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Some health information management (HIM) professionals will conduct ICD-10-CM/PCS training of coding specialists in their facilities, and many of these professionals will kick off the training in early 2013. However, in order to start ICD-10 training in 2013, these HIM professionals must do a lot of “prep work” – and that work should start now, in October 2011.
Below is a timeline for many of the most critical action items that need to be completed before ICD-10 training can start in 2013.
OCTOBER-NOVEMBER 2011
Identify all staff responsible for coding throughout the facility and document the following information for each of them:
- Name
- Department
- Job title
- Work site (in house or remote)
- Responsibility for coding cases classified as: inpatient, observation, ambulatory surgery, clinic, emergency department and ancillary visits
- Coding credentials (if applicable)
- Coding education (indicating name of learning institution or whether person was “trained on the job”)
- Number of years of experience in coding
DECEMBER 2011
Request or generate an inpatient case mix report and an outpatient case mix report for all financial classes of patients seen from Jan. 1, 2011 through Nov. 30, 2011. These reports should include, at a minimum:
- Patient name
- Medical record number
- Account number
- Date of service/discharge
- All ICD-9-CM diagnosis codes
- All ICD-9-CM procedure codes
- All CPT/HCPCS codes
- All modifiers
- All DRG assignments
JANUARY 2012
Analyze the inpatient and outpatient case mix reports to identify high-volume conditions, procedures and codes to include in the biomedicine GAP analyses and coding training. In other words, be sure to customize analyses and training materials based on the conditions and procedures that are most common to your facility.
FEBRUARY 2012
Prepare biomedicine GAP analysis exams for medical terminology and anatomy and physiology to assess coders’ strengths and to identify opportunities for improvement.
MARCH 2012
Prepare biomedicine GAP analysis exams for pathophysiology and pharmacology to assess coders’ strengths and to identify opportunities for improvement.
APRIL – MAY 2012
Administer GAP analysis exams to all staff responsible for coding.
JUNE 2012
Grade all GAP analyses and prepare summary reports detailing the findings for each coder. Use the GAP analysis results to identify staff that will need biomedicine training in addition to ICD-10 training.
JULY 2012
Schedule training dates and reserve location(s) for the training sessions. Note: the biomedicine training may need to start in 2012 if it is not feasible to perform both biomedicine and ICD-10 coding training in 2013.
AUGUST 2012
Compile facility-specific clinical notes and reports to customize ICD-10 training exercises and tests.
SEPTEMBER 2012
Order all training materials that will be needed, such as:
- ICD-10-CM and ICD-10-PCS code books
- ICD-10-CM and ICD-10-PCS training materials
- Medical terminology books
- Anatomy and physiology books
- Pathophysiology books
- Pharmacology books
OCTOBER 2012
Prepare and submit continuing education (CE) prior approval applications (and fees) to the organizations that have certified coders who will be trained in ICD-10. The CE approval process may take several weeks or more, so HIM professionals should not wait until 2013 to secure CEs for the training.
These action items are not all-inclusive, but they illustrate how imperative it is for HIM professionals to start preparing for ICD-10 coding training now!
About the Author
Lolita M. Jones, RHIA, CCS, is the principal of Lolita M. Jones Consulting Services (LMJCS), founded in October 1998 in Fort Washington, MD. Ms. Jones has over 25 years of experience in coding and consulting. She started preparing for the implementation of ICD-10-CM/PCS by going back to school. On September 12, 2010, Ms. Jones became an AHIMA-approved ICD-10-CM/PCS trainer.
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With ICD-10 on the horizon, there’s a lot to think about from a coding, reimbursement and compliance perspective. For a moment, however, let’s take a step back and a deep breath. Think big-picture: what is the goal of every healthcare provider? Being an old vet myself, I know it’s to provide excellent, quality patient care. ICD-10 will get us there and give us the opportunity to measure how well we deliver care through the ability to focus on outcomes.
When you think ICD-10, think quality and meaningful use because it all ties together.
The Benefits
So, what do we need to think about? With the implementation of a new coding system, the first thing that comes to mind is money. Yes, there’s a cost to implementing ICD-10. The Centers for Medicare & Medicaid Services (CMS), the World Health Organization (WHO), and the National Center for Health Statistics have collaborated for years to initiate ICD-10, as their focus always has been to put a system in place that improves outcomes.
