CDI (7)

As a heightened awareness and acceptance of our inevitable transition to ICD-10 develops, many of you may be wondering how to approach the task of preparing your key stakeholders, coders, clinical documentation specialists and providers for the change. Certainly we all realize the need for additional education, but just where do you begin? The HIM profession typically approaches such a change to a new payment methodology by focusing on the differences between the current method and the new method. This would work for the transition to ICD-10-CM too, as there are certainly far more similarities between ICD-9-CM and ICD-10-CM than differences. But another viable option, and a bit of a more holistic approach, focuses on the foundation of ICD-10-CM referred to as the "axis of classification."

The phrase "axis of classification" simply means a way of classifying and studying diseases. When utilizing an axis of classification for morbid conditions, diseases are assigned to a system of categories based on established criteria. Such criteria may be based on the affected part of the body (anatomy), the nature of a disease process (pathophysiology), etiology or manifestation, etc. These represent some of the many axes of classification available in ICD-10-CM. The use of assorted axes of classification is necessary to meet the needs of a varied group of users in classifying diseases, injuries and other reasons for health services being provided in a wide array of healthcare settings.

Anatomy is the primary axis of classification of ICD-10-CM, as it was in ICD-9-CM. This is evident by the fact that most of the ICD-10-CM chapter titles reflect diseases of a particular body system, such as "Diseases of the Respiratory System" and "Diseases of the Nervous System," etc. ICD-10-CM employs many other axes as well, such as etiology, as found in Chapter One ("Certain Infectious and Parasitic Diseases"). A combination of multiple and diverse axes are used in classifying some diseases within the same chapter. When designing a disease classification system, the primary axis reflects the most important statistical and clinical aspects of the disease. For example, for a diagnosis of heart failure, the first axis of classification is "type" and the second is "acuity."

ICD-10-CM utilizes a variety of axes of classification, either alone or in some combination, such as:

  • Etiology
  • Manifestation or complication
  • Specificity of anatomical site
  • Chronicity (i.e. acute, subacute, chronic, unspecified vs. acute/subacute, chronic, unspecified, etc.)
  • Degree (i.e., mild, moderate, severe, unspecified vs total/complete, partial/incomplete, etc.)
  • Type (i.e., primary, secondary, unspecified, etc.)
  • Laterality (i.e., R/L/unspecified or R/L/bilateral/unspecified)
  • Episode of care (3-16 "extension" options, depending on code category)
  • Trimester (i.e., 1, 2, 3,unspecified, etc.)
  • Number of fetus (i.e. 1-5, other.)



It is the variation and combination of these axes of classification that contribute to the tremendous increase in the number of codes available for assignment in ICD-10-CM as compared to ICD-9-CM.

To illustrate, let's talk numbers!

For Fiscal Year 2012, there are a total of 14,567 valid ICD-9-CM diagnosis codes.

For the same year, there are a total of 79,503 draft ICD-10-CM diagnosis codes.

The axes of classification vary not only by diagnosis/condition, but also to a great extent by chapter. In examining code volume variations by chapter in the spreadsheet below, you can see that 54 percent of the ICD-10-CM codes available for assignment are classified to Chapter 19 ("Injury, Poisoning & Certain Other Consequences of External Causes").


Chapter Chapter Title Code Volume Code Volume Vol Rank
1 Certain Infectious & Parasitic Diseases 1270 1292 21
2 Neoplasms 988 2026 13
3 Diseases of the Blood & Blood-forming Organs 123 298 9
4 Endocrine, Nutritional & Metabolic Diseases 335 879 8
5 Mental & Behavioral Disorders 477 927 14
6 Diseases of the Nervous System 412 792 15
7 Diseases of the Eye & Adnexa (new chapter) 795 3100 6
8 Diseases of the Ear & Mastoid Process (new chapter) 192 855 5
9 Diseases of the Circulatory System 474 1587 7
10 Diseases of the Respiratory System 255 436 18
11 Diseases of the Digestive System 596 895 19
12 Diseases of Skin and Subcutaneous Tissue 204 950 4
13 Diseases of the Musculoskeletal System & Connective Tissue 892 7939 2
14 Diseases of the Genitourinary System 389 726 16
15 Pregnancy, Childbirth & Puerperium 1104 2539 10
16 Certain Conditions Originating in the Perinatal Period 281 504 17
17 Congenital Malformations, Deformations & Chromosomal Abnormalities 421 944 11
18 Symptoms, Signs & Abnormal Clinical & Laboratory Findings 372 777 12
19 Injury, Poisoning & Certain Other Consequences of External Causes 2587 42970 1
20 External Causes or Morbidity (new chapter) 1291 7518 3
21 Factors Influencing Health Status & Contact with Health Services (new chapter) 1109 1549 20



