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Time is a funny thing. 

We often lament about the “speed” in which time flies and yet we can also be incredibly complacent about deadlines that seem really far away. 

The deadline for ICD-10-CM/PCS is one of those distant deadlines that are seen in both lights. On the one hand many professionals in the industry feel the timeframe till implementation is looming large and there is not enough time, and on the other a large contingent give ICD-10-CM/PCS very little thought, “it is just too soon.”  So what is the optimal “stance” on preparedness? 

Understanding the depth and breadth of the implementation is the easy part, as most know advisory bodies and vendors in our industry have published guides and lists of all the areas impacted and have given the 30,000-foot view of how to handle each issue. 

The hard part is putting together the “plan” and assigning the right “timeline” for completion. In order to place issues and tasks into perspective and place them into to the timetable correctly, we must have an in-depth understanding of the issue in relation to our facilities. So research and study of each component in the ICD-10-CM/PCS implementation plan is the point of this article and in particular the component of MS-DRGs and ICD-10-CM/PCS. 

CMS published the ICD-10-CM/PCS MS-DRG Version 28 Definitions Manual in February of this year to allow hospitals to understand the impact the implementation would have on case mix and the bottom line. The good news from CMS is that the draft of ICD-10 MS-DRGs is meant to replicate ICD-9-CM MS-DRGs. This means that when the coder correctly reports the documentation in the medical record that the MS-DRG for ICD-10-CM/PCS will be the same as it would have been for ICD-9-CM.  Or will it? 

Understanding the basis of the data and methodology used for the conversion project is imperative for every organization. There are so many variables that will occur from facility to facility that could and will impact the prophesized neutrality. Here is a brief list of these issues: 

  1. CMS tested the new mapping on MDC 6 the digestive MDC, and cited that five percent of mapping would require a clinical review. There could be a significant differences in other MDCs. CMS did identify that other translation issues were discovered where the assignment logic was especially complex, such as cardiovascular and orthopedic MS-DRGS. 
  2. The five percent of claims requiring review during the test did not account for service frequency, billed code volume or impact on dollars. When using GEMs to map the codes the percentage or dollars related to codes not cleanly placed into a DRG will likely be higher or lower than five percent. 
  3. When an ICD-10 code could be placed into more that one MS-DRG, MED PAR data were used in the process to select only one. Commercial health plan frequency data may have produced different results. 
  4. The improved code specificity in ICD-10-CM will eliminate some of the uncertainty that exists with ICD-9. This clarity may produce different MS-DRGs. 
  5. Although the total number of codes with complex mapping is small the total dollar and volume magnitude related to changes to CC/MCC are unknown. 

So knowledge is power and time is relative. CMS has made public its methods used for the conversion process, in a document called the ICD-10 MS-DRG Conversion Project:  

CMS has been clear and upfront with its methodologies and problem-solving strategies. Unfortunately, as with most one-size- fits-all solutions, a portion of the “all” has problems with the fit. The vital factor in this discussion is that each organization must understand how the changes apply to them. 

One size will never fit all; the best way to be prepared is to fit your plan and timeline to your individual organization. 

About the Author 

Sandra L. Draper, RHIT, CCS, is the Director of HIM Practice for Precyse and is an experienced health information professional with over 20 years of HIM management experience. She has a record of consistent success in advancing health information management department's participation in revenue cycle performance, improving accounts receivables, and DNFB reduction through project management. 

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With the approaching conversion from the ICD-9-CM classification system to the much more granular ICD-10-CM/PCS systems, there has been much talk about additional coder education to accommodate the level of necessary detail.

Many educational programs covering anatomy and physiology are being offered to beef up the skill set of the existing coding workforce. There has been much discussion and plenty of chatter on websites such as LinkedIn debating the need for such major training efforts. It made me think about the difference between what is being coded now by the staff now doing the coding, and what things might look like two years from now. What does it take to be a healthcare coder?

