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Last month on Talk Ten Tuesday, I thought it would be fun to do something a little different, so I performed an ICD-10 rap song I wrote called “Coder’s Paradise.” Except for my singing on the chorus (by the way… I thought I could sing. My mom says I can sing. I sound great in the shower. Alas, apparently I can’t sing.), the response from the TTT audience was so positive, they sent me to Los Angeles to professionally record it for posterity. This was hilarious. You can imagine how surprised the recording engineer was when he saw me. Old, bald, white guy trying to rap. I’m not a rapper. I actually wanted to be a doctor, but I didn’t have the patients.

Shortly before my workshop at MGMA’s national conference in San Antonio last week, we received the final mix of “Coder’s Paradise” and the song was a huge hit, so… now I have to travel back to Los Angeles to shoot the music video. The proposed story lines for the video include dressing me up in a pimp outfit, devil costume, and/or nurse’s uniform. For those of you who sent positive feedback, I want to personally thank you for giving me all these opportunities to humiliate myself.

Now, about MGMA national. I have manned our booth at dozens of trade shows over the last two years. Until last week, when people walked by at other conferences and I asked if they wanted to talk about ICD-10, they started walking faster, averted their eyes, and mumbled something like, “It’ll never happen,” “Too far off,” “I’m not ready to talk about it,” or just an “[Expletive] NO!” Trying to talk to people about ICD-10 when they weren’t ready made me feel like the two fish that were swimming along and ran into a cement wall. One looked at the other and said, “Dam.”

Not so at MGMA. The response was 180 degrees different from past conferences. What were people saying to me at this show? “I don’t want to talk about ICD-10 but I know I have to so… whaddaya got?” With issuance of the final rule, the awareness tide has finally turned. Hallelujah!  Our booth was mobbed nonstop by MGMA-ACMPE members and vendors alike, all wanting to talk about ICD-10 education, software, consulting.

For those who have to drive the implementation, the predominant question at the booth was, “What should I be doing right now?” For the last several months I have preached a sane, measured, and phased approach with the prerequisite for all ICD-10 efforts being staff and provider awareness education. Once you have your providers’ and staff’s attention, what should you be doing right now? Grab a pen and paper and just walk around your organization. Note everywhere diagnosis codes touch a work process, make a note, and those notes give you the basis for creating your implementation plan.

Start talking about ICD-10 to your people in terms of how it will affect their roles in the organization. Take small bites at first and don’t overwhelm anyone with more information than they can handle. What’s the ICD-10 elevator speech for the providers? “Hey doc, you just have to write down more stuff so we can meet the more specific coding requirements.” Tell them they get to play with a lot of fun new codes like R46.1, “Bizarre Personal Appearance.” By the way, you could probably code “Bizarre Personal Appearance” on any given day in your practice for numerous patients and at least one of your staff mates. I have a good joke for that code but I’ll save it for the end.

Make a preliminary call to your IT vendors and see if you can get a timeline for when upgrades and training will occur. Right now, today, you should check your EHR and PM contracts and see who has to pay for the new ICD-10 packages. You don’t want to be surprised by a big, unforeseen bill. Take a look at some of the great off-the-shelf solutions offered by ICD10Monitor. Real time savers like easy conversion tools to help you identify new documentation requirements and do-it-yourself toolkits will get you through the transition so you don’t have to call in some bozo like me at the last minute. Call your billing companies and insurance payers and find out about their ICD-10 plans. We have the gift of time, so check out what’s out there. There’s no rush. Yet. Don’t wait too long to figure it all out. After all, you have your real job to do, and trying to cram in a last-minute major implementation is expensive and UNNECESSARY.

I promised you a R46.1 “Bizarre Personal Appearance” joke. A guy walks into his doctor and says he doesn’t feel well. The doctor notices he has a stalk of celery sticking out of one ear, a carrot sticking out of the other ear, and a green olive stuck up his nose. The doctor says, “Ahhhh, I know what’s wrong with you. You’re not eating right.” (Ba-dump-bump!)

ICD-10 is just another project. Make it fun. Make it as painless as possible. And don’t wait too long.

You can do this!

About the Author

Denny is the president of Complete Practice Resources, a healthcare education, consulting, and software company headquartered in Slidell, Louisiana. He formerly served as the CEO of a large, multi-specialty physician group, full service MSO. Denny has authored or co-authored numerous “common sense” practice management books and implementation manuals. He is an award winning, nationally known consultant, speaker, and educator bringing his expertise to making the complex “simple.” He currently serves on the editorial board of ICD10 Monitor.