In ICD-9-CM, code range 800-999 has 2,587 codes, while the corresponding section in the FY 2012 draft version of ICD-10-CM (code range S00-T98) has 42,970 code options. Yes, that is right: a volume increase of 40,383 codes (or, stated another way, a 1,561 percent increase over the number of code options available in ICD-9-CM). That is more than half of the total codes in the entire ICD-10-CM code set. So essentially, by analyzing and learning just one chapter out of the 21 included in ICD-10-CM, you have just mastered more than half of the codes in the new code set. Not a bad plan of attack, I'd say! Let's keep going...

The codes in Chapter 19 are used to report a variety of injuries, such as burns and traumatic fractures, poisonings, adverse effects of drugs and a new category, "underdosing." Let's begin with the "injuries" category.

When coding injuries using ICD-10-CM, the first axis of classification is the body region affected (such as head, neck, thorax, etc.) Unlike in ICD-9-CM, injuries in ICD-10-CM are grouped by body part affected, not by categories of injury. For example, different injuries of the hand are all grouped together. The second axis of classification of injuries is the specific type of injury (such as superficial, open wound, fracture, dislocation and sprain, injuries to nerves, blood vessels, muscle and tendon damage, crushing injuries, traumatic amputation, other or unspecified injuries, etc.) Laterality is used for most codes in Chapter 19, such as injuries, and a seventh character is used to report the episode of care (such as initial, subsequent or sequel).

Example: S31.123A Laceration of abdominal wall with foreign body, right upper quadrant without penetration into peritoneal cavity

Burns in ICD-10-CM are classified by heat source - thermal (T20-32) vs. sunburn (L55.-) vs. radiation (L55- L59) - in addition to anatomical site.

Example: T23.231A, Burn of second degree of multiple right fingers, not including thumb, initial encounter

The coding of traumatic fractures exposes us to a combination of axes of classification, such as:

  • Specific anatomical site (less specified or unspecified code options are still available).
  • Type of fracture: displaced or nondisplaced. Displaced is the default.
  • Seventh digits used to capture whether a fracture is "open" or "closed" (
  • "closed" is the default).

Open fractures also require documentation of Gustilo Type I, II, IIIA, IIIB, IIIC.

  • Episode of care, with anywhere from 3-16 options available to report .
    • Initial, subsequent or sequela.
      • A subsequent episode of care also requires documentation of:
        • Routine healing
        • Delayed healing
        • Nonunion
        • Malunion
  • Fracture of surgical neck of the humerus, which is further specified as to whether the fracture is a two-, three- or four-part fracture.
  • Fracture of humeral shaft by fracture type, such as greenstick, transverse, oblique, spiral, comminuted, segmental, other or unspecified.



Example: S72.044A, Nondisplaced fracture of base of the neck of right femur, initial encounter

Poisonings by and adverse effects of drugs, medical and biological substances are combined under a single category, listed by specific drug(s) involved. Underdosing, defined as taking less of a medication than is prescribed by a provider or manufacturer's instructions with negative health consequences, is added as new terminology and combined with poisonings by and adverse effects of drugs, medical and biological substances by specific drug.

Example: T40.1x1A, Poisoning by heroin, accidental (unintentional), initial encounter

This provides a quick overview of Chapter 19 in ICD-10-CM. If you approach each chapter in a similar manner - by focusing on the use of axes of classification - learning ICD-10-CM becomes a little less daunting. By comparing your current documentation to the axes of classification available for the same diagnoses in ICD-10-CM, you will be able to identify those areas where current documentation is inadequate to fully take advantage of the granularity available in ICD-10-CM.

About the Author

Angela Carmichael, MBA, RHIA, CCS, CCS-P, is director of HIM compliance for J.A. Thomas & Associates. Angela earned a Bachelor of Science degree, in Health Services Administration from Barry University and a MBA from Nova Southeastern University. She is a Registered Health Information Administrator and also has achieved the designations of Certified Coding Specialist, and Certified Coding Specialist-Physician and AHIMA Approved ICD-10-CM/PCS Instructor.

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By now you all have heard about the transition to ICD-10-CM/PCS, particularly the increase in the volume of codes, the change in code structure and the predicted impact on productivity. Interestingly enough, however, there has been very little available information regarding the predicted impact of ICD-10 on provider reimbursement.