A coding professional requires clinical knowledge, but not hands-on clinical experience. The coder must be able to read the medical record and decipher what has been documented.  Through this analysis, a coder determines what diagnoses and procedures meet the requirements for coding. So along with possessing clinical knowledge, the coder must be a detective and have a curious mind.

A coding professional must apply the clinical facts they discern from review of documentation to the coding rules that apply to the medical setting. Since ICD-9-CM has been in place since 1979, an experienced coder knows all the rules and their many nuances. Although coding guidelines are updated on an annual basis, changes usually center on specific problematic areas (for instance sepsis or avian and novel H1N1 influenza virus), so even an experienced coder still must be able to stay current with the rules. A coder therefore also must be a list-maker, keeping track of updated rules and the dates the updates became effective.

Above all, coding professionals must know the medical record. They must know who documents what and where it all is documented. This is no less true in the electronic environment than in the world of paper. I personally mourned the loss of the many different colors that once were used to differentiate between different documents in the medical records back when all things were being printed directly at the nursing station – a development that made every form white. It is the coder’s role to identify and question any discrepancies in the documentation in order to clarify the diagnoses and procedures that ultimately are coded.

What, then, will be required to help these staffers attain this same level of proficiency with the new classification system? We have identified three primary areas in which the coder must be proficient: clinical knowledge, coding rules (as applied to their specific setting) and the medical record itself.

Clinical Knowledge

If a coder is working in a hospital setting, he or she probably already has had formal classes in anatomy and physiology, and coders apply this knowledge every day. No matter what type of facility, from a large teaching hospital to a small rural hospital, coders are familiar with the type of medicine that is practiced in their facilities. They build on their foundation of formal anatomy and physiology on a day-to-day basis simply by reading and coding. Unless there is a change in the services being provided, or if a new specialist joins the staff or new equipment is purchased, this level of coder most likely already has the clinical knowledge they need to move to ICD-10-CM-PCS. If any additional education is needed, it should be focused on new areas or wherever a coder has shown a weakness in the past. A program through which you can pick and choose the subject areas would work best here.

Knowledge and Application of Coding Rules

It would be simple if the same set of rules applied to all care settings, but the rules are different for facility coding of professional, inpatient and outpatient services. A coder who works in all three always must be aware of setting, because at times the rules are not just different but conflicting. Coding rules also are changing for all coders across all settings. This is the area where education should be focused most heavily. To understand this thoroughly let’s review the classification systems that are being introduced.

ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) is a classification of diagnoses only. There are no procedures. Because it is based on the World Health Organization’s ICD-10, the rules and conventions are similar to those we know in ICD-9-CM. Those areas that do exhibit significant differences also reflect improvements to the system made to clarify areas of longstanding confusion. For example, there are two types of exclusion notes in ICD-10-CM; one means “Do not code that here!” and one means “Not included here” (unless the patient has both conditions, in which case you may code both). In the current system, when there are conflicting exclusion notes there is always a debate. Yes, all the codes start with an alphabetic character, which is a change, and yes, you will not be able to code from memory, as all the codes are different. The basic concepts are still the same, and I think most coders will welcome the challenge posed by these new codes, including the level of specificity that now will be reflected in our code assignments.


ICD-10-PCS (International Classification of Diseases, 10th Revision, Procedure Classification System) is a brand-new classification of procedures. As such, it has new rules, and most importantly a new language for coding procedures. Much debate has occurred regarding changing the physician documentation habits to better enable coders to assign the most appropriate codes. In this area I believe the coder must master ICD-10-PCS and fully understand the concept of the root operation. It is not the responsibility of the physician to change the language used to describe the procedure, but rather the coder who must review the clinical documentation and equate it to the ICD-10-PCS root operation. It is not just a matter of becoming accustomed to the alphanumeric codes or the definitions of the seven characters in the medical and surgical section; this is a whole new approach to procedure coding. The coder first must determine the root operation, a process that will require not only formal training but enough time prior to the ICD-10 implementation to practice and become proficient. For all facility coders who will be using ICD-10-PCS, this should be the main focus of their in-service training, and ample time must be allotted to practice.