Looking at the RAND Study, an ICD-10 study done for CMS in 2004, it becomes clear that the benefits of ICD-10 will outweigh the costs. As a synopsis of this study, RAND examined one-time and cumulative annual costs over 10 years. Costs included training of coders and physicians; productivity impacts on coders and physicians; and system changes affecting providers, vendors, payers and CMS.
The high-end costs averaged approximately $1.5 billion, according to RAND, but the benefits focused on outcomes; specifically, it indicated that ICD-10 will be a gateway to accurate payment for new procedures, fewer rejected claims, fewer fraudulent claims, better understanding of new procedures and improved disease management – with an estimated benefit of more than $6 billion to the healthcare industry during the aforementioned 10-year study period.
What can you, not only to be ICD-10 ready, but also to understand how you will be able to contribute to quality outcomes and excellent patient care? The answer: know your risk areas and, first and foremost, understand how you currently do business under ICD-9. This can be accomplished through analytics, specifically through analyzing your current business under ICD-9 by translating the codes to ICD-10. A few strategies would include looking at your areas of highest risk related to coding, reimbursement and compliance.
I-10 Strategies
Coding Perspective:
Look at your utilization under ICD-9. Specifically, look at the most frequently utilized ICD-9 codes at your facility. Start with the top 10percent (depending on the size of your facility, going up to 20percent). A few caveats would include that you need to understand the workflow in your organization specifically related to how ICD-9 codes are generated and to determine whether the codes are from encounter forms, order entry or HIM (just to name a few). Also, don’t forget to find out whether the interfaces are talking to one another (although, of course, that’s a completely different topic for discussion).
You can achieve understanding of your risk under ICD-10 through the CMS General Equivalent Mappings (GEMs) data. GEMs bridge the language gap between ICD-9 and ICD-10 CM and PCS to help providers understand, analyze and manage the process of moving to the new code sets. There are many translation tools on the market; just ensure that the translation tool you choose for your facility maps forwards and backward as well as offers the capability to analyze via reimbursement mappings. Additionally, to expedite the process look for workflow tools that can batch 10-20 percent of the most utilized ICD-9 codes at your facility.
Reimbursement perspective:
Your next logical step is to analyze how you will be paid for those “most utilized” ICD-9 codes under ICD-10. This warrants gaining access to an MS-DRG grouper for ICD-10. Remember, the underlying mission for CMS was to create a system that is budget-neutral. Let’s not be foolish; do your homework. It is your fiscal responsibility to ensure that you get paid for that to which you are entitled.
This means looking at the highest-paid ICD-9 codes at your facility (and looking at the “most frequently utilized” codes doesn’t necessarily mean that they are the highest-paid). This can be accomplished by pulling your highest-paying DRGs with associated ICD-9 codes, then grouping the claims data and checking how those translate to ICD-10. This will help you understand the current case mix and also reveal a potential case mix you might want to go after – in addition to fostering understanding of your current inpatient surgical procedures and potential surgical procedures you may wish to perform at your facility in the future.
Compliance perspective:
To ensure that you stay in compliance and begin to look at the goal of quality outcomes, take the analytics a step further. Look at the most complex mapped ICD-9 codes in your current data. Alter your focus: there will be those that easily map as a one-to-one comparison via the GEMs. Instead, focus on the areas that have a one-to-many mapping to see the types of risks you are facing with ICD-10. And then, finally, focus on the areas of ICD-10 that were not present in ICD-9, which may give you the opportunity to capture great new analytics on patients by code. This includes identifying opportunities to track obstetric patient care and expenses by trimester; flagging patients who are suspected victims of domestic violence and may need additional intervention; and targeting conditions such as cardiovascular disease, cerebrovascular disease, cancer and diabetes – all conditions that are not intrinsically tied to underlying disease processes.
Analytics can be very powerful from a coding, reimbursement and compliance perspective. The specificity required with ICD-10 will allow us to better understand how we do business and give us the reporting mechanisms we need to better focus on quality and meaningful use. ICD-10 will be a financial investment, but the benefits will outweigh the costs when we have the opportunity to improve patient care through analytics.