Based on recent projections, the cost to transition to ICD-10 will be approximately $80 million more than the benefit savings—at least during the first 15 years. As a result, there will be “winners” and “losers” in the transition. Given the transition costs that both providers and payers must bear, it is even more imperative to understand ICD-10’s predicted impact on reimbursement to ensure adequate preparation and, ultimately, success. So with one goal in mind, to determine the potential impact of ICD-10 on facility-based provider reimbursement, I’d like to share what I’ve uncovered.

Determining the Impact on Reimbursement

The first step in determining the potential impact of ICD-10 on facility-based reimbursement is to consider which payers will be required to use ICD-10 codes. Often when we talk about ICD-10 we tend to focus on CMS and its MS-DRG payment methodology, however based on the fact that all HIPAA-covered entities are required to transition to ICD-10, all payers will utilize ICD-10 codes, with the exception of liability payers. (The liability payers would benefit from ICD-10’s granularity, so it is likely just a matter of time before they transition as well.)

The next step requires us to consider the current use of ICD-9-CM codes and their impact on all the major payment methods used to reimburse facility-based providers. Examining the number of payment methods that currently utilize ICD-9-CM codes to determine payment reveals that there are a number of payers, provider settings and payment methodologies that will be impacted by the transition to ICD-10 – not just acute-care inpatient Medicare stays.

The likelihood of some payment methodologies to be impacted by ICD-10 to a greater degree than others is a function of both inherent and intentional impact.

Inherent impact represents compromises a payer must make in converting to the new code sets in an attempt to remain revenue neutral that result purely from the differences between the three code sets (ICD-9-CM, ICD-10-CM and ICD-10-PCS).

Intentional impact, however, is the conscious effort to take advantage of the granularity in ICD-10 to change reimbursement (either up or down). Inherent and intentional impacts will affect both payers and providers to some degree, primarily based on each payment methodology’s dependence on ICD codes to determine payments. Certainly, not all payment methods are based on diagnosis and procedure codes, but those that are will be the most vulnerable to manipulation by payers and providers.

This financial risk could be favorable for a payer, for example, and unfavorable for a provider (or vice versa) depending on who is better prepared to use ICD-10 granularity as a strategic advantage.

So, what payment methodologies have the greatest opportunities for manipulation with ICD-10? Table 1 provides a list of various methodologies used to reimburse facility-based providers and their vulnerabilities to both compromises and manipulations as they pertain to ICD-10.



Table 1.

Reimbursement Scheme

Inherent Impact

Intentional Impact





Case Rate


Potentially significant




Potentially significant




Potentially significant




Potentially significant




Potentially significant


Inpatient Rehab PPS (IRF-PPS)

Skilled Nursing (RUGs)

Home Health (HHRGs)

Risk Adjustment (HCC/RXHCC)







Potentially significant

Potentially significant


Case Rate Carve-outs

Minimal to moderate



Episode-based Reimbursement

Minimal to moderate



Performance-based (HEDIS)




Hospital-billed Charges

Usual and Customary Reimbursement

Minimal to none


Minimal to none


Professional Services

Inpatient Billed Charges

Inpatient MS-DRG Rate

Minimal to none

Minimal to none


Minimal to none

Minimal to none

Potentially significant






Source: Compiled based on ICD-10 Impact on Provider Reimbursement, Patricia Zenner, RN, Milliman, March 2010



For Medicare, the ICD-10 versions of MS-DRGs were developed with the goal of revenue neutrality in the short term, or within the first two years. For this reason, CMS use of MS-DRGs is unlikely to cause a significant redistribution of payments across hospitals. However, once sufficient ICD-10 data becomes available, CMS likely will use the increased specificity of ICD-10 to stratify payments using MS-DRGs further. If hospitals are losing money under the current ICD-9 version of MS-DRGs, inadequate clinical documentation will continue to result in underpayments and flawed data under ICD-10.

Commercial payers have about an 18-month lead in preparing and planning for ICD-10. As a result, they are in a better position to be strategic with ICD-10 and utilize what they have learned to manipulate payments to their advantage. As a provider, the goal of revenue neutrality requires coding accuracy with ICD-10: certainly no small feat. The goal of strategic advantage, however, requires both clinical documentation improvement and accurate coding. In the end, depending on the payer’s chosen payment method and its dependence on coded data for reimbursement, accurate payment will be dependent on a robust clinical documentation improvement program and accurate code assignment.