Know the Medical Record

As previously mentioned, a coder must be completely familiar with the medical record. If you are implementing any changes to your system it would be wise to have that process completed well before the October 2013 implementation of ICD-10-CM/PCS. The last thing a coder needs is to be unsure about where they can find the information they need to identify what needs to be coded (in addition to mastering the new classification). If at all possible, the new record should be implemented long enough before October 2013 to allow users to work out all the bugs, and most importantly to become familiar with all new features and functions. This is also true if you are implementing a computer-assisted coding (CAC) system to ease the coding burden. Coders need ample time to become comfortable users with this type of new system and process changes before they have to address all of the challenges of ICD-10-CM/PCS.

About the Author

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

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Have you ever noticed how we Americans tend to accept mandates as if they were derived rationally? We experience a tax increase or decrease, and we say “rats” or “thanks,” respectively, and then move on. Gas and food prices go up, and we fuss about the high price of whatever, maybe try to justify buying a new car, and start buying cheaper cuts of meat. But as a group we tend to operate on the premise that there usually is nothing we can do.

ICD-10-CM and its illegitimate brother, ICD-10-PCS, are another two examples of the same problem. I’m not going to talk about ICD-10-PCS, which was developed by 3M under contract to CMS, because we all tend to depend on Medicare, and putting it bluntly we have no choice if we want to keep billing and processing inpatient claims.

Yes, much the same could be said about ICD-10-CM, but there is one really big difference:

ICD-10-CM wasn’t developed by 3M for CMS. It actually is rather old in IT terms, having been endorsed by the World Health Organization in 1990 and adopted by most of its members beginning in 1994. CMS and every other ICD-10 fan-boy or -girl tells us that ICD-10 is necessary for proper reporting, proper payments, proper statistics, and proper who-knows-what-else-they- can-think-of at the moment. Which brings me to the second question on my mind: if ICD-10 is so important, why did we wait 23 years from its WHO endorsement to implement it, and why are we one of the last countries to do so? Well, here’s the beginning of an answer:

Insurance companies, information technology companies, providers, clearinghouses, state entitlement programs and HCFA/CMS itself all did everything they could to delay it because of its cost and complexity. And what was the irony in that? They probably were right to do so.

The bottom line now is that CMS is pushing it because it fits in with its long-range plan to get them “points” as guardians of the public welfare. It’s much more satisfying to throw something like this at providers and payers than to clean up their own operation. Consider that it’s only June and CMS already has admitted to two errors in its pricing code for 2011. And even if they never made mistakes, CMS appears to enjoy demonizing the provider system anyway.

These are my thoughts, and mine alone. And that’s quite enough for now.

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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While some savvy and highly proactive healthcare organizations already are starting to prepare for ICD-10 well ahead of the mandated Oct. 1, 2013 deadline for implementation of the new coding system, a more pressing concern for most payers and providers is meeting the deadline for the prerequisite HIPAA 5010. Initial HIPAA 5010 trading partner testing was to begin Jan. 1, 2011, with the deadline for production usage being Jan. 1, 2012.

Unfortunately for resource-strapped (whether lacking human resources, capital, etc.) healthcare entities, the one-two punch of HIPAA 5010 followed by ICD-10 is exacerbated by the concurrent requirements introduced by the Patient Protection and Affordable Care Act of 2010 (often simply referred to as “healthcare reform”) and meaningful use requirements established by the HITECH Act. Combined, that’s a substantial amount of business process adaptation and IT work to be handled in a relatively short period of time. Most payers and providers don’t have the resources or the time to get it all done swiftly. And while ICD-10 is thought to be the more resource- and cost-intensive mandate among the two pending deadlines, the critical-path nature of HIPAA 5010 compliance (as the “payload” for ICD-10 diagnosis and procedure codes) implies that an inability to hit the HIPAA 5010 date likely will mean an inability to meet the ICD-10 date.