Educated at the United States Air Force Academy, Denny had a distinguished career as an Air Force pilot and has a long history of commitment to excellence and dedication to his clients’ success.

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E-supply chains are not unique to other industries, but it is a concept that is not considered aligned with patient care, when in fact the healthcare supply chain is measured by its ability to deliver value to the end customer: the patient!

The E-supply change, or E Health, will require an E-knowledge or data source that is consistent, standardized, and trusted. The healthcare supply chain, unlike some other industries, begins with the requisition for services and supplies at time of the “Patient Ask,” which is then translated into the medical record by the physician—and thus the supply chain process begins.

Physician documentation has always been the single most critical segment of healthcare documentation in our healthcare delivery system, and physician buy-in is the lynchpin for a successful CDI program. A healthcare event starts with a “Patient Ask,” or statement of events; i.e., information about how an event occurred prior to accessing the healthcare supply chain. It becomes a sharing of information between the patient and the providers—physicians, physician extenders, and other clinicians—which all needs to be translated into comments and style acceptable across the U.S. healthcare supply chain. One of the common links across the supply chain is the narrative diagnosis and/or ICD code. In October 2014, the industry paradigm shift to ICD-10 codes will require a dramatic shift in physician documentation, because:

  • The ICD-10 code sets include greater detail, changes in terminology, and expanded concepts for injuries, laterality, and other related factors.
  • It is all in the documentation and translation of the content to a code.

Physicians have a unique DNA that has not been aligned with the downstream process and stakeholders along the supply chain. The DNA that brings people into healthcare delivery and allows them to make a lifetime commitment is best identified by a key point in the Hippocratic Oath, which states:

  • The health of my patient comes first.
  • I solemnly pledge to consecrate my life to the service of humanity.

Physicians’, physician extenders’, and other clinicians’ DNA is all about how to bring value to humanity through improved health!

So what are the business drivers for physicians and other healthcare providers?

They are:

  • Physicians have been conditioned to document defensively, to create defensible legal medical records. This can translate into concise, specific, controlled clinician comments.
  • Physicians want to be respected, which translates into acknowledgment and recognition for the complexity of care they provide—which also translates into the alignment between complexity and reimbursement.
  • Physicians want to practice medicine; which requires ease of business administration.
  • Physicians want to be paid fairly for knowledge and skill. For the most part, they are not interested in wholesale medical practices.

So how do we align with the physicians to gain their buy-in? First and foremost, it is imperative that there is a benefit realization and value proposition for physicians to embark on a CDI program. Mandating the change will not and has not provided a successful path for many other initiatives.

  • The message of value needs to be aligned with their DNA, so that the program will not place a new burden on their ability to see and take care of their patients.
  • We must communicate a message and demonstrate that improved healthcare documentation requires teamwork, and the goals of a CDI program are aligned with the physicians’ business drivers, as well as the hospitals’ and payers’.
  • It must be demonstrated to the physicians that lack of specificity affects the quality of care, compliance risk, and reimbursement. The educational value proposition program needs to address how a CDI program will support the creation of legally defensible documentation and not put the physician at risk with more detailed documentation.

The first and most important concern of physicians is the health of their patients, and aligning the CDI with that reality will lead towards successful buy-in of physicians to a CDI program, which is critical for the transition to ICD-10 compliance and the emerging healthcare models. We need to align as an industry on the ICD-10 codes, accepting the fact that healthcare is a supply chain with consumers, vendors, services, and products. Documentation must start at the point of need to purchase, where the physician documentation sets off the content for the application of a ICD-10 code which is carried across the supply chain for that event.

About the Author

Ellen Van Buskirk is vice president of consulting services at Axiom-Systems, where she is focused on compliance strategies and public sector healthcare. The mission is to work across the healthcare value stream to meet regulatory challenges facing the industry as it moves through the various levels of reform and change. Van Buskirk brings her expertise of working for many years on the U.K. National Health Service Modernization Program, as well as her experience of working on global and domestic healthcare program change for her clients. Additionally, she has conducted business development efforts in support of ICD-10 migrations and compliance by payer organizations.

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There is a word that has long been held sacred by the chiropractic profession: The so-called vertebral “subluxation.”

Throughout ICD-9, the term “subluxation” is used to describe a “partial dislocation,” which is not how it is defined by many chiropractors.

Medicare defines it reasonably well on behalf of the chiropractic profession:

“A motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact. For the purposes of Medicare, subluxation means an incomplete dislocation, off-centering, misalignment, fixation, or abnormal spacing of the vertebra anatomically.”