About the Author

Angela Carmichael, MBA, RHIA, CCS, CCS-P, is director of HIM compliance for J.A. Thomas & Associates. Angela earned a Bachelor of Science degree, in Health Services Administration from Barry University and a MBA from Nova Southeastern University. She is a Registered Health Information Administrator and also has achieved the designations of Certified Coding Specialist, and Certified Coding Specialist-Physician and AHIMA Approved ICD-10-CM/PCS Instructor.

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Training healthcare professionals in ICD-10 implementation and usage during the past two years has unveiled some gaps in the way physicians document compared to the way an ICD-10 manual is written for selection of the most precise diagnosis codes.

In order to ensure a successful transition to ICD-10, it is imperative that coders possess a much deeper understanding of physician documentation and disease processes. Providers will be in need of education on the expectations of ICD-10 and how to align documentation with coding guidelines.

With ICD-10 implementation only two years away, there are many things that must be considered as part of an effort to be prepared for the upcoming changes. First things first: the migration to the electronic version of 5010 is just two months away!

There are many improvements that 5010 will bring regarding the electronic submission of claims. For example, 5010 will allow a hospital to report whether or not a diagnosis was present on admission (POA), and it will provide clarity in the front matter sent to the payer. It is also a necessary change to allow ICD-10 codes to be reported in an electronic format. While the deadline for 5010 compliance is Jan. 1, 2012, we will not be able to use ICD-10 codes until Oct. 1, 2013.

Once a successful migration of 5010 has been completed, many will be left wondering what they can do to prepare for ICD-10 implementation. It is important to remember that individuals must receive the right training at the right time, and this training should cover anticipated areas of change related to ICD-10.  Solutions and tools should be offered in order to begin the process of organizing the implementation effort. The training should have an interactive approach so as to provide a comfortable learning environment for all while also encouraging networking with peers to build professional relationships with others in the healthcare community.

Other training should include an overview of ICD-10 code and guideline changes, with additional guidance offering the ability to work through coding cases to get a hands-on understanding of how ICD-10-CM differs from ICD-9-CM.

Documenting Challenges

What we are hearing from the field is that one of the most common areas of concern involves how organizations will be able to educate physicians and providers about how to document so that ICD-10-CM codes can be assigned to the highest levels of specificity. There are many challenges coders face today regarding insufficient documentation, and with the available code choices increasing from approximately 14,000 to approximately 69,000, there undoubtedly will be new challenges faced by all.

The most effective way to ensure that documentation will meet the requirements of ICD-10 is to begin performing documentation readiness assessments now. Providers will need to understand what the expectations are so they can document accordingly. It is important to perform these assessments early and offer appropriate education to staff promptly so that when Oct. 1, 2013 arrives, they already will be documenting to ICD-10 standards, making the transition seamless.

Once these assessments are performed it also is important that providers are educated on the findings so they can begin to understand and incorporate the changes in their documentation that will be required in 2013.

Another concern is how codes will be cross walked for use in electronic health records (EHR or EMR). This is an area that should be scrutinized heavily by every practice or institution. Some practices will rely primarily on their vendors for this, so it is extremely important to understand what questions to ask of the vendors as well as to determine the projected costs of any software or hardware that may be required. It is imperative that practices develop a solid understanding of how their vendors will develop the ICD-10-CM codes for their use.

An in-depth understanding of anatomy and pathophysiology also will be very important in being able to assign appropriate ICD-10-CM codes to the highest level of specificity. It is recommended that coders and billers take a refresher course on A&P to ensure a solid understanding of disease processes and the clinical language used by providers. There always have been discrepancies in the languages spoken by providers and coders. But it is the coder’s responsibility to assist providers in understanding how each patient’s condition must be reported to payers to ensure prompt and appropriate reimbursement for services.



Change is coming. The question remains, can coders facilitate the change? With proper training and education, the resounding answer is “yes.” But time is running out.

About the Author

Kimberly Reid, CPC, CPMA, CEMC, CPC-I, is the Director, ICD-10 Development and Training for AAPC.

Kim brings more than 22 years of progressive coding experience in healthcare to her role as director of ICD-10 development and training for AAPC. She has a vast range of knowledge developed from working in a variety of professional medical settings, including a large academic medical group in Vermont with 500+ physicians. Her most recent role as a senior coding educator proved her success in leading physicians and students to achieve comprehensive levels of understanding on complex coding and documentation guidelines. She is a national speaker who presents regularly on various coding topics across the country.

At this point in time, preparation efforts for ICD-10 should be well underway, with most providers having completed at least Phase 1 (“Impact Assessment”) and some having covered Phase 2 (“Overall Implementation”) from AHIMA’s June 2007 ICD-10 Preparation Checklist.

