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EDITOR’S NOTE: This is a continuation of an article from Michael G. Calahan appearing in last month’s edition of ICD-10monitor e-news entitled, “It’s Time to Get to Work!”

Last month we provided an introduction into how practice NPPs (physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, nurse midwives) can assist in the ICD-10 conversion process preliminarily without the benefit of having gone through ICD-10-CM classes and without access to special ICD-10 software. This preliminary preparation step involves the performance of a baseline medical record (MR) documentation assessment. The practice NPP is perfectly suited to perform or assist with this endeavor.

The baseline assessment will help expose areas where a practice’s various providers might need to shore up their MR documentation so practical conversion from ICD-9 to ICD-10 will be more efficient. Various additional benefits can be realized as well: as you perform the MR documentation assessment you may come across missed opportunities (that is, services that should have been “captured” but were missed) as well as services reported but under-documented enough so that the billing for these services could be questioned by an outside reviewer such as an OIG, RAC or CERT auditor. The focus, however, will be on the documentation of diagnostic statements supporting the final assigned ICD-9-CM codes and how well that documentation would support the ICD-10-CM codes. Case selection, or determining what dates of service to review (as stated in last month’s article) should be accomplished by analyzing frequency reports generated by a billing software system to assess, at a minimum, the top 25 ICD-9-CM codes reported to payers during the last year.

Source Documents

In preparing source documents for the MR documentation review, remember that the final reported ICD-9-CM codes for each selected case may need to be compared with information contained in the practice superbills or encounter forms (also known as “charge tickets”), since physician practices often utilize this type of form as a charge-capture tool.

This form is typically the source document and data facilitator for billing information, which in turn gets translated to the CMS-1500 claim forms submitted to payers for reimbursement. However, errors in the translation of data from the MR documentation to the superbill are not rare. And even though this is a documentation review for ICD-9-to-ICD-10 comparison purposes, the CMS-1500 claim forms for each date of service also should be on hand.

The CMS-1500 claim forms are important source documents that can be used for comparing what was reported to the payers versus what the MR documentation states as actual case data. The true crux of an audit is ultimately a comparison of the MR documentation against the CMS-1500 claim forms.

At a minimum then, you will require the following source documents to carry out a full MR documentation assessment for diagnosis comparison purposes:

- Original MR documentation (i.e. an office visit note)
- Ancillary documents such as provider orders, operative reports, pathology reports, radiology reports, etc., if germane to the office visit
- Practice superbills or encounter forms (i.e. the “charge tickets”)
- CMS-1500 claim form copies.

To perform a comparison and contrast of ICD-9-CM-to-ICD-10-CM codes, an ICD-10 tool also will be needed. This can be a pre-2013 ICD-10-CM book, an encoder with ICD-10 mapping or the public CMS files that include listings of the ICD-10-CM/PCS codes as well as “GEM” files (general equivalency mapping spreadsheets) that tie ICD-9 and ICD-10 together.

Review Process

It’s time to begin the review. Select a patient date of service, arranging in front of you the original MR documentation, ancillary documents, the superbill and a copy of the CMS-1500 claim form. Scan the progress (office visit) note for the recorded diagnostic data. Most of the current reportable ICD-9-CM codes found on the CMS-1500 claim form and encircled on the practice superbill will arise out of the diagnostic statement(s) listed under the “assessment” section (if providers follow the SOAP note format), or alternatively this section can be labeled “impressions” or “diagnoses.” There should be uniformity in terms of provider note organization and final documentation of patient data.


 

Also scan the ”history” section of the office visit note. Within the history component of the typical patient office encounter you will find four distinct elements required to be documented for most evaluation and management (E/M) services: chief complaint (CC); review of systems (ROS); past, family and social history (PFSH); and history of present illness (HPI). A chronic but current/ongoing diagnosis impacting current care also commonly will be listed within the elements of the history, but not carried down or relisted in the diagnostic area found under the assessment section.  This practice should be avoided as it is often confusing for coders as well as outside medical reviewers. Chronic but ongoing (and therefore reportable) diagnoses frequently are missed when they are buried in the history component of an E/M service file and not relisted under the assessment.

At this juncture let’s look at a case study to demonstrate the comparison process. For illustration purposes we will use a patient with essential hypertension (HTN) coded to ICD-9-CM code 401.9; consider that no other ICD-9-CM codes were assigned or are listed on the CMS-1500 claim form for this particular office visit. In this scenario the patient’s CC is “Here for F/U of HTN,” and in fact the “impression” line states “HTN, doing well on current meds.” However, the patient also has generalized osteoarthritis and is undergoing active treatment for this condition, as evidenced by a note under the “plan” section reading “Increase Celebrex to 100mg b.i.d.” A quick glance at the history reveals the physician had documented a correlating diagnosis in the ROS as “Musculoskeletal - gen OA w/noctural multi-jt. pain.” Your conclusion in reviewing these notes is that the OA did in fact impact the current date of service, and therefore two diagnoses for this office visit should have been coded: the HTN and the OA.

In relation to the hypertension, there is no annotation or indication of concurrent hypertensive heart disease or chronic kidney disease (or any combination thereof): it is strictly noted as “HTN.” Under the current ICD-9-CM coding structure, because the descriptor “benign” (ICD-9-CM code 401.1) or “malignant” (ICD-9-CM code 401.0) was not recorded in the MR documentation along with the acronym “HTN,” the official coding guidelines and instructions state that the unspecified ICD-9-CM code 401.9 must be reported for “essential hypertension.” Now compare this code with the anticipated requirements and information under ICD-10-CM. Utilize your ICD-10 tool to locate the code for essential hypertension and you find a small surprise: in ICD-10-CM the descriptors “benign” and malignant” no longer apply. The full description mapped to the current ICD-9-CM essential hypertension code series (401.0, 401.1 and 401.9) match up to “I10 Essential (Primary) Hypertension” (see table). What will be required in this case in terms of MR documentation for accurate ICD-10-CM coding of the recorded information? First, establishing the hypertension as “essential” appears tantamount to getting it coded correctly.

This baseline classification should be established in the MR documentation in a highly visible area at some point even if it is not repeated each and every time the hypertension is recorded. Secondly, ensuring that the current state of hypertension is not connected etiologically to hypertensive heart disease, chronic kidney disease or a combination of these two is vital for correct coding (these conditions map to other ICD-10-CM codes).