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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ICD-10-PCS Procedure Coding of PTCA with Insertion of Coronary Artery Stents
By Lynn Cleasby, RHIT, AHIMA-Approved ICD-10-CM/PCS TrainerAs we prepare and progress in our understanding of the future ICD-10 coding system, we continue to uncover the differences from the ICD-9 system. This article will review the difference between the current procedural coding guidelines of ICD-9-CM and the ICD-10-PCS as they relate to the coding of a percutaneous transluminal coronary angioplasty (PTCA) procedure with insertion of coronary artery stents.
Editor’s Note: On a recent Talk-Ten-Tuesday podcast, the ever-popular Billy K. Richburg
described the perils of mapping. His segment is transcribed below.
I’ve been accused of being somewhat cynical when it comes to anything the federal and state governments do, and I’ll confess there’s considerable truth in that. But today I want to talk about the kinds of things non-government payers do – apparently with the sole purpose of irritating the rest of us.
ICD-10 has all sorts of advantages, one of which is that it’s the same everywhere, thanks to the feds. “Mom and Pop’s Health” out of some backwater burg in rural America can’t make up their own codes unless they really thrive on violating the HIPAA Transaction Rule, which is illegal.
But what about the things related to ICD-10 not addressed by the Transaction Rule? How about a specific example: crosswalks!
Crosswalks are a critical component of our transition to ICD-10, but as incomprehensible as it seems, there isn’t a single mandated crosswalk. Yes, CMS publishes GEMs, but right on its website they say the mappings can be used to develop “alternative mapping systems” for specific purposes. In other words, “Mom and Pop’s Health” can make up their own mapping.
So how exactly is this a problem?
For most hospitals, larger clinic groups and the like, it probably means very little. But using multiple mapping systems would make it impossible to reliably model ICD-9 and ICD-10 versions of the same claims to see how DRG grouping would compare, for example. “Mom and Pop’s Health” claims might map right one time and wrong the next.
But the greatest risk is to smaller providers – small clinics, small home health agencies, mid-level independent practitioners such as therapists and nutritionists – that think they cannot afford to have their claims professionally coded, so they instead depend on crosswalks to simulate proper coding. For those people, multiple crosswalks may be their ultimate nightmare: they’ll never know how they’re going to be paid. It’s bad enough to use one flawed system (like GEMs), but it’s a bona fide disaster-in-the-making to try to use several of them simultaneously.
So no matter who you are, no matter how large or small your practice or your organization, do not think for a moment about using GEMs or any “how gullible are you?” alternatives to code claims. It’s just not worth it.
About the Author
Billy K. Richburg, MS, FHFMA, is HFMA-certified in accounting and finance, patient accounting and managed care. Bill graduated from the University of Alaska in Anchorage and earned his MS in healthcare administration from Trinity University in San Antonio, Texas. During a career spanning more than 40 years, Bill has held positions including CEO, COO, CFO and CIO in hospitals ranging from 75 beds to more than 300 beds, and in home health agencies, DME stores and a home infusion company. Bill is a board member of the Lone Star Chapter of the HFMA and is director of government programs for the Revenue Cycle Management business segment of MedAssets Inc. His office is in Plano, Texas.
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Sound advice and solid guidance formed the foundation of the recent HIMSS Virtual Briefing: Critical Factors of the ICD-10 Conversion. The audio included five inter-related topics presented by 12 speakers with expertise in the steps required to make the transition to the ICD-10 system. Highlights of the briefing are provided below, but, first, here are a few important sound-bites delivered by speakers that emphasized the need to get started on the transition now, not later.
Editor’s Note: On a recent Talk-Ten-Tuesday podcast, the ever-popular Billy K. Richburg used the Rubik’s Cube as an analogy for ICD-10 compliance. His segment is transcribed below.
Rubik’s Cube is a puzzle invented by a Hungarian engineer and teacher in 1974. Subsequently it was marketed worldwide beginning in 1980 by Ideal Toy Corporation.
When you buy a (Rubik’s) Cube, it’s “solved.” That is, each face is all one color and you mess it up by twisting the layers. Once the colors are mixed on each face, you then solve it – making the faces a solid color again – by twisting the layers around the central core. Sounds simple enough … until you actually try it.
How difficult is it to solve? Well, there are 43.25 quintillion possible solutions, unless you take it apart. … To put that in perspective, 43.25 quintillion Rubik’s Cubes – which are roughly 2-1/4 inches on each side – would cover the earth to a depth of 52 feet – roughly 5 stories.