My company is involved with a number of mandate engagements (HIPAA 5010 and ICD-10 alike) for both payer and provider organizations. Our observations about the state of preparedness for this key enabler of ICD-10 are as follows:

- The majority of the large payers (more than 300,000 covered) will be ready by the end of the second quarter.

- Smaller commercial payers are trailing behind in terms of readiness and preparation, with HIPAA 5010 companion guides not even being in draft versions.

- Most commercial payers will begin trading partner testing beginning in the third quarter.

- Governmental payers are all over the map and changing timeframes daily as the compliance date gets closer.

- The providers seem to be about four to six months behind the payers in preparedness for trading partner testing.


We believe that the vast majority of payer organizations will be ready for HIPAA 5010 on time, but a significant number of provider organizations will not be fully remediated for HIPAA 5010 on time. As such, we are concerned that even for the majority of the payer community, insufficient testing will have been performed to ensure a smooth (and revenue-neutral) production cutover due to the gap we are seeing in timelines.

We expect that challenges in smoothly transitioning to HIPAA 5010 will have a material impact on ICD-10 programs. “Laggards” will start ICD-10 programs even later than they should due to the need to tackle HIPAA 5010 transition issues, and early adopters may need to divert ICD-10 team members from in-flight ICD-10 programs to address HIPAA 5010 conversion challenges.

About the Author 

John Wollman is the Executive Vice President of Healthcare for HighPoint Solutions, a Management and Information Technology consulting firm focused on Healthcare and Life Sciences.  John is responsible for HighPoint’s Healthcare industry group, catering to Payers and Providers.  John is a recognized expert in several healthcare business domains (Reform, HIPAA 5010, ICD-10, Platform Strategy) and technical domains (Master Data Management, Analytics).  Since graduating from Duke University, John has held executive level positions at consulting and technology companies over his 25 years in business.

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

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

Does the CDS need to be a professional coder?

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

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

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

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

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

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


What about physician education?

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

Next Steps for the CDI Team

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


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

About the Author

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

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

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

The rumors “flying around” that the Centers for Medicare & Medicaid Services (CMS) will delay implementation of the new ICD-10 coding systems “don’t hold water,” said Denise Buenning, MsM, director of CMS’s administrative simplification group in the office of E-health standards and services—one of the seven presenters at the May 18 National Provider Teleconference on CMS ICD-10 Conversion Activities.

ED. NOTE: This is Part 2 in a three-part series of articles on the impact of technology and ICD-10.

In Part 1 of this series I discussed the importance of performing an ICD-10 risk assessment at your facility sooner rather than later. What I have noticed is that some have begun, but many others have their heads buried in the sand. For those of you who have kept current and are trying to wrap your arms around this big undertaking, I’d like to share some implementation-related best practices I have learned from my fellow colleagues: in particular I will be focusing on the strategy and workflow processes you may want to consider as you implement ICD-10 at your facility.

I had the opportunity to attend the AHIMA ICD-10 Summit in April, and one remark that stood out to me indicated that almost every system in your facility will be affected by ICD-10, with the exception of housekeeping. “Really?” I thought to myself. Yes, really – one director of patient financial services spoke about more than 80 systems being affected at his facility. This same director’s strategy when it came to ICD-10 was to take the opportunity to improve the overall business practices of his organization, looking at ICD-10 as a “benefit” versus a “have to.” The organization developed a strategy in regard to ICD-10 that allowed it to better measure outcomes, enhance clinical care to promote wellness over time, begin accountable care organization (ACO) negotiation with contracting, consider the opportunity to earn stimulus funding by becoming early adopter of ICD-10, and provide physician education.