 

ICD-9-CM Code

Current Descriptor

ICD-10-CM Code

I-10 Descriptor

401.0

401.1

401.9

Essential hypertension: malignant, benign, unspecified

I10

(“eye”-10)

Essential (primary) hypertension

 

For the generalized osteoarthritis (OA) that you have uncovered as not being reported but clearly documented and impacting current care, the ICD-9-CM code based on the MR documentation should be “715.00 Generalized osteoarthrosis, unspecified site.” (Note: if the adjective “generalized” was not noted in the MR documentation, then ICD-9-CM code “715.90 Osteoarthrosis, unspecified whether generalized or localized, unspecified site” would be assigned in this case.) Each of these descriptions for OA (715.00 and 715.90) maps to ICD-10-CM code M15.9 Polyosteoarthritis, unspecified.


 

However, it should be noted ICD-9-CM code 715.90 dually maps to ICD-10-CM code “M19.90 Unspecified osteoarthritis, unspecified site” as well. This particular ICD-10-CM code encompasses numerous other, more specific ICD-9-CM codes for various joints afflicted with OA, whether localized or not specified as “generalized or localized” (see table below). The analysis reveals that osteoarthritis, depending on how specific the provider has been in his or her documentation, can be coded in several ways under ICD-10-CM. As with ICD-9-CM coding now, the more specific the MR documentation, the more accurate the coding – and this holds true in ICD-10-CM coding.

 

ICD-9-CM Code

Current Descriptor

ICD-10-CM Code

I-10 Descriptor

715.00

Generalized OA, unspecified site

M15.9

Polyosteoarthritis, unspecified

715.90

OA, unspecified whether localized or generalized, unspecified site

M15.9

Polyosteoarthritis, unspecified

715.30, 715.31, 715.32, 715.33, 715.37, 715.38, 715.90, 715.91, 715.92, 715.93, 715.97, 715.98,

(715.3x series) Localized OA not specified whether primary or secondary, unspecified site,  -shoulder region, -upper arm, -forearm, -ankle and foot, -other specified sites;     (715.9x series) OA, unspecified whether generalized or localized, unspecified site, -shoulder region, -upper arm, -forearm, -ankle and foot, -other specified sites

M19.90

Unspecified osteoarthritis, unspecified site

 

Your Findings

As the NPP “auditor,” you have found upon comparison of the MR documentation to the CMS-1500 claim form that the ICD-9-CM code for OA was not reported at all, and you further find that it was not even encircled on the practice superbill. The lesson buried in this for providers? The MR documentation should be as clear, concise and explicit as possible, especially when summarizing impressions or diagnoses. The lesson herein for coders is that there often is corroborating information between the history and plan sections of the note, and both should be reviewed for possible “missed diagnosis opportunities” for ICD-9 and ICD-10 coding purposes. Lastly, do not rely solely on the superbills for diagnostic information.

Delineating between old (past or no longer under treatment) and current (new or ongoing conditions that impact care) diagnoses is important so that practice coders can benefit from nicely detailed and organized MR documentation. The common denominator in deciding if a diagnosis should be coded for the current encounter is if it impacts care in some way; the condition must be demonstrated in the note to have been evaluated, assessed, managed and/or treated to some extent. This can be accomplished by straightforward statements such as “no change in hypertension; current regimen to be continued,” or it can be made clear by more unassuming statements such as that outlined in the above scenario: “Increase Celebrex to 100mg b.i.d.”


 

If unconfirmed diagnostic statements are made, such as “ruled out,” “probable,” or “suspected,” then the patient’s signs and symptoms should be demarcated clearly in the notes so the practice coders can assign appropriate ICD-9-CM codes (and, in the future, ICD-10-CM codes) to represent fully the signs and symptoms prompting the patient’s office visit.

General documentation standards should be reviewed while assessing the status of the MR documentation. These standards include legibility, provider signature/authentication, identification/credentials of annotations made by non-provider staff and adequate patient identifiers, including patient name, MR number (if used), date of service, time (if timed services such as prolonged care are being provided), etc.

In many instances ICD-10-CM promises to demand greater specificity on diagnosis code descriptions and assignment, therefore a correlating level of specificity is expected to be found in the MR documentation. Performing a baseline audit and having the practice NPP perform or assist with this audit is often a rewarding exercise.  We will explore more complex “greater specificity” ICD-10-CM coding scenarios in upcoming articles.

About the Author

Michael G. Calahan, PA, MBA, is the director of physician services at KForce Healthcare, Inc. Michael has more than 25 years of experience in health care, beginning as a physician assistant with the USN. He has served as an administrator for several physician practices and has enjoyed a varied career in healthcare consulting, being affiliated with Ingenix, CGI, Navigant, PWC and Parente-Randolph. He has authored numerous industry publications and articles in physician, IP/OP/ASC, DMEPOS, ESRD, HHA, ambulance, HIPAA and in Medicare Parts C & D for Medicare Advantage.

Contact the Author

To comment on this article please go to

The ICD-10-CM and ICD-10-PCS are coming, and, by now, most of you have at least heard about the systems. Some health information management (HIM) professionals have been certified as trainers, and some already have begun to teach sessions on ICD-10-CM and ICD-10-PCS, while others are just beginning to review the intricacies of the new system.  

A comparison shows that the two systems are very different. It’s very clear that coders will need to have a solid understanding of anatomy and physiology, terminology, and the procedures being performed. It will take some time in training to get use to the new requirements as well as the new system.  

The following common cystoscopy procedure demonstrates how to assign the ICD-10-CM codes in the outpatient setting. 

Case Study 

Postoperative Diagnosis: Left ureteral calculus 

Procedures: Cystourethroscopy, left retrograde pyelogram, left ureteroscopy with stone, and extraction and stent placement 

Anesthesia: General

Procedure Description: After informed consent was obtained, the patient was brought to the operating room and placed on the table in the supine position. He was then given a general anesthetic and placed in dorsal lithotomy position, prepped and draped sterilely. 

Cystourethroscopy was performed using a 21-French rigid cystoscope with video assistance, which showed a normal anterior urethra. Prostatic urethra was also normal, consistent with minimal, if any, BPH.  

Upon entering the bladder, there was some cloudy urine coming from the left ureteral orifice. A retrograde pyelogram with contrast was then performed using a 50:50 mix of Conray and sterile water, and an 8-French cone-tip catheter.  This showed several small filling defects in the distal ureter, approximately a centimeter up from the ureteral orifice. This was consistent with the stone seen on the CT.  The cystoscope and the cone-tip catheter were then removed.  A 0.035 French Sensor Dual-Flex guidewire was then passed through the cystoscope and up into the renal pelvis and coiled under fluoroscopic guidance. 

The Olympus 9-French ureteroscope was then used to perform distal rigid ureteroscopy. The stone fragments were seen at the distal ureter. Initially, I was going to use a laser, but due to a laser malfunction, I decided to try to basket these stones since they were fairly small. I was able to successfully basket the three largest fragments, which were sent to pathology for evaluation.  The remainder, if any, fragments were way too small to be retrieved successfully using the 1.5- French stone basket.  