The current record time for solving the cube is 5.66 seconds, set by Feliks Zemdegs in Melbourne just this year. Feliks also holds the record for “average solution times,” at 7.64 seconds.
“So what’s your point,” you ask? Glad you asked!
The process of preparing for ICD-10 actually has a lot in common with (solving a) Rubik’s Cube.
If each diagnosis code could be used with any procedure code and vice-versa – which is not the case, but stay with me here – then there are approximately 5-1/2 billion combinations, and that’s only using one procedure code and one diagnosis code at a time.
And how many ways are there to implement ICD-10 in your organization – hospital, payer, clearinghouse, or vendor? Actually, the number probably is infinite, because each individual involved in the process will influence how it is done, and let’s be honest: we each think our way is best.
There is a grand irony in all this.
In the final analysis, and with apologies to Carl Sagan, there are “billions and billions” of ways to implement ICD-10, but – like the Cube – there is only one correct implementation. No matter how you approach the problem, your implementation of ICD-10 has to look pretty much like every other one.
That’s the beauty of the HIPAA Transaction Rule, you see: How we comply is up to us and is infinitely variable. There is no “best way” to implement ICD-10. But the final solution is specified, mandated, forced, compelled, coerced: pick your verb. It must look the same everywhere.
And that’s okay, because if it didn’t, it wouldn’t be a “standard,” and it would have no value. A primary purpose of ICD-10 is to allow comparison, statistical analysis, trending and other data manipulation – and if it doesn’t look the same everywhere, those goals are meaningless.
So, smile, hold your head up high, pursue your solution to the problem even though you must tolerate those other people in your organization who think they have a better idea, and take some comfort in knowing that several hundred thousand other people are doing exactly the same thing – but you’ll all end up in the same place. After all, anything less is failure.
About the Author
Billy K. Richburg, MS, FHFMA, is HFMA-certified in accounting and finance, patient accounting and managed care. Bill graduated from the University of Alaska in Anchorage and earned his MS in healthcare administration from Trinity University in San Antonio, Texas. During a career spanning more than 40 years, Bill has held positions including CEO, COO, CFO, and CIO, in hospitals ranging from 75 beds to more than 300 beds, and in home health agencies, DME stores and a home infusion company. Bill is a board member of the Lone Star Chapter of the HFMA and is director of government programs for the revenue cycle technologies business segment of MedAssets Inc. His office is in Plano, Texas.
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THE PROBLEM
The key to success with ICD-10 is the same as it is with ICD-9: documentation is everything. Unfortunately, ICD-10 is significantly more complex than ICD-9, and this begs the number one question related to the entire ICD-10 implementation experience:
How do I convince a recalcitrant physician to document their care adequately so we (the hospital, ASC or other institution) can optimize ICD-10 coding and realize the greatest possible benefit from this system?
Evaluating Technology to Attack ICD-10 from a Coding Perspective: Paper Versus Electronic
By Maria Bounos, RN, MPH, CPC-H
The ICD-10 countdown continues, as all certified coders are facing the task of familiarizing themselves with the new coding system.
With Oct. 1, 2013 on the horizon, many will be preparing to take ICD-10 certification exams as part of certain coding association requirements. Paper and electronic methods are the two paths coders face as they begin to think about an attack on ICD-10 – so which path should you choose?
The use of the word “attack” is widespread, as every U.S. organization is faced with transitioning from roughly 60,000 codes in ICD-9 to more than 150,000 in ICD-10. The numbers are overwhelming; so overwhelming, in fact, that many seasoned coders have stated that they will retire before ICD-10 is implemented. Being that many coders are visual thinkers, many believe that paper is the only option, specifically since those sitting down to take the ICD-10 certification exam will need to use a paper ICD-10 code book.
Whether you are a coder, a HIM director with coding staff or part of an ICD-10 risk assessment committee, do you know how you, your team and/or your organization are going to attack learning the ICD-10-CM and PCS coding systems? Many may default to paper code books, but if you think about coding from a workflow perspective, it makes the most sense to take advantage of modern technology. Still, there is no need to choose one or the other. You can pair them together as a single plan of attack and look for electronic tools that can assist coders in learning how to use the required paper code book.
Considering Workflow Tools
From a broader perspective, aside from the paper code book option, other types of ICD-10 workflow tools to consider obtaining include any that will assist in learning the actual code sets, assist in current workflow activity to translate codes from I-9 to I-10 and assist in learning ICD-10 from a regulatory standpoint. These tools possibly could include a subscription to electronic educational courseware, specifically sources with a strong focus in anatomy and physiology.