As suggested by AHIMA, preparation and implementation planning for ICD-10 should be accomplished in a phased approach. As such, Phase 1, which also covers implementation plan development, was recommended to be completed sometime between the first quarter of 2009 and the second quarter of 2011, while work on Phase 2 should have begun during the first quarter of 2011.

The tasks associated with Phases 1 and 2 from AHIMA’s abbreviated checklist are included here for your review, along with our suggestions for adequately preparing your physicians, clinical documentation specialists and coding professionals.

Phase 1

Organization-wide Implementation Strategy

  • Establish a cross-functional team to prepare for 5010 transaction standard and ICD-10-CM/PCS code sets;
  • Create a communication plan to provide awareness training and status updates;
  • Assess organization readiness for data standard changes and data conversion options;
  • Ensure that the health information management team is aware of the benefits and value of ICD-10, and assess education needs;
  • Develop budgets for 5010 and ICD-10 implementation;
  • Evaluate data, workflows and operational processes for improvement opportunities; and
  • Determine the extent of changes required for systems, processes, policies and procedures.

Information Systems

  • Orient IS staff on specifications of the code set and HIPAA changes;
  • Perform a comprehensive systems audit for ICD-10 compatibility;
  • Determine vendor readiness and timelines for upgrading software;
  • Build flexibility into systems to ensure ICD-10 compatibility; and
  • Perform (with IT vendors) a comprehensive system audit for necessary HIPAA transaction changes.

Education of Coding Professionals

  • Assess staff knowledge and skills necessary to translate clinical data into codes for secondary use.

Documentation Improvement

  • Conduct medical record documentation assessments to Identify documentation improvement opportunities;
  • Identify a physician champion to assist in communicating and resolving documentation deficiencies;
  • Implement a documentation improvement program to target deficiencies; and
  • Report documentation assessment and improvements to senior management.



Note that ICD-10-CM does not require improvements in documentation, as many nonspecific code options have been retained, but high-quality documentation still will increase the benefits of a new coding system and increasingly is being demanded by other initiatives such as value-based purchasing. Procedure code assignment using ICD-10-PCS may require improved documentation in order to assign procedure codes, as there are very limited code options for nonspecific procedures.

Phase 2

Organization-wide Implementation Strategy

  • Contact payers, business associates, other HIPAA trading partners and vendors for ongoing updates, preparations, and testing for HIPAA transaction standards and ICD-10 changes;
  • Develop strategies to minimize problems during transition;
  • Revise processes, policies and procedures as appropriate;
  • Determine the impact of the coding system change on longitudinal data analysis;
  • Provide updates to senior management and affected staff; and
  • Develop a schedule leading up to “going live,” establishing key stakeholders’ roles and responsibilities.

Information Systems

  • Follow up with system developers or suppliers regarding their readiness;
  • Modify reports and redesign forms identified in Phase 1;
  • Implement and test system changes, including in-house and proprietary changes; and
  • Maintain testing schedules with vendors and all HIPAA and ICD-10 trading partners.

Education of Coding Professionals

  • Coding staff should increase familiarity with new coding systems and associated coding guidelines.

Documentation Improvement

  • Continue to assess and improve medical record documentation practices, engaging clinical staff in the process.

Awareness Training

Phase 1 of the ICD-10 preparation includes the provision of awareness training. While this training is necessary for the organization as a whole, physicians, clinical documentation specialists and coders should be the primary recipients. ICD-10 awareness training provides:

  • An introduction to ICD-10-CM/PCS;
  • Tips for preparing for the transition;
  • Understanding of the impact; and
  • The dispelling of myths.

Awareness training should have begun in 2009, continuing through 2011. This training is important in that it provides a foundation for the next two phases of training for your CDI team: developmental and role-specific training.



Developmental Training

Developmental training involves assessing and acquiring, core skills commonly referred to as biomedical skills. Biomedical training would cover medical terminology, anatomy and physiology, pathophysiology, and pharmacology. Skills in these areas are critical to learning and working successfully with ICD-10-CM/PCS. While it is argued that both the CDS and coder already have advanced knowledge of biomedical subjects, there are many reasons why an assessment of this knowledge, coupled with additional training, is of great value in preparing for ICD-10-CM/PCS.

First of all, most of us in CDS and coding roles received our biomedical training decades ago. This is concerning because research indicates that when we are exposed to a complex idea in a short amount of time, at the end of 30 days most of us will have retained less than 10 percent of the material. Much of the education acquired in biomedical courses taken during those early college years was not utilized while working with ICD-9-CM due to its lack of specificity. The same cannot be said for either ICD-10-CM or ICD-10-PCS. In fact, ICD-10-CM/PCS has tens of thousands more terms than ICD-9-CM.