At this point, the patient’s ureter appeared to be stone free.  I decided to leave the stent, given the appearance of the distal ureter due to stone fragments there.  A 4.6 x 30 cm double J ureteral stent was placed without difficulty. The patient tolerated the procedure well.  His bladder drained, and he was taken to recovery in stable condition. 


 

Code Assignments

The first table below shows a comparison of the ICD-9 diagnosis codes and the ICD-10 diagnosis codes. As you can see, the descriptors are similar.

 

ICD-9-CM Diagnosis Codes

ICD-10-CM Diagnosis Codes

592.1  Calculus of ureter

N20.1 Calculus of ureter

 

Note that each digit of the ICD-10 diagnosis code is a specific identifier, and this is how the above code would be interpreted: N = Chapter 14—Disease of Genitourinary System; 20 = urolithiasis; .1 = ureter. 

The second table below lists the ICD-9 procedure codes against the ICD-10 procedure codes, and you will see that their descriptors differ. Keep in mind that in the outpatient setting ICD-9-CM procedure codes would not be reported (per Health Insurance Portability and Accountability Act [HIPAA]) guidelines), but they are provided for illustrative purposes.

 

ICD-9-CM Procedure Codes

ICD-10-PCS

Cystoscopy, other

 Transurethral removal of obstruction    form ureter or renal pelvis

Ureteral catheterization

87.74  Retrograde pyelogram

OTC78ZZ Excision left ureter via natural opening, endoscopic

 

OT778DZ Dilation, ureter via natural opening endoscopy, intraluminal device

 

BTO7YZZ Pyelogram

 


 

Like the ICD-10 diagnosis codes, each digit in the ICD-10-PCS column identifies a specific feature: 1st character: O = medical surgical and B = imaging; 2nd character: T = urinary system; 3rd character: C = extirpation, 7 = dilation, and O = plain radiography; 4th character:  7 = left ureter; 5th character: 8 = endoscopy via natural opening and Y = other contrast; 6th character:  Z = no device and D = intraluminal device; and the 7th character: Z = no qualifier. 

For the above outpatient case, you also will need to assign the following CPT procedure codes:

52352        Cystourethroscopy with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)

52332        Cystourethroscopy with insertion of indwelling ureteral stent 

The following code is bundled into code 52352 and, per National Correct Coding Initiative (NCCI) edits, should not be assigned:

52005        Cystourethroscopy with ureteral catheterization with or without irrigation, instillation or ureteropyelography, exclusive of radiological service (pyelogram) 

At the following web site, you will find the latest version of ICD-10-CM and ICD-10-PCS: http://www.cms.gov/ICD10

About the Author 

Peggy Hapner is manager of the HIM consulting division at Medical Learning Inc. (MedLearn), St. Paul, MN. 

Contact the Author 

To comment on this article please go to

As to be expected with any wide sweeping change there will be misconceptions and ICD-10 is no exception.

 

We have compiled a few of the more pervasive myths in an attempt to help set the record straight and assist you in planning for the transition to ICD-10.

 

True or false, CMS is expected to push back the compliance deadline from October 1, 2013 to October 1, 2015, essentially providing a two- year delay.

(F)

 

True or false, CMS will accept ICD-10 codes prior to the mandatory compliance date if providers are ready to begin submission.

(F)

 

True or false, ICD-10-PCS codes will be reported for all inpatient procedures and all professional fee services provided in the inpatient setting.

(F)

 

Professional fee services provided in the inpatient setting will be reported with CPT® codes.

 

True or false, the time to begin in-depth ICD-10-CM/PCS coding training is now.

(F) Only awareness and biomedical skills training should be provided prior to 2013.

 

True or false, ICD-10 requires the submission of electronic claim forms, so all coding must be done electronically and not by book.

(F)

 


 

CDS/CIS will need to learn how to code in order to work with ICD-10 codes.

(F)

 

True or false, like many other healthcare initiatives, ICD-10 will be phased in over time with hospital providers requiring compliance on October 1, 2013 and physician providers requiring compliance on October 1, 2015.

(F)

 

True or false, ICD-10-PCS will replace all levels of HCPCS codes

(F) HCPCS codes, including CPT, will continue to be used for all outpatient services.

 

True or false, ICD-10 will not be implemented in the United States because ICD-11 is near completion and will provide even more benefit.

(F)

 

True or false, with ICD-10 non-specific codes are no longer available for use and therefore a CDI program is required to obtain the necessary documentation to avoid delayed claim submission.

(F)

 

True or false, ICD-10 is so specific that the number of clarifications or queries will increase 5 fold.

(F)

 

True or false, the sheer number of codes available for assignment in ICD-10-CM/PCS makes it very difficult to use and therefore necessitating computer assisted coding and use of encoder software to assign codes.

(F)

 


 

True or false, the HIPAA mandate to transition to ICD-10 is only applicable to providers. Payers will be able to choose between paying based on ICD-9-CM or ICD-10-CM/PCS.

(F)

 

True or false, the coding guidelines applicable to ICD-10 will be the same as those used to code in ICD-9-CM.

(F) No, chapter specific coding guideline changes are already apparent.

 

True or false, there are 20,000 ICD-10-PCS procedure codes as compared to 4,000 ICD-9-CM procedure codes.

(F) There are 71,957 in ICD-10-PCS 2011 version.

 

True or false, the official coding advice in Coding Clinic, published by the American Hospital Association since 1984 will still be applicable to coding in ICD-10.

(F)

 

True or false, the transition to ICD-10 is required only when billing Medicare, not state Medicaid programs.

(F)

 

True of False, the federal government can and will levy fines on those entities that are not compliant with the final ICD-10 go live date.

(T)

 

True or false, non-compliance with ICD-10 will be similar to what was encountered with non-compliance with HIPAA, you will still be paid, but may have to pay fines if not compliant.

(F) There will be no Medicare payment for non-compliance under ICD-10.

 


 

True or false, after the transition to ICD-10, ICD-9-CM will no longer be maintained.

(T)

 

True or false, the assignment of ICD-10 codes requires greater knowledge of anatomy and physiology than was required with ICD-9-CM.

(T)

 

True or false, the transition to ICD-10 is expected to negatively impact coder productivity.

(T)

 

True or false, the transition to ICD-10 is expected to worsen the current coder shortage.

(T)

 

True or false, much of the detail found in ICD-10-CM diagnoses codes is currently already found in medical record documentation, but not required by ICD-9-CM.

(T)

 

True or false, ICD-10-CM for diagnosis reporting is very similar to ICD-9-CM, however, ICD-10-PCS for procedure reporting is very different from ICD-9-CM procedure coding.