There are options out there in the marketplace, and many organizations already have multiple tools that may help them accomplish some of these objectives. Also, take a moment to assess the coding workflow. You soon will realize how your organization easily can limit coder apprehension about learning the new coding system, increase coder longevity and productivity and save money at the end of the day if you choose coding workflow tools wisely.
Workflow coding tools should provide the following in one easy-to-use format:
Coding – Ensure that electronic code books are available and contain both ICD-10-CM and PCS. The CM electronic code book should be comprehensive, featuring guidelines and indexes, and the PCS e-code book should include guidelines, indexes and a reference manual. The electronic code books should be paired with some type of ICD-9-to-ICD-10 translation tool. This tool should assist the coder in analyzing current code sets under ICD-9 in comparison to those in ICD-10.
Regulatory Resources – Correct coding is driven by regulatory information. Providing access to CMS notifications and regulatory issuances such as The Federal Register and CFR will be key to a coder’s success. Additionally, a quality coding workflow tool should have the capability to highlight and anticipate the addition of local and national coverage determinations as well as updates to the ICD-10 coding system in the form of CMS manuals and transmittals. Be prepared, as payers and CMS soon will provide direction for accurate claims submission as we continue to move forward towards ICD-10.
Education - Electronic educational courses paired with coding and regulatory information can be very powerful in helping the coder tie it all together. Courses should include not only a comprehensive overview of the ICD-10 coding system but also components related to anatomy and physiology, clinical implications, and medical terminology: items to help coders adjust to the specificity required by coding with ICD-10.
The Role of Technology
Evaluating technology used to facilitate learning of ICD-10 code sets is not an easy task, yet the technology should be able to do the following from a coding workflow perspective:
I. Offer an electronic translation tool that allows the user to perform a simultaneous keyword search of ICD-9 and ICD-10 for direct comparison (and not just by code searching).
II. Provide transparent access to the General Equivalent Mappings (GEMs) and reimbursement maps so that the search results are obvious and direct, including forward and backward mapping.*
*Many have argued that coders should not use GEMs to code or even have access to the reimbursement maps. The GEMs and reimbursement maps should serve solely as a guide for coders, and should not be seen as a replacement to actually learning the new coding system.
III. Provide understanding of the implications of ICD-10 on MS-DRGs via an interactive MS-DRG grouper.
IV. Present current and archived guidance to assist coders in understanding how ICD-10 impacts other coding areas such as claims processing, Medicare benefit policy rules and national and local coverage determinations.
V. Include free training and support; this is an unfunded mandate from the government. Although development is an incurred cost by vendors for these workflow tools, institutions should not be burdened with software installation and training costs.
Choose to be a leader in learning ICD-10, and pair paper code books with electronic tools to facilitate the transition. The use of electronic coding workflow tools not only will improve efficiencies and lower administrative costs, but also reduce coding errors and claim rejections. It will lead to achieving an organizational enterprise goal to be in compliance and submit clean claims correctly the first time.
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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“Embrace it; don’t postpone it.” That’s one key piece of advice that Dr. Daniel Duvall, medical officer for the hospital and ambulatory policy group at the Center for Medicare, gave to those who listened to an August 3 national provider call sponsored by the Centers for Medicare & Medicaid Services.
The presentation by Duvall and others from CMS, entitled ICD-10 Implementation Strategies for Physicians, seemed to be designed as a way to replace providers’ fears about the new system with information about what they need to do to get ready for the October 1, 2013, implementation date.
Billy's World: Healthcare Providers: Victims of an Environment They Cannot Control
By Billy Richburg, M.S., FHFMAThat’s not a particularly shocking statement; most of you probably agree. But let’s consider one small example of what it means.
Have you ever noticed how every time someone comes up with some change in payment systems, coding systems, cost containment systems or whatever, consultants (me, for example) seem to come out of the woodwork?
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When coders for inpatient rehabilitation facilities were instructed to use a code from the V57.xx series to indicate principal diagnosis, there was a loud howl of protest from those who felt that these codes did not represent diagnoses but rather the treatment a patient would receive.