A big part of an effective strategy is organizing the effort around ICD-10 and developing project goals. Particularly, one of these common goals should be to establish a governing body. The governing body should take a “top down” approach, as leadership typically should lead the charge for change within a facility. This governing team will create a timeline and define responsibilities and priorities.

Some of the project goals also should include facilitating organizational awareness, support education and training, coordination of resources, understanding of reimbursement impact and the linkage of technology requirements with informational needs. The governing team will include moving parts, and not just leadership.

Whereas there will be some who serve as part of project management and focus on establishing project goals, an advisory team of key stakeholders will focus on outcomes, budget impact and continuous evaluation of those goals.

Furthermore, a steering committee will concentrate on impacted systems and departments, such as information technology, clinical and financial members.

There are many areas in your organization to think about from a technology perspective. Will all systems be go come Oct. 1, 2013? As you think about your strategy and workflow with regard to ICD-10, consider the following:

Information Technology - Understand how you currently do business under ICD-9.  There needs to be an assessment of all systems that utilize ICD-9 codes.

Check all systems with the exception of housekeeping.

-         Perform a system inventory of ICD-9 data storage.

-         Be 5010-ready.

-         Understand system transitions and conversions of historical data.

Reporting – Understand the reporting workflow impact of ICD-9 to ICD-10 and vice versa.

-         Identify all current reporting workflow processes that utilize ICD-9 data.

-         Assess which vendors are available to facilitate understanding of the comparisons from I-9 to I-10.

-         Identify what tools are available on the market to facilitate understanding of the transition process and assure that GEMS mapping available through CMS is part of the workflow tool assessment.

    • Perform a vendor readiness survey.

Finance - Understand what the reimbursement impact on your facility will be and assess payer readiness.

-         Assess payer contracts – now is the time to negotiate.

    • Negotiations should include preparing future contract language to include references to ICD-10.
    • Create a payer readiness survey.

-         Perform a reimbursement impact analysis (using reimbursement maps provided by CMS).

    • Recommend starting with top 10 DRGs at your facility.

Documentation – Understand your risk related to documentation. It is probable that documentation is a key area of risk due to the specificity involved in coding with ICD-10.

-         Recommend engaging a third-party vendor to review documentation.

    • Consider the ratio of records slated for review to hospital bed size:  review 100-200 records per 100-300 beds.
    • Review third-party documentation recommendations and identify gaps in current documentation processes; revise templates as warranted and educate physicians on documentation requirements.

Education – Identify training needs for all personnel. Training will be differentiated based on staff roles.

-         Start with ICD-10 educational awareness programs.

-         Identify methods, timing and depth of training by type of personnel.

    • Account for ongoing education and new staff training.

Team ICD-10 – Identify members who will drive all of the moving parts to implementation. For some, this is the steering committee.

-         This team needs to ensure that all areas that could be affected by ICD-10 are addressed.

-         Members must be involved in training and education, ensuring that every aspect of the transition is communicated clearly throughout the organization.


It’s overwhelming to say the least, but the implementation process needs to be addressed. As you look at your current workflow processes, you may want to modify your current workflow or revamp it completely. It truly depends on how well your current processes work under ICD-9. Just remember that implementing ICD-10 is a work in progress and you can and will need to be flexible.

Ultimately, change can be good, as it often provides an opportunity to improve.

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 ICD-9-CM classification system does not always provide codes allowing an Inpatient Rehabilitation Facility (IRF) to report the root condition that required admission. ICD-10, with its increased number of codes, will allow IRFs to collect additional details about the reasons for admission. However, in order to assign these more detailed codes, physicians will need to improve the quality of their documentation.