To use ICD-10-CM/PCS effectively, coders and CDS staff must know:

  • Greek and Latin prefixes, suffixes, roots and combining forms, which are used as the basis of most medical terms;
  • Commonly accepted and approved medical abbreviations;
  • Eponyms and names of syndromes;
  • Alternative names and descriptions for diseases;
  • Adjectives used to describe and define diseases and disorders (purulent, necrotic, etc.);
  • Verbs and terms used to describe surgical approaches and techniques (resect, dissect, incise, excise, aspirate, -scopic, -otomy, -ectomy, etc.); and
  • Technology-driven and manufacturer-given names for tests, devices and procedures.

JATA suggests that developmental training begin either in 2012 or early 2013, prior to the start of the next phase of training, which is referred to as “role-specific training.”

Role-Specific Training

The scope and depth of role-specific training is dependent on the role of the individual, such as a physician, CDS or coder. At minimum, the following role-specific training would be required:


Study of clinical documentation requirements of ICD-10-CM/PCS, by specialty

(Note: J.A. Thomas and Associates advises utilizing a physician ICD-10-CM/PCS expert to provide both physician awareness and role-specific training).


Study of:

Clinical documentation requirements unique to ICD-10-CM/PCS;

Official coding guideline changes;

CDI software training; and

Possibly ICD-10 coding training, depending on the sophistication of software used to develop clarifications/queries.




Study of:

Clinical documentation requirements unique to ICD-10-CM/PCS;

Official coding guideline changes;

Coding training (basic, intermediate and advanced); and

Encoder software enhancements.

In the end, there are no shortcuts to preparing your CDI team for ICD-10. To stay on track with your preparedness efforts, we advise making 2011 the “year of awareness,” 2012 the ”year of development” and 2013 the “year of role-specific training.”

About the Author

Angela Carmichael, MBA, RHIA, CCS, CCS-P, joined J.A. Thomas & Associates in 2008. She is a HIM Product Development Specialist specializing in clinical documentation improvement, coding education & reimbursement methodologies. Angela earned a Bachelor of Science degree, in Health Services Administration from Barry University and a MBA from Nova Southeastern University. She is a Registered Health Information Administrator and also has achieved the designations of Certified Coding Specialist, and Certified Coding Specialist-Physician and AHIMA Approved ICD-10-CM/PCS Instructor.

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Change is life’s only constant. To that end, the long-anticipated transition to ICD-10 is imminent and preparations are beginning now even though the launch date is Oct. 1, 2013.

If your first inclination to this statement is an autonomic sympathetic response (flight or fight), take a deep breath and commit to an exciting time in the coding and documentation industry. The following questions and answers examine the role and preparation of documentation specialists when it comes to ICD-10.

Does the CDS need to be a professional coder?

Documentation specialists do not need to become coders to achieve success in ICD-10. Having said that, the clinical documentation specialist (CDS) does need to understand coding structure and what documentation is important for coding specificity required by ICD-10.The DRGs will not change initially; that’s a blessing for all since at least something will remain familiar.

The CDS is a key team member who will ensure that the clinical terminology necessary for measuring quality, safety, efficacy of care and compliant reimbursement is documented by providers. And this is true even though the code set will increase to some 155,000 codes in ICD-CM-10.

Is the RN CDS’s clinical expertise and experience advantageous?

Strong clinical and pharmacology knowledge certainly provides the necessary foundation for the RN CDS’s ability to recognize potentially under-documented diagnoses in the medical record. But do not be overconfident or think you are off the hook because of your clinical background. The clinical specificity required for both procedural coding and diagnostic coding is tremendous. When was the last time you reviewed the vascular tree or considered the different large bowel segments, all of which will be necessary for accurate coding specificity? It is anticipated that the majority of documentation strategies will remain the same in ICD-CM-10: the second blessing for all.

Why the big uproar over ICD-CM-10, and what benefits does it bring to patient care and reimbursement?

The recent CMS inpatient hospital mandate for value-based purchasing (VBP) incentive payments largely will be determined by coded data. The mandate and development of accountable care organizations (ACO) focus on clinical integration and management of population health. Population health metrics are derived from coded data. The current ICD-9 code set is outdated and inaccurate. Although CMS will not be adding new codes or DRGs during the first two years of ICD-10 implementation, it is those first two years that will be scrutinized closely. Hopefully the documentation and final coding will mirror accepted clinical practice. Delving into the data should reveal the outcomes.