It was inconsistent, as staff did not report a code to admit for medical care or a code to admit for surgery. However, this was an efficient method through which to group a patient to DRG 462 for rehabilitation. Rehabilitation facilities excluded from the DRG payment methodology also were instructed to use this code to indicate principal diagnosis.
The 2002 implementation of the IRF PPS included completion of the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF PAI). The IRF PAI required code assignment for the etiology, comorbid conditions, complications and reasons for interrupted stays or death. The IRF PAI instructions for code assignment mandated the etiology-advised coders to report the diagnostic code for the acute condition that was responsible for the impairment. This was unusual, and ran contrary to how the official guidelines instructed coders to operate.
Once again, coders had to accept change, although they did not understand why code V57.89 couldn’t be reported as the etiology, as it was appropriate for the billing form. The response to this was that the billing form and the IRF PAI are separate documents. The IRF PAI is a separate data set, meaning the Official ICD-9-CM Guidelines for Coding and Reporting do not apply to code assignment for it.
Then Came MS DRGs
With the introduction of Medicare Severity – Diagnostic Related Groups (MS –DRGs), the rehabilitation DRGs changed to DRG 946, rehabilitation with major complication/comorbidity (MCC), and DRG 945, Rehabilitation without CC or MCC.
ICD-9-CM codes for the principal diagnoses that assign DRGs 945 or 946 include:
V52.8 Fitting and adjustment of other specified prosthetic device
V52.9 Fitting and adjustment of unspecified prosthetic device
V57.1 Other physical therapy
V57.2 Occupational therapy and vocational rehabilitation
V57.3 Care involving use of rehabilitation speech-language therapy
V57.89 Other specified rehabilitation procedure
V57.9 Unspecified rehabilitation procedure
It is possible to map codes V52.8 and V52.9 to ICD-10-CM codes in the Z44 series of codes. These codes seldom are used as a principal diagnosis by inpatient rehabilitation facilities.
The official ICD-9-CM coding guidelines indicate that only one code from the V57 series of codes should be reported. Inpatient rehabilitation facilities report code V57.89 for inpatient admissions to indicate that a patient will receive therapy in multiple therapy disciplines.
Mapping Won’t Get You There
A simple mapping of the V57 series of codes found in ICD-9-CM over to ICD-10-CM is not possible, as codes that duplicate the V57 series currently are not included in ICD-10-CM classification. Inpatient rehabilitation coders will need to be flexible, as change is inevitable. How to assign the inpatient rehabilitation DRGs when ICD-10-CM is implemented is a matter still being studied.
One possible solution for assignment of the rehabilitation DRGs is to add additional codes to the ICD-10-CM classification, replacing the current V codes used for ICD-9-CM. Another possible solution would be to map to the rehabilitation DRGs the ICD-10-PCS procedure codes for Physical Rehabilitation and Diagnostic Audiology, F00-F15.
A solution will need to be found prior to Oct. 1, 2013.
About the Author
Patricia Trela, RHIA, is the director of HIM and rehabilitation services for Diskriter, Inc., a consulting firm offering integrated HIM rehabilitation consulting services, including HIM Interim management, IRF PPS compliance and education, coding and auditing support, dictation/transcription, and other solutions. She has more than 25 years of healthcare industry experience. As a consultant, Pat has worked with many acute-care hospitals, rehabilitation hospitals and long-term acute-care hospitals (LTACH). Pat facilitates the AHIMA Coding Physical Medicine Rehabilitation Community of Practice (COP).
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This is my third article for ICD10monitor, and after the first two I suspect that some of you may be wondering why I’m even a contributor. After all, my entire work history (at least since 1977) has fallen under provider financial responsibilities, and my dominant focus now is Medicare payments. I’ve never worked in health information management (HIM, or “medical records,” its understated former name), and I generally am a useful addition to any room full of HIM professionals. Add to that the fact that I consider ICD-10 to be a monumental bore and perhaps a prime example of the term “necessary evil,” and I can understand why you might question my involvement.
The problem with the notion that I really have nothing of value to say lies in ignoring the synergistic and co-dependent relationships among clinical care professionals, HIM professionals and patient financial services (formerly “business office” or “patient accounting”) professionals. Let’s consider this for a moment as I seek to defend my role.