(T)

 

True or false, although General Equivalence Mappings exist to translate ICD-9-CM codes into ICD-10-CM codes, providers will still need to be able to assign codes using native ICD-10 codes.

(T)

 

True or false, ICD-10-CM/PCS was designed with considerable input by physician specialty associations.

(T)

 


 

True or false, the transition to the 5010 was necessary before ICD-10 codes could be submitted.

(T)

 

True or false, the General Equivalence Mappings (GEMS) developed by CMS are applicable to all payers not just Medicare.

(T)

 

True or false, the current 2011 version of ICD-10-CM/PCS is in draft form only and subject to change prior to implementation.

(T)

 

True or false, there are 69,368 ICD-10-CM diagnoses codes as compared to 13,500 ICD-9-CM diagnoses codes.

(T)

 

True or false, the average age of the typical hospital inpatient coder is 54, adding to the concern that there will be a shortage of experienced coders available to assist with the transition to ICD-10 coding.

(T)

 

True or false, the majority of additional diagnoses codes found in ICD-10-CM can be contributed to the ability to capture specific anatomical sites, and report laterality and episode of care.

(T)

 

True or false, when assigning an ICD-10-PCS procedure code there is no requirement to utilize the Alphabetical Index first, prior to referring to the procedure tables in the Tabular List.

(T)

 


 

True or false, providers will not reap the full benefit of ICD-10 without a robust clinical documentation improvement program in place.

(T)

From the time ICD-10 was ready for adoption, in 1990, there have been many myths perpetuated about the new classification system. We hope this helps debunk some of those prevailing myths.

 

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.

 

Contact the Author

 

 

To comment on this article please go to

EDITOR’S NOTE: This is final installment in a three-part series of articles on the impact of technology and ICD-10.

When I began to think about writing this article series on the impact of technology and ICD-10, I thought about how I would approach the mammoth task of transition if I was leading an ICD-10 governing team. I immediately thought about applying a workflow process that resonates with me and reflects the “nursing process.”

As to be expected with any wide sweeping change there will be misconceptions and ICD-10 is no exception.

 

We have compiled a few of the more pervasive myths in an attempt to help set the record straight and assist you in planning for the transition to ICD-10.

 

True or false, CMS is expected to push back the compliance deadline from October 1, 2013 to October 1, 2015, essentially providing a two- year delay.

(F)

 

True or false, CMS will accept ICD-10 codes prior to the mandatory compliance date if providers are ready to begin submission.

(F)

 

True or false, ICD-10-PCS codes will be reported for all inpatient procedures and all professional fee services provided in the inpatient setting.

(F)

 

Professional fee services provided in the inpatient setting will be reported with CPT® codes.

 

True or false, the time to begin in-depth ICD-10-CM/PCS coding training is now.

(F) Only awareness and biomedical skills training should be provided prior to 2013.

 

True or false, ICD-10 requires the submission of electronic claim forms, so all coding must be done electronically and not by book.

(F)

 

CDS/CIS will need to learn how to code in order to work with ICD-10 codes.

(F)

 

True or false, like many other healthcare initiatives, ICD-10 will be phased in over time with hospital providers requiring compliance on October 1, 2013 and physician providers requiring compliance on October 1, 2015.

(F)

 

True or false, ICD-10-PCS will replace all levels of HCPCS codes

(F) HCPCS codes, including CPT, will continue to be used for all outpatient services.

 


 

True or false, ICD-10 will not be implemented in the United States because ICD-11 is near completion and will provide even more benefit.

(F)

 

True or false, with ICD-10 non-specific codes are no longer available for use and therefore a CDI program is required to obtain the necessary documentation to avoid delayed claim submission.

(F)

 

True or false, ICD-10 is so specific that the number of clarifications or queries will increase 5 fold.

(F)

 

True or false, the sheer number of codes available for assignment in ICD-10-CM/PCS makes it very difficult to use and therefore necessitating computer assisted coding and use of encoder software to assign codes.

(F)

 

True or false, the HIPAA mandate to transition to ICD-10 is only applicable to providers. Payers will be able to choose between paying based on ICD-9-CM or ICD-10-CM/PCS.

(F)

 

True or false, the coding guidelines applicable to ICD-10 will be the same as those used to code in ICD-9-CM.

(F) No, chapter specific coding guideline changes are already apparent.

 

True or false, there are 20,000 ICD-10-PCS procedure codes as compared to 4,000 ICD-9-CM procedure codes.

(F) There are 71,957 in ICD-10-PCS 2011 version.

 

True or false, the official coding advice in Coding Clinic, published by the American Hospital Association since 1984 will still be applicable to coding in ICD-10.

(F)

 

True or false, the transition to ICD-10 is required only when billing Medicare, not state Medicaid programs.

(F)

 

True of False, the federal government can and will levy fines on those entities that are not compliant with the final ICD-10 go live date.

(T)

 


 

True or false, non-compliance with ICD-10 will be similar to what was encountered with non-compliance with HIPAA, you will still be paid, but may have to pay fines if not compliant.

(F) There will be no Medicare payment for non-compliance under ICD-10.

 

True or false, after the transition to ICD-10, ICD-9-CM will no longer be maintained.

(T)

 

True or false, the assignment of ICD-10 codes requires greater knowledge of anatomy and physiology than was required with ICD-9-CM.

(T)

 

True or false, the transition to ICD-10 is expected to negatively impact coder productivity.

(T)

 

True or false, the transition to ICD-10 is expected to worsen the current coder shortage.

(T)

 

True or false, much of the detail found in ICD-10-CM diagnoses codes is currently already found in medical record documentation, but not required by ICD-9-CM.

(T)

 

True or false, ICD-10-CM for diagnosis reporting is very similar to ICD-9-CM, however, ICD-10-PCS for procedure reporting is very different from ICD-9-CM procedure coding.

(T)

 

True or false, although General Equivalence Mappings exist to translate ICD-9-CM codes into ICD-10-CM codes, providers will still need to be able to assign codes using native ICD-10 codes.

(T)

 

True or false, ICD-10-CM/PCS was designed with considerable input by physician specialty associations.

(T)

 

True or false, the transition to the 5010 was necessary before ICD-10 codes could be submitted.

(T)

 


 

True or false, the General Equivalence Mappings (GEMS) developed by CMS are applicable to all payers not just Medicare.

(T)

 

True or false, the current 2011 version of ICD-10-CM/PCS is in draft form only and subject to change prior to implementation.

(T)

 

True or false, there are 69,368 ICD-10-CM diagnoses codes as compared to 13,500 ICD-9-CM diagnoses codes.