What about physician education?

Physicians will want to know and need to understand why ICD-10 is important to the integrity, accuracy and pertinence of documentation as they get caught up in healthcare reform and all the other mandates being established. They will look to the documentation specialists and coders for support, education, and some tolerance and forgiveness. A steady infusion of ICD-10 education and awareness favors acceptance and retention versus a last-minute, fire-hose approach. The right time to begin ICD-10 physician education and awareness is now.

Next Steps for the CDI Team

  1. 1. Educate yourselves. Take advantage of education from reputable sources. Beef up your anatomy and physiology knowledge; you will need it to be successful in ICD-10.
  2. 2. Update your CDI communication and education plans to include ICD-10. This is a team initiative calling for your involvement. Create a timeline for staging your education.
  3. 3. Consider the challenges facing CDI management when it comes to timely evaluation of benchmarks in ICD-10. It is predicted that coder productivity initially will decrease by 20 to 50 percent. Use concurrent reports to forecast program benefits, monitor benchmarks and manage accordingly. Revisit remittance advice verifying DRG reimbursement.
  4. 4. Request and be apprised of any ICD-9-to-ICD-10 translation assessment findings. This will help you target areas for documentation specificity improvements.
  5. 5. Begin clarifying how ICD-10 will affect documentation for physicians one year prior to the official ICD-10 launch. This will help ease the perceived burden of increased clarifications.


Your success with documentation improvement in ICD-10 should be similar to your current success with documentation improvement in ICD-9. If you approach ICD-10 transition with the same energy, focus and commitment you invested in your initial CDI implementation and program management, you will get the same results.

About the Author

Melinda Tully, MSN, CCDS, is Senior Vice President of Clinical Services and Education for J.A. Thomas & Associates. Melinda has 25+ years in Acute Care as a Clinical Specialist and Nurse Practitioner. Her area of specialty is clinical documentation education focused on continuous quality improvement.

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“Insufficient documentation” has long been the battle cry of Medicare contractors conducting claim reviews—and a key challenge for the transition to a more comprehensive coding system was a theme echoed during the recent American Health Information Management Association’s (AHIMA) 2011 ICD-10 Summit that brought together more than 500 health information professionals, providers, payers, and vendors came together in Baltimore in mid-April.


The simple fact of the matter is that documentation, as it is currently provided by clinicians, will not make full use of the new code set. Without comprehensive documentation, coders won’t have enough data to record the new codes to their fullest extent, according to a summary in the Journal of AHIMA(1).


As Ann Watt, MBA, RHIA, the Joint Commission’s associate director, department of quality measurement, said, “There is a tremendous educational challenge in terms of physicians documenting practices and making sure they understand the level of specificity needed in the record.”


Other presentations, discussions, and overheard conversations revealed several key areas of concern, which are briefly summarized below.


Digging for the Details

Expectedly, system inventories have been at the top of everyone’s to-do list, and summit attendees have begun to identify databases, systems’ applications, and interfaces that currently use ICD-9 codes and, subsequently, will need to be switched to ICD-10. Many expressed surprise at “how deeply the ICD code set had worked its way into the enterprise’s operations.”


For example, Linda Martin, MA, PMP, Banner’s information technology project management senior consultant, said, “This kept me up at night as we were uncovering more areas that were affected. It was just mind-boggling.” To get control, Banner developed a spreadsheet listing all applications, interfaces, and report extracts across all business units.


Delivering Specific Documentation


On this point, discussion revolved around how the electronic health record (EHR) system might help with that challenge “by triggering documentation alerts for clinicians, reminding them that the new code set requires additional specificity, such as the severity level…” Many attendees left the summit realizing that they needed to contact their software vendors about the EHR and its capacity to nudge clinicians toward providing more comprehensive data.


Coding Consensus


It’s too soon for coding professionals to begin in-depth training on the new code sets since implementation is still more than two years away. However, HIM professionals agree that coders may begin to work with more specific documentation.



(1)American Health Information Management Association, “ICD-10 in 2011: A Report from the AHIMA 2011 ICD-10 Summit,” Journal of AHIMA, April 27, 2011,



For example, managers could begin to introduce the concepts, code structures and conventions behind ICD-10 and evaluate the extent of staff knowledge of anatomy and physiology. Depending on the size of a facility, managers may want to begin to create training plans covering inpatient and outpatient coding for all skill levels and learning styles.