I ride a “trike:” a Harley-Davidson Ultra Classic with a Roadsmith conversion kit from The Trike Shop in Minnesota. Wait, I think I have a photo somewhere … ah, yes, here it is:
While I readily concede that my trike is little more than a manifestation of one form of mid-life crisis, it does serve to make a key point, to wit:
The one thing that distinguishes a trike from all other forms of transportation are those three round hunks of rubber, steel, aluminum and various other materials on each corner. It’s a funny thing about something with three wheels: if any one of them doesn’t do its job, the vehicle won’t go. That is, it won’t succeed in doing what it’s meant to do.
It’s the same with healthcare finance as practiced in provider settings (hospitals, physician offices, ASCs, ESRD facilities, you name it). If the front wheel represents patient care, the back wheels are HIM and PFS. While it’s true there is no money without good patient care, it’s no less true that HIM significantly impacts the collectible revenues on any given claim, and PFS has to be at the top of its game – all the time – to collect those revenues. My favorite maxim is no less true than when it first was stated: “No Margin, No Mission.” And neither caregivers nor HIM nor PFS can claim they are the most important part of the equation. In fact, the system only works, it only thrives, when all three components of the revenue cycle perform at their best.
While my interest and expertise lie in the area of payments, that simply means that my focus is on the PFS third of this relationship. But I readily embrace the reality that my success depends in large measure on HIM providing the best records and coding possible, and, as always, on the clinicians providing the best possible care. Think of my trike as “the Revenue Cycle.” It’s neither a unicycle nor a bicycle; it’s a tricycle, and it succeeds only because of that distinguishing fact.
Quite simply, it is impossible to separate the three core functions of the revenue cycle and operate on the presumption that one or the other (or the other) is “the most important.” As a payer watchdog, someone who helps providers identify when they are underpaid by FIs and MACs, I depend on HIM to give me an accurate bill, on patient financial services to collect it and on the clinical care professionals to generate the next day’s revenue. It’s a funny thing about cycles: they repeat. So with every new day the clinicians must do as well as they did the day before, as must the HIM and PFS professionals.
Those of us who live, breathe, succeed and prosper working on the provider side of healthcare are not standing in three corners of a wrestling ring waiting for a fight to begin. Rather we are the three keys to any provider’s long-term financial success: the front wheel (clinicians, leading the way), one rear wheel (HIM, assuring that billing is accurate and timely) and the other rear wheel (PFS, generating the bill, following up with payers and collecting everything to which the provider is entitled).
Because we all depend on each other, we also have the right and responsibility to consider each other’s priorities and preferences as we pursue our own. Thus my role is not to be focused on the technical aspects of ICD-10 implementation and conversion; there are many people here who are far more capable in that area than I. Rather, my role is to contribute some small insights into one of the other two-thirds of the ICD-10 milieu: patient financial services (and perhaps to serve as a counterpoint to all the “tech talk”). I also reserve the right to be tongue-in-cheek any time I feel like it.
So let us know if you have a topic you’d like me to address. I have opinions about almost everything!
About the Author
Billy K. Richburg, M.S., FHFMA is HFMA-Certified in Accounting and Finance, Patient Accounting and Managed Care. Bill graduated from the U. of Alaska, Anchorage and earned his M.S. in Health Care Administration from Trinity University, San Antonio, TX. Over a career spanning more than 40 years, Bill has held positions including CEO, COO, CFO, and CIO in hospitals ranging from 75 beds to over 300 beds, and in home health agencies, DME stores, and a home infusion company. Bill is a Board Member of the Lone Star Chapter, HFMA, and is Director of Government Programs for the Revenue Cycle Technologies business segment of MedAssets, Inc. His office is in Plano, Texas.
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As hospitals begin preparations for ICD-10, it should be recognized that a parallel process will be taking place in the physician office setting. Fully integrated systems will produce the benefit of providing integrated education to physicians. In fragmented systems, physicians will be responsible for purchasing new IT systems, providing training for office billing staff and in many, many instances hiring new staff due to the anticipated attrition of professional billers as we transition to the new system.
What kind of awareness training should physicians receive now? The first step should be fostering awareness of the complexity of the system from a very high level to persuade physician leaders to begin preparations. In this article, I’ll focus on the diagnosis side of ICD-10.
Most healthcare leaders are aware that the number of diagnosis codes increases dramatically from ICD-9 to ICD-10. However, while the raw aggregate number of codes increases from approximately 13,500 to 70,000, the increase is not consistent across all categories.