(T)

 

True or false, the average age of the typical hospital inpatient coder is 54, adding to the concern that there will be a shortage of experienced coders available to assist with the transition to ICD-10 coding.

(T)

 

True or false, the majority of additional diagnoses codes found in ICD-10-CM can be contributed to the ability to capture specific anatomical sites, and report laterality and episode of care.

(T)

 

True or false, when assigning an ICD-10-PCS procedure code there is no requirement to utilize the Alphabetical Index first, prior to referring to the procedure tables in the Tabular List.

(T)

 

True or false, providers will not reap the full benefit of ICD-10 without a robust clinical documentation improvement program in place.

(T)

From the time ICD-10 was ready for adoption, in 1990, there have been many myths perpetuated about the new classification system. We hope this helps debunk some of those prevailing myths.

 

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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About 11 years ago, in January 2000, I wrote an urgent news flash entitled “What’s the scoop on the release of ICD-10-CM?” This article, appearing in a non-physician practitioner (NPP) newsletter published by Ingenix, surmised an imminent release of the ICD-9 diagnostic and procedural coding systems and a subsequent conversion to ICD-10, because the Centers for Medicare & Medicaid Services (CMS) (then called the Health Care Financing Administration, or HFCA) had decided not to release any annual changes to the 2000 ICD-9-CM codes pending full implementation of Y2K compliance initiatives.

Remember Y2K? Rumors were swirling; the industry was abuzz. Both “Y2K” and “ICD-10” were on the lips of nearly everyone. So we’ve come full circle: the more things promise to change, the more they stay the same.

Again, that was in the year 2000. The switchover from ICD-9-CM/PCS to ICD-10-CM/PCS finally now is assured. No longer a rumor, the hard-and-fast implementation date of Oct. 1, 2013 is right around the corner, and there are laundry lists of tasks to accomplish: let’s face it, there are mountains to move. And moved they will be … thus we will arrive at the threshold of that implementation date prepared, knowledgeable and set to go.

At the ICD10monitor.com (specifically under my byline), we’ll be bringing you relevant how-to articles from the NPPs’ perspective (note: NPPs include physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and nurse midwives) exploring various concerns related to ICD-10-CM/PCS, covering topics including preparation, knowledge base fortification and tips for easier and more effective ICD-10 implementation.

Many of the ICD-10 issues to be tackled are provider-driven and squarely in the purview of the NPP; that is, in order for ICD-10 to work properly the physicians and NPPs must be an active part of the conversion process from ICD-9 to ICD-10. Take, for example, medical record (MR) documentation: ICD-10 codes will be generated from, substantiated by and/or validated through this critical aspect of each and every provider’s patient care efforts.

MR documentation represents the beginning, middle and end of the current ICD-9-CM/PCS life cycle; it is foundational to the entire process of diagnosis coding, and there is nothing currently indicating that this promises to change with ICD-10.

Provider documentation will continue to initiate the derivation and assignment of codes, drive the assessment of medical necessity for payment of services and serve to validate those services upon review by oversight entities such as Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs) and Comprehensive Error Rate Testing (CERT) reviewers, just to name a few (and there are more to name). Federal oversight entities loom like specters on the horizon, hovering around the ICD-10 implementation date. With recovery monies now budgeted into the government’s appropriations on the front end (not simply seen as “found” money or additional funds added on the back end), the advent of ICD-10 will not slow down or alter the fed’s plans to audit, audit, audit.

How does the typical practice NPP, one employed by several physicians and working with several other NPPs, begin to get ahead of the curve when it comes to assisting in the ICD-10 conversion process? What can be done now as a first step without fancy new IT systems, without any particular depth of knowledge about ICD-10 and without emptying the patient schedule to free up huge blocks of time? Start at the foundation: a baseline MR documentation assessment.  

A baseline MR documentation assessment will enable physicians and NPPs within any specialty or any-sized practice or clinic (or outpatient department) to recognize where its incumbent providers need to strengthen their MR documentation so that ICD-10-CM, with its heightened requirements of specificity and attention to detail (for example, in aspects of anatomy and physiology) can be implemented successfully.



The practice administrator or manager should initiate this project and set the scope of work. The practice NPPs, using their clinical insight and established history of mastering adept techniques in MR documentation, easily can bridge the gap between physicians and coders, and will be invaluable in this process.  

To begin the baseline assessment, a “review sample” of medical records must be selected. Criteria in this selection must be stratified to include, by frequency and volume, at least the top 25 ICD-9-CM diagnosis codes currently being assigned by the practice. The practice administrator should generate a report from the billing system highlighting these claim details.

Several documentation standards then should be assessed while reviewing the assigned ICD-9-CM diagnosis codes derived from the MR documentation completed for each patient visit. These standards include legibility, authentication (i.e. signature requirements), patient identifiers, timeliness and presentation of the diagnostic data within the body of notes, delineations between old (past) diagnoses and current (new or continuing) diagnoses, details of each diagnostic statement when unconfirmed (such as “rule out” or undifferentiated signs/symptoms), and more.   

Next month, we will present the final portion of this timely article on performing a baseline MR documentation assessment as part of your preparations for converting to ICD-10. Look for it!        

About the Author

Michael G. Calahan, PA, MBA, is the director of physician services at KForce Healthcare, Inc. Michael has more than 25 years of experience in health care, beginning as a physician assistant with the USN. He has served as an administrator for several physician practices and has enjoyed a varied career in healthcare consulting, being affiliated with Ingenix, CGI, Navigant, PWC and Parente-Randolph. He has authored numerous industry publications and articles in physician, IP/OP/ASC, DMEPOS, ESRD, HHA, ambulance, HIPAA and in Medicare Parts C & D for Medicare Advantage.  

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There is an amazing amount of synergy being created between information technology and service providers regarding the issues of meaningful use and ICD-10. These two hot topics continue to gain momentum as their effective dates near. These initiatives together will help move our industry towards modified payment models such as bundled payments, pay for performance and Accountable Care Organizations, and they will help catapult us into providing better measurements for improved quality of care. These changes will create recognition and satisfaction for the winners who can achieve compliance coupled with outstanding results.  

When one thinks about the scope and magnitude of change being enacted with these two initiatives, it calls into question core competencies and knowledge required to implement and adopt these two initiatives successfully. Such success requires skills and knowledge from many different disciplines. Hardware, software and business process experts alike will participate in planning and implementation. Successful organizations either will have the benefit of a strong internal team complete with ample resources dedicated to these initiatives, or they will have robust partnerships with one or more vendors to provide necessary solutions and tend to the many tasks to be completed. Organizations focused on transition to ICD-10 may find it helpful to partner for solutions in some key areas.