Put more simply, it is a condition of minor, sometimes painful, misalignment that is treatable by manipulation. The ICD-9-CM definition is more in line with the “partial dislocation” viewpoint, which is treated by medical doctors with medication. ICD-9-CM has never provided a code that differentiates between the chiropractic subluxation and the allopathic subluxation. Chiropractors have been compelled to try to fit a square peg into a round hole for many years. At first glance, it appears that ICD-10-CM is a chiropractic coder’s dream. ICD-10-CM offers a wide range of new possibilities; however, the debate is still undecided.

Currently, most Medicare Administrative Contractors (MAC) require chiropractic physicians use an ICD-9-CM code from the 739 category in position 1 of box 21 on the CMS-1500 claim form. This code range is defined by ICD-9-CM as a “Nonallopathic lesion, not elsewhere classified.” This definition is a far cry from the one taught by chiropractic colleges. This description only says what it is not, rather than what it is. Fortunately the fine print that follows adds “segmental and somatic dysfunction.” This helps clarify a little, but it is safe to guess that no chiropractors were consulted when this definition was written.

According to General Equivalency Mapping (GEMs), the commonly used ICD-9-CM code of 739.1 (Non-allopathic lesions; cervical region cervicothoracic region) may be replaced with M99.01, which is “segmental and somatic dysfunction of cervical region.” This differs little from ICD-9-CM and still does not use the word “subluxation.” However, nearby we find the code M99.11, which is defined as “subluxation complex (vertebral) of the cervical region.” This sounds just like the verbiage most chiropractors use, but GEMs points this code back to 839.00, not 739.1 in ICD-9-CM. This is the code for “closed dislocation, cervical vertebra, unspecified,” which implies that the definition is still not geared towards the chiropractic model.

In Chapter 19 of ICD-10-CM we find several appealing codes in the S13.11 category. They are defined as “subluxation of cervical vertebrae.” The new codes will provide information about the specific spinal level, whether it is a subluxation or dislocation, and whether the encounter is the initial or a follow-up visit. This is detail that chiropractic physicians have never been able to report using ICD-9-CM. Unfortunately, GEMs points these codes back to the 839 category rather than the 739 category again in ICD-9-CM. This implies that these new codes may be intended for use by allopathic physicians for dislocations, rather than the chiropractic subluxation.

There are two more factors to consider: First, GEMs is only an approximation, and some judgment is required to select the codes that most accurately describe the situation. Mapping is rarely a one-to-one match, so these may not be the only options. Second, payers will have to determine which codes will properly document medical necessity, and this is the big mystery. Payers have their business rules encoded for ICD-9-CM. No one has come forward to let chiropractic coders know if they should use M99.01, M99.11, or S13.11, or something else. Will payers be able to apply old decision logic to these new codes? Chiropractic coders probably won’t find out until they submit the first claims after October 1, 2014. They will just have to wait and hope that the subluxation they have been diagnosing all these years will finally be reportable with ICD-10-CM.

About the Author

Evan M. Gwilliam, is the director of education and consulting for ChiroCode Institute. Dr. Gwilliams holds multiple coding certifications and graduated from the Palmer College of Chiropractic in 2003 as valedictorian. He teaches seminars across the country for chiropractic offices.

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References

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Chiropractic_Services_Booklet_ICN906143.pdf
ChiroCode, “Complete & Easy ICD-10 Coding for Chiropractic, First Edition

Developing an ICD-10 project plan for complying with the October 2014 deadline is one important first step many organizations have accomplished.

While there are some great resources for organizations to utilize in order to manage key remediation components involving assessment and implementation, many organizations are relying on a “check-the-box” methodology for mitigating risks associated with the conversion to ICD-10. While this is a good framework for managing the global tasks associated with ICD-10, this approach will not provide an organization with the content expertise required for this high-risk, enterprise-wide initiative. While many organizations have many talented resources, the average organization’s resources are stretched so thin, it just does not have the bandwidth of personnel to manage all of the activities required to prepare while maintaining current operations.

Managing a multi-year, enterprise-wide initiative is a monumental task requiring planning, preparation, collaboration, progress evaluations and alternative decisions made throughout the life cycle of the project. With any multi-year enterprise project, how do organizations measure year-by-year efficiency gains? How do you deal with attrition to ensure that loss of staff resources at any given stage does not negatively impact project outcomes?

Simple Solution on a Project Plan

For example, consider that there is an industry-wide shortage of medical record coders. The simple answer to meet the demands of the industry would be to train more coders. This might be a viable solution for the productivity issues associated with ICD-10, but how many CFOs would be comfortable with entry-level coders determining their organizations’ reimbursement? How well do you think compliance officers would sleep, knowing the risk to their organization if it proves to be dependent on entry-level coders?