In 1979, when ICD-9-CM was implemented, there were no official guidelines for the assignment of codes by IRFs. Codes reported for principal diagnoses were inconsistent. The following example shows how different facilities would report the principal diagnosis:

The patient was admitted to the IRF for rehabilitation following a transverse fracture of the femur shaft that was treated at the acute-care facility via open reduction and internal fixation.   The codes that facilities once would assign for the principal diagnosis included:

821.01.                Fracture shaft of femur

905.4                   Late effect of fracture of lower extremities

719.7                   Difficulty walking

Since 1979, guidelines have been developed for IRFs reporting codes. The Official ICD-9-CM Guidelines for Coding and Reporting advises that code V57.89 should always be assigned as the principal diagnosis when a patient is admitted for rehabilitation, with additional codes added to indicate the conditions that required rehabilitation. If the above patient was admitted to an IRF today, the case would be coded as follows:

V57.89                Admission for other specified rehabilitation procedure

V54.15                Aftercare for healing traumatic fracture of upper leg

Detailed information is not always required to assign ICD-9-CM codes, as codes that report aftercare do not include detail. Enhanced documentation including additional details will be required to assign ICD-10 codes. For the above case, the coder would need additional information about laterality, the site of the fracture and whether the fracture is open or closed, displaced or non-displaced. In ICD-10 a fracture not specified as displaced or non-displaced should be coded as displaced, and a fracture not specified as open or closed should be coded as closed. In this case neither was specified, so codes indicating a closed, displaced fracture should be reported. A seventh digit is required to show this type of encounter. Remember, the patient was admitted following fracture treatment at the acute-care facility, so a code that indicates a subsequent encounter should be selected.

For code S72.321 there are 16 options listed for the seventh digit. The options require that documentation indicates whether the encounter is for:

  • The initial or subsequent treatment of the fracture or for the sequela;
  • An open or closed fracture and, if open, the type of open fracture; or
  • Routine healing, delayed healing, non-union or malunion.

The possible seventh digits include:

A.      Initial encounter for closed fracture

B.      Initial encounter for open fracture, type I or II (open NOS or not otherwise specified)

C.      Initial encounter for open fracture, type IIIA, IIIB, or IIIC

D.      Subsequent encounter for fracture with routine healing

E.      Subsequent encounter for open fracture, type I or II with routine healing

F.      Subsequent encounter for open fracture, type IIIA, IIIB or III C with routine healing

G.      Subsequent encounter for fracture with delayed healing

H.      Subsequent encounter for open fracture, type I or II with delayed healing

J.       Subsequent encounter for open fracture, type IIIA, IIIB or III C with delayed healing

K.      Subsequent encounter for fracture with nonunion

M.     Subsequent encounter for open fracture, type I or II with nonunion

N.      Subsequent encounter for open fracture, type IIIA, IIIB or III C with nonunion

P.      Subsequent encounter for fracture with malunion

Q.      Subsequent encounter for open fracture, type I or II with malunion

R.      Subsequent encounter for open fracture, type IIIA, IIIB, IIIC with malunion

S.      Sequela

So the ICD-10 code assignment for this fracture is:

S72.321D Subsequent encounter for displaced transverse fracture of shaft of right femur with routine healing

The physician did not specify whether the fracture was displaced or non-displaced, so a code for displaced was assigned. The above example illustrates the need for detailed documentation by the physician. It currently is not uncommon for physicians to document the admission diagnosis as status post-femur fracture without including any additional information about the fracture. Physicians will require education on the need to document the required information for assignment of the seventh digit.

Now is the time to start educating physicians about the documentation that will be required for accurate ICD-10 code assignment for those diagnoses that are treated often at your rehabilitation facility.

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.  She was responsible for the initial start-up of HIM departments at three large acute medical rehabilitation hospitals where she designed, developed and implemented policies and processes. She was part of the 11-member task force that developed the Functional Independence Measure (FIMTM) and the minimum data set for the Uniform Data System for Medical Rehabilitation (UDSMR), an integral part of Medicare’s prospective payment system for inpatient rehabilitation facilities (IRFs). 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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ED. NOTE: This is the first of a two-part series on physician education as part of the transition to ICD-10.