Look to Partnering

ICD-10 demands additional specificity in clinical documentation. The sheer volume of new codes is proof of the greater specificity in coding. There is a clear deficiency in coding documentation in the existing ICD-9 environment, and the demand for clarity will increase with ICD-10.  If one focuses now on closing the gaps in ICD-9 requirements, ICD-10 improvements can be integrated simultaneously. Documentation of conditions, anatomy and instrumentation will continue to be important. Look to partner with highly skilled personnel who can help; identify clinical staff who can distinguish when too little documentation is provided, evaluate medical record documentation for assurance that care is comprehensively recorded and reflected in the record, and ensure that what is documented adds value and integrity to the process of coding. Partnerships such as these are essential to ensure accuracy in an electronic health record environment that may require changes to care plans, order entry or admission processes.

New Code Sets

Naturally, with the change to the ICD-10 code sets, the rules and regulations surrounding use become important. With the new diagnosis code set to be used for all healthcare settings, medical records coding will be performed by using an expanded number of digits. However, aside from its greater specificity, the ICD-10-CM environment is very similar to that of ICD-9. Some of the new features include combination codes that fully identify multiple diagnoses for certain causes, conditions or manifestations; laterality added to the description; episode of care added as extensions; inclusion of time frames for certain codes; and added definitions of two types of excluding notes.

Unlike those tied to the diagnosis code set, the procedure code set changes are much more significant, with each of the seven digits having a specific meaning. And, depending upon what section, body part or procedure is being coded, the value for the digits selected by the coder will vary. For medical records coding, having someone in your organization who is knowledgeable about existing ICD-9 code sets and who is educated on the changes in adopting ICD-10 is an important partnership, as training in this area is a necessity for proper use of the enhanced code sets.

ICD-10 Technology

The American National Standards Institute (ANSI) develops and maintains electronic data interchange and other standards that drive business processes. Information technology changes required for ICD-10 start with compliance with the HIPAA-mandated adoption of standards for electronically conducting certain administrative healthcare transactions between certain HIPAA entities. This includes electronic standards for eight different types of transaction, among them claim submissions and payment processing. This technology change is known as adopting X12 Version 005010, commonly referred to as version 5010. A separate piece of legislation from ICD-10, but related nonetheless, this mandate includes hundreds of technical changes needed in order to migrate from existing standards under 4010 to the new 5010 standards.

Technical changes related to ICD-10 include the addition of ICD-10 data files and fields. After 5010 is implemented, system vendors then will be expected to work on changing ICD-10 code related to logic. These information technology changes also demand that interfaces and interoperability be tested prior to implementation. These mandates, requiring structural data file modifications, structural changes, and logic changes, also require detailed information technology and coding knowledge. Many organizations have some staff in place to make the modifications, but few have enough. Without advanced planning, compliance deadlines may be missed.

Most expect to start monitoring ICD-10 reimbursement trends on Oct. 1, 2013, the scheduled implementation date. Still, be on the lookout for monitoring of reimbursement tied to revenue changes in 2012 as well. It may be that, with the change to 5010 effective Jan. 1, 2012, this will affect revenue transactions as well. On this date clearing houses, payers and providers will begin transferring electronic data using the 5010 standard. If interoperable testing is not completed successfully by then, a broken link along the continuum of transactions could impact what is paid for or what is reimbursed. Also in 2012, expect to begin seeing contract terms tied to ICD-10 diagnosis and procedure codes. While there are a large number of contracts that have reimbursement terms based on MS-DRGs when it comes to carveouts or procedure type terms, beware of how contract changes might impact your reimbursement.

As part of your preparation and partnership work, a contracts modeling application may be a good tool to implement. Then, as one migrates beyond Oct. 1, 2013, look for assistance in validating payment accuracy and claims submission processes, as well as for monitoring of reimbursement processes such as claims submitted, rejected or denied.  

For each of the major areas of anticipated impact in ICD-10 (clinical documentation, medical records coding, information technology and reimbursement), as you move through your planning process be sure to define your needs and partnership requirements for success. As one realizes the magnitude of change required to achieve compliance, a review of resources available to your organization is a wise idea. Where you have expertise, commit staff to critical tasks. Where resources or expertise does not exist, consider partnering for success and developing a comprehensive plan.  

About the Author

Veronica Hoy, MBA, is vice president of SOURCECORP HealthSERVE Consulting, Inc. Veronica has been an operating executive for 10 years, focusing on providing strategic leadership and direction to healthcare professionals and organizations. She has over 20 years of healthcare experience in business process outsourcing, accounts receivable management, coding, billing, release of information, consulting, and systems implementation.

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Close your eyes and imagine a coding classification system created for coders instead of statisticians, developed with the help of people who actually use the codes!

Well, even if you can’t envision it, it will become a reality on Oct. 1, 2013 — the official launch date for ICD-10-CM. This coding system, including the ICD-10-CM Official Guidelines for Coding and Reporting, will replace the ICD-9-CM code set for diagnosis reporting.

Unlike ICD-9-CM, ICD-10-CM was created to classify morbidity data for medical records, medical care assessment, ambulatory care and other forms of medical services, as well as for basic health statistics. ICD-10-CM’s expanded scope improves the grouping of codes by disease process, which in turn gives healthcare professionals the ability to match code selection to actual care and treatment.  Thus, the codes need to be more specific than those used for statistical data in order to describe the clinical characteristics of a patient accurately.  

Although there are many differences between ICD-10-CM and ICD-9-CM, the new code set keeps the same basic format as well as many of the same conventions as the old one; therefore, it will not be completely foreign to coders already familiar with the current system. Chapters have been added, reorganized and rearranged due to advances in understanding of the science and pathophysiology of disease. For example, rather than grouping codes by injury or type of wound, ICD-10-CM groups injuries by the site and then the type. Even seemingly insignificant changes make ICD-10-CM easier to use, for example its utilization of complete subcategory code titles so coders don’t have to go back several pages to read previous descriptors just to understand what a code really means.

What coder hasn’t struggled to find the right code because there is not enough clinical specificity in available codes due to space and number constraints? The vagueness inherent in ICD-9-CM makes it difficult for coders to accurately determine appropriate assignments. ICD-10-CM not only offers coders greater specificity, but also clinical concepts and terminology that are more relevant to ambulatory care encounters, making the system more applicable in non-hospital encounters than ICD-9-CM. For example:

•    Laterality is not a code qualifier in ICD-9 even though documentation often is provided in the record. In ICD-10-CM, coders must identify conditions by “left side,” “right side” or “bilaterality” for applicable diagnoses, and if documentation in the medical record does not provide the location, a code for “unspecified” is still available.