The process of coding is more complex than simply assigning a code from a coding book – it takes years of education, training and mentoring in order to become a seasoned coding veteran. You may have met the goal of providing staff education and training, but do you have confidence that, after the coders and physicians are educated, they will achieve the same level of proficiency they exhibited with the ICD-9 system?

Managing the requirements of clinical documentation specificity and coding quality is a continuous process that will require dedicated resources focused on documentation improvement, operational process improvement and financial analysis to ensure receipt of appropriate reimbursement.

Clinical documentation and coding quality complexities long have existed within the ICD-9 coding system. To manage this process effectively requires technical resources collaborating together with the common goal of appropriately documenting the patient story, which in turn is used for reimbursement, compliance, quality measures, etc. Professionals who specialize in these areas – including clinical documentation specialists, coders, auditors and finance staff – all understand the complexities associated with this process.

There also are technology solutions being developed every day, and we are in the beginning of a genuine transformation. But this costs money, even if it’s money well spent, and that’s something of which organizations do not always have a surplus.

What Really Matters?

What really matters? Not necessarily that the implementation activities simply get done, or checked off the list. What really matters is that the implementation activities get done right, and that you have a mechanism with which to measure the effectiveness of those efforts. Waiting until after October 2014 to determine whether the education provided to coders and physicians was adequate, or whether the IT system testing conducted could have been more robust, when your cash flow is being disrupted due to failed claims – that is not a good strategy.

So be sure to use a checklist to measure outcomes.

About the Author

John Pitsikoulis, RHIA, serves as a strategic advisory services client executive and ICD-10 practice leader at CTG Health Solutions. He has more than 25 years of health information management, coding, compliance and hospital revenue cycle consulting experience. His experience includes working with clients on RAC engagements, hospital performance improvement initiatives, case mix index analyses, revenue cycle performance improvements, clinical documentation improvements, coding quality infrastructure implementations and charge capture engagements. He also has directed numerous national engagements involving clinical management and litigation advisory assistance.

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My company is dedicated to all things ICD-10 all the time, so it’s important for us to stay abreast of what’s happening around the country, and we do that by occasionally polling health care organizations.

For last month’s survey, we focused on small-to-medium-sized practices and asked two simple questions: “What do you know about ICD-10?” And, ”Given the government finalized the implementation date, what are you doing about it?”

The results were a little shocking. Fifty percent of those polled admitted they didn’t know very much about ICD-10. Forty-five percent said it was too far away to worry about. Four percent said they already had it handled because they have an EMR, and one respondent said, “No worries. We have coders on staff.” NOT ONE PERSON SURVEYED answered that they were actively working on the ICD-10 implementation.

People, let me tell you what this feels like to me. I’m watching a reeaaallllyyyy slllooowww train wreck where you know the train is stuck on a track heading for disaster, with the time and place the train is going to crash already pre-determined. The time is October 1, 2014, and the place is your office, if you don’t start taking this challenge seriously.

Your EMR isn’t going to train your doctors to provide the written foundation that drives your codes. Your EMR isn’t going to train your staff about the changes to order entry or pre-authorization. Your EMR isn’t going to give you a heads-up on the loss of productivity and revenue ANY new process causes.

Likewise for your coders. Your coders aren’t going to handle the new payment policies certain to be issued by your insurance payers. Your coders aren’t going to work with your referring or referred-to providers to make sure you’re all on the same page when it comes to providing new information.

This is not rocket science. Yeah, there are a lot of moving parts and a lot to accomplish, but you can do this. We’ve been talking about a sane, measured, and phased approach to ICD-10 for six months. CMS issued a bulletin a few weeks ago suggesting the same phased approach.

The prerequisite first phase is getting your doctors and staff engaged, aware, and educated. Start by simply talking about ICD-10. “Hey Doc, do you realize we treat a lot of asthma and with ICD-10, you are now going to be required to document whether it’s mild, moderate, severe, intermittent, persistent, and tobacco use?” “Hey staff, do you realize you’re going to have to change the way you pre-authorize and enter orders under ICD-10?” “Hey everyone, don’t worry, we have time to do this right and we’ll train in a timely, organized fashion.”

That’s the first phase. It’s easy. Once you complete the first phase, then you can move on to organizing your team, performing your impact assessment, which is easy and which will also be the focus of my next Talk Ten Tuesday segment. Once you identify your action item objectives with your impact assessment, you create your plan and budget, implement your plan, and then try and anticipate the post-transition implications. Easy. Because you have time.