Consider one localized group of fractures, those occurring in the femoral head and neck region. Under ICD-9 there are 12 available codes such as 820.02 Midcervical Femoral Neck Fracture, Closed or 820.11 Epiphyseal Fracture Transcervical, Open. These fractures are distinguished from peritrochanteric and shaft fractures.
In ICD-10-CM, Chapter XIX: Injury, poisoning and certain other consequences of external causes (including subchapter S00-T98, Injuries to the Hip and Thigh) are addressed in sections S70-S79. S72 is titled Fracture of Femur and is subdivided into S72.0 Fracture of the Neck of the Femur, S72.1 Pertrochanteric Fracture, S72.2 Subtrochanteric Fracture, S72.3 Fracture of the Shaft of the Femur, and so on.
In comparison to the 12 available codes for all femoral head and neck fractures in ICD-9, consider S72.0 Fracture of the Neck of the Femur. This appears to be a specific code, but under S72.0, using the appropriate additional digits S72.0xyz allows for markedly increased specificity.
There are, in fact, 576 subtypes of fracture within S72.0. There are 48 specific codes for Fracture of Unspecified Part of Neck of Femur, another 48 specific codes for Unspecified Intracapsular Fracture (of the femur), 96 codes for epiphyseal fractures (48 displaced, 48 undisplaced), 96 codes for mid-cervical fractures (again half displaced, half non-displaced), 96 codes for fractures of the base of the neck (same pattern), 48 codes for unspecified fractures of the head of the femur, 96 codes for articular fractures of the femoral head (displaced and non-displaced, and 48 codes for “other fractures of the head and neck of the femur.” If one considers all codes for femoral fractures from the proximal to distal aspects bilaterally, by my calculations there are 2,466 codes (though I may have missed a few).
The level of specificity required appears daunting. Can we expect coders currently using12 different codes to find the detail necessary to specify one of 576 codes? Further, do we expect orthopedic surgeons to provide all the necessary detail for this specificity? The challenge may not be as insurmountable as it initially appears.
ICD-10-CM diagnosis codes have 3-7 characters (compared to 3-5 in ICD-9) laid out in a specific format, with each character organized within any subchapter in a specific manner (see ICD-9-CM diagnoses/ICD-10-CM sidebar comparison).
The first three digits indicate the category. The first character is always alphabetic, the second is always numeric and the third can be either. Consider the following specific diagnosis code listed below (it’s one of the 576 codes):
S72031K Displaced midcervical fracture of right femur, subsequent encounter for closed fracture with nonunion.
The category of fracture is S72 – femoral fracture; S72.0 narrows the description to those of the head and neck. The remaining digits indicate, in this example, the subsequent encounter for a non-union in a fracture that originally was closed. This level of detail typically is included in the clinical record, though it may not be summarized succinctly by the orthopedic surgeon at this point.
By developing a collaborative educational approach for physicians as well as coders and documentation specialists, ICD-10 at least can be demystified partially. The anticipated benefits of ICD-10, according to CMS, are listed in the sidebar. Successful implementation will require peer-to-peer discussions to provide the motivation and knowledge necessary for physicians to collaborate in the inpatient ICD-10 process.
BENEFITS OF ICD-10-CM
ICD-10-CM incorporates much greater clinical detail and specificity than ICD-9-CM. Terminology and disease classification have been updated to be consistent with current clinical practices. The modern classification system will provide much better data needed for:
- Measuring the quality, safety and efficacy of care;
- Reducing the need for attachments to explain the patient’s condition;
- Designing payment systems and processing claims for reimbursement;
- Conducting research, epidemiological studies and clinical trials;
- Setting health policy;
- Performing operational and strategic planning;
- Designing healthcare delivery systems;
- Monitoring resource utilization;
- Improving clinical, financial and administrative performance;
- Preventing and detecting healthcare fraud and abuse; and
- Tracking public health and risks.
Source: Quick Reference Information: ICD-10-CM Classification Enhancements, available at https://www.cms.gov/ICD10/Downloads/ICD-10QuickRefer.pdf
About the Author
Paul Weygandt is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Dr. Weygandt is vice president of physician services for J.A. Thomas & Associates and is a partner in the firm.
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NPPs and ICD-10: Performing a Baseline Medical Record Documentation Assessment
By Michael Calahan, PA, MBA
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.
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