The terminology in ICD-10-CM also is more up-to-date and consistent with current clinical practice. The new classification system includes diseases and clinical concepts that don’t exist in ICD-9-CM, such as:

•    T45.526D – Underdosing of antithrombotic drugs, subsequent encounter  
•    Y90.5 – Blood-alcohol level of 100-119 mg/100 ml

Coders frequently are forced to assign unspecified codes due to specific terminology in ICD-9-CM that is not commonly used in clinical practice. Take hypertension, for example:

•    ICD-9-CM:      401.x Essential hypertension (specify malignant, benign, unspecified )
•    ICD-10-CM:    I10 Essential (primary) hypertension (includes high blood pressure, arterial, benign, essential, malignant, primary and systemic)

Malignant and benign hypertension no longer are considered clinically significant, meaning they are not typically documented in the physician’s diagnostic statement, resulting in assignment of the unspecified code 401.9.

ICD-10-CM has modified several chapter-specific guidelines based on new knowledge about conditions and/or disorders. For example:

•    The time frame for use of acute myocardial infarction (AMI) in Chapter 9, Diseases of the Circulatory System, has been changed from eight weeks or less in ICD-9 to four weeks or less in ICD-10-CM.

•    There also has been a major change in the cutoff point for differentiating abortion from fetal death, a switch from 22 to 20 weeks in Chapter 15, Pregnancy, Childbirth and the Puerperium. Additionally in this chapter, the codes now are identified by the trimester in which the condition occurred rather than by the episode of care (delivered, antepartum, etc.) used in ICD-9.

Coding the cause of injury, the intent, and the place, activity and status at the time of occurrence in ICD-9-CM is a laborious process requiring several codes. For example, to log attempted suicide by ingestion of barbiturates in ICD-9-CM, coders need to assign multiple codes:

•    967.0 - Poisoning by barbiturates  
•    E950.1 - Suicide and self-inflicted poisoning by barbiturates  
•    Additional codes to specify the effects of the poisoning, the place of occurrence and the    activity and status of the patient at the time.

In contrast, here is an example of an ICD-10-CM combination code for poisonings and their associated external cause:

•    T42.3x2S - Poisoning by barbiturates, intentional self-harm, sequela (7th character “S”)

The multiple coding rules in ICD-9-CM are complex and confusing. While there are a few combination codes in ICD-9-CM through which a single code is used to classify two diagnoses or a diagnosis and a complication, ICD-10-CM has many more combination codes, including some for certain conditions and manifestations, and others for both diagnosis and commonly associated symptoms. This change will eliminate sequencing problems and result in fewer cases documented by more than one code. For example:

•    I25.110 - Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
•    K50.011 - Crohn’s disease of small intestine with rectal bleeding
•    K57.21 - Diverticulitis of large intestine with perforation and abscess with bleeding
•    E11.341 - Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema

Supplementary classifications of the external causes of morbidity, or E codes and V codes noting factors influencing health status, are incorporated into the ICD-10-CM classification system.  These codes and descriptions are located throughout all chapters of ICD-10-CM and no longer are designated as E codes and V codes as in ICD-9-CM.

Most of the coding conventions/rules are the same in ICD-10-CM as they were in ICD-9, but there are a few changes. One of the most significant changes is the addition of the Excludes 1 and Excludes 2 code use instructions. Excludes 1 signifies “not coded here.” The code being excluded is never used with the code in question, and the two conditions cannot occur together or be coded together. Exclude 2 signifies “not included here.” The condition being excluded is not a part of the condition represented by the code, and it is acceptable to use both codes together if the patient has both conditions.

In summary, complete, accurate and detailed documentation will be necessary for assigning appropriate ICD-10-CM codes, just as it is in ICD-9-CM. For coders, ICD-10-CM is a much-improved, more functional system of classification.

Despite the many differences between ICD-10-CM and ICD-9-CM, it will not be difficult for experienced coders to learn the new system and use it proficiently – thus the reason we love ICD-10-CM!

About the Author

Sarah A. Serling, CCS, CCS-P, CPC, CPC-H, CPC-I, CEMC, ICD-10-CM/PCS Trainer, is a Medical Coding Educator/Developer for Precyse. Sarah is credentialed by the AHIMA as an ICD-10-CM/PCS Trainer, a Certified Coding Specialist (CCS) and Certified Physician-based Coding Specialist (CCS-P). She is also credentialed by the AAPC as a certified coding instructor (CPC-I) and as a certified professional coder of physician (CPC) and hospital services (CPC-H) with specialty certification in Evaluation/Management Services (CEMC).

ICD-10 will provide the U.S. healthcare system with many benefits, including improved public health surveillance, treatment and research data, the means to refine payment systems and pay-for-performance, and new ways to identify fraud and abuse and improve healthcare quality.

The enhanced data provided by ICD-10-CM/PCS will allow for more effective tracking of outcomes than ICD-9-CM permitted, and the additional detail in the expanded code set will facilitate implementation of electronic health records and make their use easier for practitioners.

But despite the wide range of benefits that comes with ICD-10-CM/PCS, the change presents challenges for both healthcare providers and health plans, particularly when it comes to the implementation costs involved.

America’s Health Insurance Plans conducted a survey of 20 health insurance plans’ estimated ICD-10 implementation costs. Overall, the projected incremental cost of ICD-10 implementation for all responding plans was estimated at $1.7 billion, and since the survey didn’t include the entire U.S. health insurance market, the total projected system-wide cost for insurers is estimated to be in the $2-3 billion range.

The projected extra per-member cost of implementing the new coding system ranges from an average of $38 for small health plans to $11 for large plans with more than 5 million members. For health plans covering fewer than 1 million people, the estimated per-member implementation cost ranges from $8 to $68, while the cost for a medium-sized health plan (covering 1-5 million), is expected to range from $4 to $42. Health plans covering more than 5 million individuals estimated their implementation costs to range between $3 and $15 per member.

In a continuing effort to help, CMS recently released some new ICD-10 resources, including the written transcript and recording from its January 12 conference “Preparing for ICD-10 Implementation in 2011."

CMS also posted the ICD-10 MS-DRGs v28 Definitions Manual update, which is based on FY2011 MS-DRGs and is part of the ICD-10 MS-DRG Conversion Project, which uses the General Equivalence Mappings (GEMs) to convert our current CMS Prospective Payment Systems. It is important to note, however, that while CMS is sharing this information, these are not the finalized ICD-10 MS-DRGs.

Information and resources for both ICD-10-CM and ICD-10-PCS can be found on the CMS website at http://www.cms.gov/ICD10.