Let’s be honest. If you are listening to this weekly broadcast, you already get it. So YOU need to be evangelical about ICD-10 and start gently educating those of your peers that don’t get it. Talk it up at your get-togethers. Make sure your professional organizations are providing ICD-10 topics. This is going to take a village, and you need to be the chief “word spreader.” Kind of like Amway for ICD-10, or Mary Kay Cosmetics. Spread the word. What’s in it for you? Raise your hand if you’ve heard of Carl Spackler. Ok. I can’t see your hands, but Carl Spackler was the greens keeper character played by Bill Murray in Caddyshack. Here’s what you will receive if you spread the ICD-10 gospel, according to Carl Spackler in Caddyshack:

“So, I tell them I'm a pro caddy, a pro jock, and who do you think they give me? The Dalai Lama, himself. Twelfth son of the Lama. The flowing robes, the grace, bald... striking. Big hitter, the lama. So we finish the eighteenth and he's gonna stiff me. And I say, ‘Hey, Lama, hey, how about a little something, you know, for the effort, you know.’ And he says, ‘Oh, uh, there won't be any money, but when you die, on your deathbed, you will receive total consciousness, Gunga galunga.’”

So if you spread the word about ICD-10, you got that goin' for you… which is nice.

Next segment? Phase 2’s Organizing an Impact Assessment

About the Author

Denny is the president of Complete Practice Resources, a healthcare education, consulting and software company headquartered in Slidell, La. He formerly served as CEO of a large, multi-specialty physician group and full-service MSO. Denny has authored or co-authored numerous “common-sense” practice management books and implementation manuals. He is an award-winning, nationally known consultant, speaker and educator, bringing his expertise to bear on making the complex, simple. He currently serves on the editorial board of ICD10monitor.

Educated at the U.S. Air Force Academy, Denny had a distinguished career as an Air Force pilot and has a long history of commitment to excellence and dedication to his clients’ success.

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A seventh character has been added to some chapters of ICD-10-CM. The meanings of the seventh character vary across chapters and categories, though. The language of each applicable ICD-10-CM category will identify the necessity to use a seventh character. The applicable seventh character is required for all codes within certain categories, or as the notes in the tabular lists instruct. A code that has an applicable seventh character is considered invalid without the seventh character. Such characters also always must be the seventh characters in the data field, and if the code is not of sufficient length, a placeholder of “x” is required to fill empty characters.

As I discussed last month, engaging your physicians in the transition to ICD-10, despite your best efforts and months of planning, may continue to seem a daunting task – a notion fueled by the recent delay, peer skepticism and a lack of focus on a requirement that won’t be implemented until 2014. Furthermore, in an effort to bring physicians into the fold, many industry, professional and trade associations have downplayed the impact in order to increase buy-in.

In my travels across the country, I am told by many physicians that their organizations are trying to shift the burden of coding to busy clinicians working at the point of care, a plan being executed under the guise of the elimination of superbills and charge sheets. The most common complaint I hear from physicians is that their organizations are requiring them to attend Web-based training courses on ICD-10, sessions that are far too time-consuming and much more in-depth than what they truly need.

If your physicians are bolting toward the nearest exit each time you mention ICD-10, perhaps it is time to rethink your strategy and prepare an approach similar to the one recently unveiled by Nicholas Holmes, MD, and this writer at the ICD-10 Summit last April. The plan featured 10 steps to increase physician engagement in order to assure a successful implementation:

  1. Assess the current physician documentation workflow.

  2. Outline the future state of clinical documentation to support ICD-10.

  3. Perform a coding and documentation gap analysis.

  4. Perform an impact analysis.

  5. Set realistic expectations and timelines to remediate documentation capture shortfalls.

  6. Develop a marketing and communication plan.

  7. Prepare a training plan.

  8. Identify strategies, solutions and/or refinements.

  9. Develop a budget.

  10. Prepare a transition road map.

As you approach the first step, it is critical that you brush up on information regarding the current workflow associated with clinical documentation capture and identify what the present choices as it pertains to capturing patients’ Diagnoses. Most organizations use a variety of methods, and many have not transitioned to a fully electronic record (some still are utilizing a hybrid record). Below are the most common methods of collecting diagnostic and procedural input:

  1. Utilization of a niche system problem list (SNOMED CT is mapped to ICD-9-CM) that interoperates within an electric health record system environment.

  2. A pick list, which features a pre-populated, shorter list (often referred to as a preference list) of packaged terms from which to choose.

