today’s healthcare coders are legion, and spread far and wide from the hospital HIM department to the most rural of family practitioner’s offices. Even within the hospital there can be coders in multiple areas not reporting through the same chain of command -  all of whom need trained in ICD-10-CM/PCS. Today’s coders are not concerned about the number of books on their desks, because the vast majority of them will be using some form of electronic encoder to assist them in their transition and continue to guide them in assigning the correct ICD-10-CM/PCS codes long after the October 1, 2013 implementation date. The encoder - along with all the other systems in place - needs to be updated to accommodate the new classification system.

Back to Code Books

But do you need an encoder to code with ICD-10-CM/PCS? No. The code books are available and are of a manageable size. You will need two of them since ICD-10-CM is diagnoses only and ICD-10-PCS is procedures only, and they are being currently used for all the training provided by AHIMA.  My personal preference for training new coders is to not allow them access to the encoder until they have become proficient in using the books. This was true for ICD-9-CM training and it will also be true for ICD-10-CM. The ICD-10-PCS book is very helpful, but it does not require the process of accessing the Index to then use the Tabular that coders are accustomed to  and which is still true with ICD-10-CM.

This is the time to evaluate your current encoder product and to compare with other options available. Ask yourself, what is needed in an encoder to get the user through the learning process and beyond the implementation of ICD-10-CM/PCS? I believe fundamentally  it needs the code books themselves. This includes all instructional notes of Includes/Excludes/and Notes. It also needs an ICD-10-CM/PCSbased DRG grouper, although this is not essential during the learning period. CMS has maintained the same case coded using the ICD-9 system, and the ICD-10 systems will group to the same DRG. CMS has demanded that this conversion to ICD-10-CM/PCS be budget-neutral.

All of the familiarity coders have with ICD-9-CM codes, rules and reimbursement implications ultimately will be  irrelevant. Even the most experienced coders will need much more information when beginning to code with ICD-10-CM/PCS. Maintaining convenient access to reference materials and clear edit messaging will be very important and should include making available the ICD-10-CM Official Guidelines for Coding and Reporting and the ICD-10-PCS Coding Guidelines. It also should include the AHA Coding Clinic for ICD-10-CM/PCS and the AHA ICD-10-CM/PCS Coding Handbook as soon as they become available. None of the users are going to know that a guideline exists, or that there is a rule associated with a specific code, so the accessibility of the references is going to be critical. You don’t want coders looking for guidelines that aren’t there, and you want applicable references to be displayed conveniently while not distracting or annoying the user. This will build the coders’ confidence that they are assigning these new codes accurately.

GEMs:  Tool of Choice

Another tool that can be used by coders during this transition/training period and should be made available in the encoder is the General Equivalence Mappings (GEMs), which will aid in converting from ICD-9 to ICD-10 and allow coders to become familiar with the ICD-10 equivalent codes. Since 95 percent of the ICD-10 codes are translated to a single ICD-9 code in the GEMs, this tool can be used for any analysis or conversion project.

Much has been published stating that current medical record documentation is not sufficiently detailed to allow for accurate coding in ICD-10-CM/PCS. But while documentation reflecting accurate and specific codes will result in higher-quality data, nonspecific codes are still available for use. This is the same argument made during the ICD-9-CM implementation, and I consider it to be fueling the fear factor of this conversion. I contend that the efforts directed toward documentation improvement should focus on clinical documentation from a pure perspective of clear, concise and thorough documentation, avoiding the matter of reimbursement implications. It is true, however, that some coders are going to require a greater knowledge of pathophysiology and human anatomy. It is also true that the use of ICD-10-CM/PCS likely will expose weaknesses in documentation practices.

Using the Encoder

An ICD-10-CM/PCS encoder also should provide translation from the traditional language of surgery used by both the medical community and the coder to the new language of surgery used by ICD-10-PCS, root operations. This should be made available to the user in as many formats as possible, and nothing should be assigned without the complete knowledge and acceptance of the coder. This is a whole new language, and as those of us who have been in the trenches for any length of time can attest, we still haven’t been entirely successful in our attempts at clinical documentation improvement that began in 1979 with the implementation of ICD-9-CM. These efforts further intensified in 1984 with the implementation of the CMS IPPS and the associated DRGs, yet in 2011 this is still a major focus for healthcare consultants and HIM practitioners alike.

As new ICD-10-CM/PCS reference material becomes available, your encoder vendor should be integrating it. It is important, however, to stay focused on “official” reference material, as inexperienced coders won’t be able to make their own determinations. You don’t want coders blindly to accept information that is not coming from an official source.
You also want your encoder to retain the information it currently provides for ICD-9-CM. As we all know, there are always those straggler cases that for whatever reason are not completed in a timely fashion, and users will want to access the reference information provided to address any future audits. At a minimum you want this retained for three years post-implementation, as RACs are going that far back.

Computer-Assisted Coding

Finally, no article on ICD-10-CM/PCS and encoding would be complete without mention of computer-assisted coding technology (CAC). CAC has the potential to alter the coding landscape radically by performing the first pass at coding. This is especially useful in outpatient settings where there can be “rote” coding of the same procedures over and over that can be handled accurately by the CAC systems. The use of CAC in conjunction with an encoder can improve consistency and productivity, which will help offset the loss of coder productivity during the transition period. It also frees up coders for validation of questionable cases, and to focus on coding the more difficult cases. Any new encoder should be one that can be integrated with any CAC product choice.

About the Author

Rebecca DeGrosky, RHIT, is the Product Manager for TruCode. She brings over 35 years experience in health information management.  She worked for 11 years in HIM software development for QuadraMed and MedAssets, including product management, content maintenance, implementation and training, and client support.  She is an active member of the Pennsylvania Health Information Management Association, where she has served on multiple committees including Chairman of the Education Committee and the Coding Roundtable.

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Read 180 times Updated on September 23, 2013
Rebecca DeGrosky, RHIT

Becky DeGrosky, RHIT, is the Product Manager for TruCode. She brings over 35 years experience in health information management.  She worked for 11 years in HIM software development for QuadraMed and MedAssets, including product management, content maintenance, implementation and training, and client support.  She is an active member of the Pennsylvania Health Information Management Association, where she has served on multiple committees including Chairman of the Education Committee and the Coding Roundtable.