Preparation for ICD-10 is beginning to heat up.

Hospitals, insurers, physicians and other providers need to ensure compliance with ICD-10 diagnosis and procedural coding requirements by Oct. 1, 2013. It is important, however, for those with a professional focus on I-10 to recognize that this initiative is just one of the many challenges facing organizational leaderships these days.

J. A. Thomas & Associates recently conducted a survey of client hospitals to assess the statuses of their preparations for ICD-10. The findings of that survey are interesting and informative.  Participants included representatives of the C-suite, physicians, clinical documentation specialists and HIM professionals.

Approximately 80 percent of respondents indicated that they have begun preparing for ICD-10. Approximately 50 percent of those who have not started preparations cited competing priorities as a reason. When considering hospital challenges such as capital improvements, decreasing reimbursement, competition, the newly introduced value-based purchasing program, core measures, medication reconciliation and EMR conversion, among others, those involved in I-10 preparations must recognize that such competing priorities are not inconsequential.

Among those who have launched preparations, there also appears to be a pattern. More than 70 percent have formed I-10 committees, 46 percent have implemented or expanded their CDS programs in anticipation of challenges, 53 percent already have invested in training (primarily for HIM staff) and 15 percent have purchased new technology. One of the most revealing questions, however, was “What is your greatest challenge in the move to ICD-10?”

While 13 percent reported facing challenges in getting buy-in from executive management, 39 percent had difficulty finding space in the budget and 40 percent faced challenges in upgrading EMR/technology. A whopping 75 percent listed “getting buy-in from physicians and then training physicians” as their most daunting perceived challenge. Similarly, when asked to identify what I-10-related services would benefit their hospital most, the most common response (more than 70 percent) identified education and training as where they need the most help.

Finally, when asked what types of resources their organizations intend to use to prepare for I-10, five options were available, including:

  • In-house (34 percent),
  • External/Third Party (22 percent),
  • Professional organizations (34 percent),
  • Local colleges (12 percent), and
  • A mixture of in-house and external training programs (72 percent).

Note that the sum of these selected alternatives totals 174 percent. What is indicated clearly here is that organizations are realizing that they will need different providers of services and education to meet the needs anticipated by the I-10 committees.

The Challenge of Providing Physician Training (Let Alone Getting Buy-in)

It is fairly early in the I-10 preparation cycle, but several trends already can be identified. Most organizations have begun their formal I-10 preparation processes, typically by initially forming an I-10 committee (often driven by HIM professionals who recognize the importance of preparing).


Providing training is clearly a challenge, and more than 70 percent of survey respondents plan to combine in-house and external training programs – likely reflecting necessary approaches to different constituencies and different levels of current competency. Perhaps most importantly, more than three-quarters of respondents identified getting buy-in from physicians and providing  training as their greatest perceived challenges.

In recent interactions with a variety of facilities, from large academic centers to small community hospitals, it has become evident that there is some reticence of hospital HIM professionals to provide in-house I-10 training for staff physicians – or even to approach physicians about I-10 at all. This is due in part to timing in that HIM departments themselves are getting an early start in the I-10 educational process.

But concerns about approaching the medical staff probably are based more on HIM wisdom than lack of knowledge. As discussed in a previous article, it is extremely unlikely that there is going to be broad, immediate physician buy-in to I-10.

Surgeons particularly are likely to react negatively when approached about ICD-10-PCS. They are likely to perceive no benefit from I-10 procedural coding (since they will continue to bill professionally using CPT procedural codes), and will be prone to viewing the requirement to provide necessary documentation to support the required seven-digit alphanumeric coding necessary for ICD-10-PCS as an additional administrative burden foisted upon them by an unsympathetic hospital administration.

ED. NOTE: Part II on physician education continues in the next edition of ICD10monitor.enews May 17, 2011.

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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