  3. Free text of diagnostic and procedural information, either handwritten or electronically entered into a progress note, with a history and physical or discharge summary.

  4. Use of dictation and speech recognition software, which are still a common method – many of the speech recognition systems interoperate nicely within an electronic health record.

  5. Direct entry into EHR templates, utilizing many of the approaches above.

Following the identification of current practices and evaluation of provider satisfaction with current documentation tools and the technology, efficiency and effectiveness of each approach, the next step is to determine the gaps and opportunities to create an optimized future state.

Next month’s article will continue the journey and provide details regarding the execution of each step.

About the Author

Cassi Birnbaum, MS, RHIA, CPHQ is vice president of health information management for Peak Health Solutions, specializing in providing remote coding, auditing, data collection and analysis, clinical documentation improvement, ICD-10 transition, and HIM resource planning services nationwide. For the last 15 years, Birnbaum was the director of health information and privacy officer at Rady Children’s Hospital in San Diego, Calif.

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In what might the first healthcare parody of the Carly Rae Jepsen’s mega hit, “Call Me Maybe,”  Maria Bounos last week sang her version adding to the list on Internet parodies on the song that seems to have Americans humming these days.

Bounos sang her version during the Wednesday edition of Talk-Ten-Tuesday that originated live from the AHIMA national exhibit and convention in Chicago, Oct. 1-3.

{audio}i10_baby.mp3{/audio}

Here, by popular request are her original lyrics:

Hey, the rule is final now,
Provider’s gone crazy,
But here’s the number,
It’s I-10 baby

It’s hard to think that,
The lull is over,
But here’s the number,
It’s I-10 baby

Hey, the rule is final now,
Provider’s gone crazy,
But here’s the number,
It’s I-10 baby

Many in disbelief,
Awaiting another delay,
But here’s the number,
It’s I-10 baby

We’ve been working in I-9
And it’s so bad
Yes it’s so bad
It is so so bad

We’ve been working in I-9
And it’s so bad
Yes it’s so bad
It is so so bad

It’s hard to think that,
The lull is over,
But here’s the number,
It’s I-10 baby

Hey, the rule is final now,
Provider’s gone crazy,
But here’s the number,
It’s I-10 baby

Many in disbelief,
Awaiting another delay,
But here’s the number,
It’s I-10 baby

We’ve been working in I-9
And it’s so bad
Yes it’s so bad
It is so so bad

We’ve been working in I-9
And it’s so bad
And you should know that
It’s I-10 baby

About the Author

Maria T. Bounos, RN, MPM, CPC-H, is the Business Development Manager for Regulatory and Reimbursement software solutions for Wolters Kluwer. Maria began her career at Wolters Kluwer as a product manager, responsible for product development, maintenance, enhancements and business development and now solely focuses on business development. She has more than twenty years of experience in healthcare including nursing, coding, healthcare consulting, and software solutions.

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The U.S. healthcare industry has had a sharp focus on ICD-10-CM, in turn publishing a great amount of guidance on the upgraded coding set and its projected impacts.

However, the real game-changer is ICD-10-PCS. ICD-10-PCS is a new classification system that replaces the third volume of ICD-9-CM, which is used for coding inpatient procedures. By design, it is a completely different classification system. Each portion of the seven-character code represents a characteristic of the operative procedure:

  1. Section
  2. Body System
  3. Root Operation
  4. Body Part
  5. Approach
  6. Device
  7. Qualifier

Many coders have asked the question: What is the best way to tackle learning ICD-10-PCS? Since the classification system is based on 31 root operations, mastering the definitions and applying them to case studies is the answer. Remember, it is the coder’s responsibility to translate the physician’s documentation into ICD-10-PCS codes. Definitions for the root operations allow for that translation. For example, if the surgeon states that an entire gallbladder was removed, how does this translate into root operations? The root operation for removal of the complete gallbladder is “resection” because the definition of that term is “cutting out or off, without replacement, all of a body part.” The operative term “removal” is one of the 31 root operations, but the definition for that term is “taking out or off a device from a body part.” If the physician states “removal,” the coder then can translate the procedure into “resection” because it meets the root-operation definition.

Learning root operations will be the key to your success! Now, let’s take a look at a step-by-step approach to get you there.

Step 1- Focus on the Groupings

The 31 root operations are classified into nine general categories. For example, five root operations (excision, resection, extraction, destruction, detachment) fall into the category that describes “procedures that take out some or all of a body part.” If the intent of the procedure is to remove the uterus (a hysterectomy), there is no reason to review all 31 root operations; shift your focus to just these five root operations.