Planning for a Big Budget

There’s no easy way to say it: The transition to ICD-10 will cost, for some larger organizations, millions of dollars. Smaller facilities and offices will, of course, get by spending a lot less.


Dave Biel, MS, a principal at Deloitte Consulting, reported that budgets for the transition and post-implementation auditing tasks for the company’s clients averaged $25 to $30 million for three years, depending on the size and complexity of the organization. Intermountain Healthcare’s current estimate comes in at $20 million with 40 percent going toward capital costs and 60 percent toward operational expenses.


Juggling the Priorities


Implementation of ICD-10 is just one of many priorities facing the healthcare industry. As AHIMA reports, “The convergence of regulatory requirements in the coming three years is unprecedented: HITECH and the meaningful use program, the HIPAA 5010 standard, the ICD-10 transition, healthcare reform, accountable care organizations, and intensified pay-for-performance initiatives.”


Needless to say, complying with all of these requirements is stretching resources in more ways than just financially. Attendees shared war stories about lack of time and staff to do the jobs that need to be done and conflicts about what tasks should take priority.


Initially, industry representatives believed that the transition would focus on IT and/or coding issues but they’ve learned differently. Those now in the trenches of implementation realize that ICD-10 is an integral part of everything they do, affecting people, departments, and functions throughout their organizations. For example, ICD-10 is a reimbursement issue, a quality initiative, and a business-driven initiative.


George Alex of the Advisory Board Company agrees, saying, “We thought this was an HIM problem and would contain mainly HIM issues. That was far from the truth. It is really a multidisciplinary effort,” requiring collaboration.



“Providers, payers, and vendors are all in this together,” said Dennis Winkler of Blue Cross Blue Shield of Michigan. “It is important for us all to figure it out so that on October 1, 2013, we don’t go bump in the night.”


For more resources on ICD-10 planning and preparation, visit AHIMA’s website at


About the Author

Carol Spencer, RHIA, CHDA, CCS, is a senior consultant with Medical Learning, Inc. (MedLearn®) in St. Paul, Minn. She brings more than 20 years of experience in health information management, coding, teaching, data quality and revenue integrity. She is an accomplished local, regional, and national speaker and author covering topics such as recovery audit contractors (RACs), payment audits, MS-DRG reimbursement systems, ICD-9-CM coding, and is an AHIMA-approved ICD-10-CM/PCS Trainer. Ms. Spencer is a thought-leader in data analytics and an expert on compliance in coding, query, and clinical documentation improvement strategies.

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The ICD-10 train has left the station….no doubt about it.

There is no turning back. The train now needs willing passengers with expectations that ICD-10 is good, that it provides data that will ultimately improve patient care and outcomes.  Herein is the challenge. Yes, Health Information Management (HIM) professionals appreciate the need for ICD-10.  The current ICD-9 code set is simply running out of codes. But do providers appreciate the benefit of the ICD-10 expanded code set?

Clinical Documentation Improvement (CDI) in the world of ICD-10 will require a higher level of rigor and precision for coders and Clinical Documentation Specialists (CDS).  CDI programs must provide compelling and convincing education for providers regarding the benefits of ICD-10 documentation requirements.

This compelling education should be a collaborative initiative from the CDI medical director, the documentation specialists, HIM professionals and C-level leadership. Without support and acceptance from physicians CDI for ICD-10 will be dead in the water.

Today is the day when CDS’s should begin their CDI programs and launch their campaigns for provider/physician support.

Providing and delivering compelling ICD-10 education infers that the CDI team is well educated and prepared. CDI programs at this time should at the minimum created awareness of the changes ICD-10 will bring. A solid plan for skill assessment and education for the CDI team should be mapped out at this time.

The number of codes in ICD-10 increases from about 13,000 to 68,000. This will provide a greater level of specificity and comprehensive data for clinical decision support, public and population health, clinical data, research, quality measurement and patient safety. As Accountable Care Organizations develop and expand effective population health management depends on accurate clinical documentation.

Comprehensive clinical documentation and accurate coding drive that metaphoric train. CDI will always be paramount for improving patient care and outcomes.

In the words of another contributing editor Paul Wegandt, MD, “Hospitals should provide the infrastructure necessary to assist the physician in providing the most accurate, concurrent, compliant documentation of the condition and treatment of each patient, and assignment of the appropriate DRG”.

About the Author

Melinda Tully, MSN, CCDS, is Senior Vice President of Clinical Services and Education for J.A. Thomas & Associates. Melinda has 25+ years in Acute Care as a Clinical Specialist and Nurse Practitioner. Her area of specialty is clinical documentation education focused on continuous quality improvement.

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