About the Author


Sarah A. Serling, CCS, CCS-P, CPC, CPC-H, CPC-I, CEMC, ICD-10-CM/PCS Trainer, is a Medical Coding Educator/Developer for Precyse. Sarah is credentialed by the AHIMA as an ICD-10-CM/PCS Trainer, a Certified Coding Specialist (CCS) and Certified Physician-based Coding Specialist (CCS-P). She is also credentialed by the AAPC as a certified coding instructor (CPC-I) and as a certified professional coder of physician (CPC) and hospital services (CPC-H) with specialty certification in coding and auditing Evaluation/Management Services (CEMC).



The use and acceptance of non-physician practitioners (NPPs) in healthcare settings such as the private physician practice, outpatient clinics and the inpatient hospital milieu has become commonplace and widespread.

For many patients, it is no longer unusual to be evaluated and treated by a highly skilled physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS) and/or certified nurse midwife (CNM). The utilization of such professionals for the economic delivery of healthcare services has sustained and even allowed for an expansion of primary care and specialty services in a climate of growing uninsured patient populations and dwindling third-party payer reimbursements.   

The framework of duties performed by any particular NPP can be rather diverse and dependent on certain variables. Outside of the typical, clinical medicine “scope of practice” laws enforced by each state, the NPP can find him/herself acting in quite unique roles in a physician practice, at an outpatient clinic or within a hospital’s medical floor or emergency department. The NPP has become a key component of the clinical and administrative operations of the healthcare entity, at times facilitating the flow of clinical data from the physicians to targeted practice coders and facility health information management (HIM) staff.

In many cases, employing the NPP to the fullest advantage now also includes his/her involvement in coding workflow and procedures. Even at the lowest threshold of service, NPPs must be aware of coding protocols – as must physicians – that enable their own medical record (MR) documentation to be “translated” into the appropriate ICD-9-CM codes. Above and beyond that, deciphering physician MR documentation, providing clarification on clinical issues buried in diagnostic statements and assessing treatment nuances lying outside the purview of the typical coder are just some of the adjunct duties the NPP may be called upon to do.

Bridging the Gap


Savvy HIM staff long have known that when a physician is unavailable for general queries, the NPP can be an invaluable and more easily accessible “bridge” in elucidating routinely gray areas – helping out with tasks such as discerning from the treating physician’s MR documentation, for example, whether a patient has systemic inflammatory response syndrome (SIRS) or full-on sepsis, whether pneumonia was ventilator-associated in etiology, or whether specific signs and symptoms are the usual late-effect manifestations of a former condition or illness. The NPP doesn’t substitute for the treating physician’s clarification of MR documentation when such data is incomplete (or illegible) in these instances, but the NPP often can provide answers to queries when such documentation is not fully understood by the coders or HIM staff.   

Many NPPs have taken steps to obtain basic coding education and some even have advanced to securing coding credentials, either as a Certified Procedural Coder (CPC) via the American Academy of Professional Coders (AAPC) or as a Certified Coding Specialist - Physician Based (CCS-P) via the American Health Information Management Association (AHIMA). Diagnosis coding, specifically within ICD-9-CM and post-Oct. 1, 2013 within ICD-10-CM, is the language with which the healthcare industry communicates illnesses, injuries and conditions as well as reasons for clinical patient presentations. Under ICD-9-PCS, hospitals code and communicate procedures performed.

Getting Up to Speed


To become familiar with and speak the language of these coding systems is much like making preparations for an extended stay in Italy by taking and mastering a course in conversational Italian. This analogy also is applicable to the imminent transition from ICD-9-CM to ICD-10-CM (and ICD-10-PCS for procedure coding). Both the essential increased familiarity with anatomy and physiology as well as the heightened coding skill level required to be successful in applying ICD-10-CM/PCS protocols are immediately recognizable when reviewing the publicly available ICD-10-CM/PCS code indices and tabular sections approved to date (note: the Centers for Medicare & Medicaid Services (CMS) provides ICD-10-CM and ICD-10-PCS information as well as links to coding resources such as the National Center for Health Statistics [NCHS]).  

Physician Query Process


The NPP’s role in the physician query process will be immensely valuable during the transition from ICD-9-CM to ICD-10-CM, and this can be exploited to everyone’s benefit. The NPP will be able to facilitate dialogue between practice coders and the treating physicians, plus provide insight and guidance when the expanded coding detail in ICD-10-CM requires clear, specific and comprehensive MR documentation to support the appropriate assignment of codes.  

Prominent on the lengthy “to-do” list for the crucial preparations in migrating from ICD-9-CM to ICD-10-CM/PCS will be hosting education and training (E&T) programs. By all means, the practice, clinic and hospital NPPs should be included in these E&T initiatives, and if adroit hospital and practice executives plan their ICD-10-CM/PCS curricula correctly, NPPs will be at the forefront among staff receiving baseline and higher-level training in the new system.

By placing NPPs in a prominent role in such efforts, these professionals will be able to assist physicians and coders/HIM staff more effectively during a potentially sticky and protracted transition period. In many cases, healthcare entities will be operating parallel systems of both ICD-9-CM and ICD-10-CM before, during and after the official implementation date of Oct. 1, 2013.

The Bridge Between Physicians and HIM

The NPPs can play a vital role in the changeover by taking part and sharing in real-life patient treatment scenarios per their usual scope of duties, thereby assisting physicians during the process of understanding why meticulously detailed MR documentation is such a critical component of the ICD-10-CM/PCS experience. Also, the NPPs can provide expert guidance to coders/HIM staff in translating MR documentation into ICD-10-CM/PCS codes.

NPPs also will be able to help coders/HIM staff understand various subtleties of anatomy and physiology, the comprehension of which will be necessary for correct code assignment under the ICD-10-CM/PCS structure.

Summary

Leveraging the unique clinical and administrative position of a non-physician practitioner such as a practice PA, a clinic NP and/or a hospital CNS during the transition from ICD-9 to ICD-10 ultimately can help facilitate what promises to be an enormous undertaking by all healthcare entities. These highly skilled professionals, many of whom are already knowledgeable and trained in ICD-9-CM coding, can potentially assist in this transition by acting as informational “bridges,” closing the gap between physicians and coding/HIM staff.      

About the Author

Michael G. Calahan, PA, MBA, is the director of physician services at KForce Healthcare, Inc. Michael has more than 25 years of experience in health care, beginning as a physician assistant with the USN. He has served as an administrator for several physician practices and has enjoyed a varied career in healthcare consulting, being affiliated with Ingenix, CGI, Navigant, PWC and Parente-Randolph. He has authored numerous industry publications and articles in physician, IP/OP/ASC, DMEPOS, ESRD, HHA, ambulance, HIPAA and in Medicare Parts C & D for Medicare Advantage.  

Contact the Author