Step 2 – Ask the Question: What is the difference?

Each aforementioned grouping has common characteristics, but the individual root operations within the groupings have distinct meanings. For example, there are three root operations under the classification of “procedures that take out or eliminate solid matter, fluids or gases from a body part.” What are the differences between the three root operations (drainage, extirpation and fragmentation)? If you are reading the operative report for a patient who had a thoracentesis for pleural effusion, the definition of “drainage” applies, since the intent of the procedure was to remove fluid. If the surgeon excised a piece of a chicken bone lodged in the throat, the root operation “extirpation” applies for taking or cutting out solid matter from a body part. Why wouldn’t the root operation “excision” apply? Comparing the two root operations (excision and extirpation) will reveal that “excision” is reserved for cutting out a portion of a body part. A piece of chicken bone is not a body part; therefore, the root operation goes to the grouping that “eliminates solid matter.”

Step 3 - Use the Alphabetic Index

Although coding guidelines state that final code selection must be accomplished using the PCS table, use the Alphabetic Index to discover how the classification system works. Remember that ICD-10-PCS is a classification system; therefore, part of the learning process will include discovering how procedures are grouped. For example, the

operative term thrombectomy leads you to “extirpation.” For the operative procedure meatotomy, the Alphabetic Index states to see “drainage” of the urinary system. The procedure epididymoplasty in the Alphabetic Index reveals the following:

See repair, male reproductive system
See supplement, male reproductive system

This entry begs the question, “What is the difference between the root operations “repair” and “supplement”? The answer lies in the definitions for these two root operations. If the patient required a device to repair the epididymis, then the root operation “supplement” applies. If not, the procedure would be classified as “repair.”

Keep in mind that the Alphabetic Index provides guidance, but again, the final coding decisions are based on the PCS table that matches the documentation in the health record.

 

Step 4 - Practice Exercises

At first, practice sessions may include assigning root operations to one-line operative statements, but eventually, sessions will have to involve real case studies. Consider obtaining a list of your facility’s 20 most common inpatient procedures and practice assigning root operations for those procedures.

Next Steps

After mastering the root operation definitions, the next step involves coding case studies and applying official coding guidelines. This will allow coders to leverage their knowledge about the classification system, guidelines and anatomy in order to capture the codes that tell the complete story about every operative episode. Mastering the root operations will allow you to feel more confident about taking the next steps, delving into case studies and official coding guideline application. As you can see, ICD-10-PCS is much different than ICD-10-CM – and it is a game-changer for coders as they learn ICD-10.

About the Author

Maria T. Bounos, RN, MPM, CPC-H, is the Business Development Manager for Regulatory and Reimbursement software solutions for Wolters Kluwer.  Maria began her career at Wolters Kluwer as a product manager, responsible for product development, maintenance, enhancements and business development and now solely focuses on business development.  She has more than twenty years of experience in healthcare including nursing, coding, healthcare consulting, and software solutions.

Contact the Author

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EDITOR’S NOTE: This is the third installment in a three-part series about the author’s encounter with a physician and his staff regarding the clinical documentation of a patient who had suffered a hairline fracture of the left ankle. In this final installment, the author describes the granularity of ICD-10.

Granularity of Documentation Under ICD-10-CM

As compared to the current status of MR documentation, improvements will need to be made in the quality, not quantity, of provider notes, in many instances. Similar to the orthopedic audit we have been discussing, certain patient case specifics, if documented, can improve the clinical data quality and at the same time make it easier for coders to interpret and assign correct ICD-9-CM codes (and prepare for assigning ICD-10-CM codes). That’s a lot of pluses for simply improving the details captured in the MR documentation! We will discuss a few of these documentation specifics only as they pertain to the patient case outlined above for Dr. Jones.

Type of fracture

Let’s begin this subsection with this dictum: If the coder is in doubt about the MR documentation specifics, query the provider. Working off of that directive, we will both query the provider and reread the case notes for missed information. Dr. Jones’ patient sustained a non-traumatic fracture of the left ankle, confirmed by X-ray, but written correlation by the provider was not made to the concomitant osteoporosis in the original MR notes.

The orthopedic coder’s first clue in this case is that the fracture was sustained non-traumatically; when there is no reported trauma or if the patient has sustained minor trauma that in another patient with normal, healthy bone would not have resulted in a fracture to the affected site, a pathologic fracture scenario becomes a possibility. In audit case No. 1 for Dr. Jones, there are also the facts that the patient is elderly and has a documented diagnosis of senile osteoporosis. While all of these fit nicely together in the equation for a pathologic fracture, with ICD-9-CM code 733.16, pathologic fracture of the tibia or fibula (Ankle NOS), and 733.01, senile osteoporosis, the physician practice coder still cannot assume that a pathologic fracture due to senile osteoporosis is present unless the provider has documented the cause-and-effect relationship.

At this time, our query has returned with a confirmed correlation of the fracture to the underlying disease process.

Laterality

Making note of the right or left side and/or bilateral status is obviously commonplace when coding orthopedic procedures (i.e., when assigning CPT codes), but it has rarely been a part of the diagnosis coding process in the orthopedic arena (with the exception of attributing effects of certain diseases or events, such as paralytic syndrome or CVA, to a specific side of the body such as dominant, nondominant or bilateral). Soon, under ICD-10-CM, laterality will be a common characteristic captured by codes, making the necessity for documenting this information apropos to documenting the case within expected limits. In other words, it will be the new norm. We’ll see how this data impacts the ICD-10-CM code for the pathologic fracture we’re analyzing in case No. 1 in a few minutes.

Types of encounters

As previously implied, the practice coder in this audit case unfortunately erred by making several false assumptions. She assumed that, because the fracture was described as “acute,” it automatically equated to the traumatic fracture categories in ICD-9-CM. Also, she did not query the provider for a correlation to the documented osteoporosis, and she assumed that because the patient was being seen in follow-up, including her last recorded visit for the fracture care, all of those visits were to be coded with the acute fracture code. The latter assumption is actually a very common error in orthopedics, because the coding concept of aftercare is not always readily understood – and there don’t seem to be any penalties or follow-up by payers when practices continue to assign the acute fracture codes throughout the course of the patient’s treatment.

In ICD-9-CM, aftercare is to be assigned following the initial encounter for care of the acute fracture. To make that crystal clear, both the official coding guidelines and Coding Clinic instruct to code the initial encounter (for treatment) with the acute fracture code and to assign an aftercare code for subsequent visits. In this case, under ICD-9-CM, the aftercare code would have been V54.26, aftercare for healing pathologic fracture of lower leg (which includes the ankle, NOS). Therefore, the first remedial step is to understand basic coding principles and guidelines. Not surprisingly, under ICD-10-CM the encounter type is actually embedded in the code, and much like laterality, the encounter type is captured by a single ICD-10-CM code.

In a Nutshell

For audit case No. 1 then, the facts lead us to ICD-10-CM code assignment of M80.072x, “age-related osteoporosis with current pathological fracture, left ankle and foot,” with “x” being reserved for the type of encounter. The initial encounter would be coded with the seventh character x = A, initial encounter for fracture, with the subsequent visits described with V-codes under ICD-9-CM for aftercare (in this particular clinical case, presenting no healing difficulties) denoted by 7th character x = D, subsequent encounter for fracture with routine healing.

Note that with these codes, M80.072A or M80.072D, we have captured the following data sets: a) type of fracture (pathologic), b) underlying disease (age-related osteoporosis), c) laterality (left) and d) the two types of encounters contained in the audit performed: initial and subsequent (aftercare). ICD-9-CM captured some but not all of this data by assigning ICD-9-CM codes (initial encounter) 733.16 + 733.10 and (subsequent encounters) V54.26 + 733.01.

Conclusions

The march into ICD-10 can be eye-opening for many practices, and the process of performing a documentation assessment can cause more than just diagnosis coding issues to emerge. As stated, this particular orthopedic documentation assessment resulted in good news wrapped in a few layers of bad news. The bad news: the practice wasn’t quite ready to begin full-on ICD-10-CM training; certain remedial steps needed to be taken first.

The good news: the practice had a new outline of activities to undertake and a clear path to ICD-10-CM training and implementation. A timeline could be built on these remedial steps, and the practice acquired a window into how to stage their journey, especially considering the recently revised implementation date of Oct. 1, 2014.

Lastly, I advised the orthopedic surgeons to look at all of the discussed coding and documentation guidelines and the various federal/state regulations as protections, not as tethering regulations. The term “regulations” has such a negative connotation. But by following these myriad protections, the practice can improve data quality for clinical purposes and improve its coding accuracy to receive optimum but appropriate reimbursement. It also can stay squarely within federal/state compliance parameters, protecting its hard-earned reimbursements from payer recoupments, and potentially freeing the practice from associated fines, penalties, pre-payment screens of claims and future focused medical reviews.

About the Author

Michael G. Calahan, PA, MBA, is vice president of physician and hospital compliance for HealthCare Consulting Solutions (HCS).

Contact the Author

mikiecal@hotmail or

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