October 7, 2013

Documentation is the Key to Success in ICD-10-CM/PCS

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As the October 1, 2014, implementation date for ICD-10-CM/PCS approaches, facilities are realizing they must mitigate the risks they may be facing as a result of gaps in their documentation. One of the most important steps in mitigating these risks is to conduct an in-depth review of the current state of documentation, and how that compares to the data that will be required to support ICD-10-CM/PCS.

We have found that documentation practices are systemic and can be broken down into overarching categories or types of practices and patterns, such as lack of documentation to support disease acuity and type or terminology/naming errors, for example. To identify the degree of specificity and granularity required for ICD-10-CM/PCS, the data cannot be code-specific. This is because in the majority of cases, the ICD-10-CM code that will replace the ICD-9-CM code used for the same reimbursement will need more specific disease identification.

A good example is the diagnosis of Regional Enteritis. In ICD-10-CM, the code title was changed to the more specific diagnosis of Crohn’s disease. In ICD-9, there are a few code choices based on site. In ICD-10-CM, there are 28 codes. Providers will need to specify the site as well as the presence of rectal bleeding, intestinal obstruction, fistula, abscess, or other complications.

Through an analysis of documentation practices and patterns, facilities will be able to identify gaps in ICD-10 documentation and educational needs that are not single record- or encounter-driven, but are specific to the ICD-10-CM/PCS classification. Education can then be tailored to specifically address these gaps by diagnosis and specialty.

In our experience, we are finding that many providers are lacking documentation in four major areas:  disease acuity, disease type, site specificity, and disease stage.

Disease Acuity

ICD-10-CM classifies many diseases primarily on the basis of acuity. Providing documentation to identify the acuity of a condition will support a more accurate representation of the severity and urgency of the patient’s condition.

For example, the diagnosis of congestive heart failure lacks acuity. Better acuity would be chronic diastolic congestive heart failure.

Documentation of disease acuity supports the MS-DRG with other diagnoses that are being treated simultaneously with the principal diagnosis. By adding a few more terms (in this example, chronic diastolic), the coder is provided with the information necessary to accurately assign an ICD-10-CM code.

Disease Type

ICD-10-CM allows identification of the exact type and origin of the disease process. We have found this to be a very common area of documentation deficiencies. It is important to identify where records are lacking specificity of disease type for diagnoses, such as:

  • Acute Renal Failure – Is it with tubular necrosis, acute cortical necrosis, or medullary  necrosis?
  • CAD – Is it without angina, with unstable angina, with spasm, with other forms of angina pectoris?

Many diagnoses such as hypertension, COPD, and hyperlipedemia will require identification of the type in order for the correct ICD-10-CM code to be selected. If records are lacking this documentation, it will be necessary to query the physician. Increases in queries may result in increased bill holds and accounts receivable, as well as decreases in productivity.

Disease Stage

Staging is a key area where ICD-10-CM gives facilities the opportunity to code conditions more accurately based on their true risk and severity. The staging of a disease shows a relationship between the severity of a patient’s condition and costs for the patient’s encounter. ICD-10-CM has stages, phases, and degrees or levels of certain diseases.

We are finding that many diagnoses such as non-pressure skin ulcers are lacking documentation of the level of tissue breakdown; providers are not specifying the stage of Chronic Kidney Disease, for example Stage I-IV or ESRD; or the degree of malnutrition (mild, moderate, or severe).

Site Specificity

One of the primary goals of the ICD-10 transition is that each code will be complete and as precise as possible. Site specificity has been added to thousands of codes in ICD-10-CM that were not a part of the broadest-based codes in ICD-9-CM. We are finding site specificity lacking in many diagnoses such as UTI, osteoarthritis, gout, and sinusitis. Identifying the site of UTI (e.g., urethritis, cystitis, pyelonephritis) or specifying osteoarthritis by joint(s) affected and identifying if it is primary, secondary, or post-traumatic will be important for accurate code assignment.

It is important to provide ICD-10 education to providers on the key impacts for their specialty that is focused and impactful. Contrary to popular belief, it is not too early to introduce specificity and granularity in ICD-10-CM/PCS to the provider population, as documentation improvements take time to realize. Documentation improvements made today may also impact the accuracy of coding in ICD-9-CM.

For example, through ICD-10 documentation, impact audits facilities can identify by diagnosis and specialty the key areas of documentation deficiencies. This can assist facilities in determining where to focus peer-to-peer physician education or e-learning to educate providers on those impact areas such as disease acuity, disease type, disease stage, and site specificity.

Through documentation impact audits, your facility may discover that orthopedic records are lacking documentation to support assignment of the seventh character to identify the episode of care for fractures, or OB records may be lacking documentation to support identification of the trimester in which a complication occurred. These represent opportunities for ICD-10 education.

Some facilities are choosing to focus their education on their most impacted diagnoses such as asthma, acute respiratory failure, and chest pain by providing specific documentation tips, and case examples of inadequate and required documentation to support ICD-10-CM.

Education can be offered to providers in a number of ways through e-learning, mobile apps, on-site peer-to-peer physician education, webinars, and videotaped presentations. The key is to identify the documentation practices, patterns, and gaps, so that ICD-10 education can be focused and impactful for the provider population.

About the Author

Anita Majerowicz, MS, RHIA, is director of ICD-10 and educational services, for Precyse (www.precyse.com), a Health Information Management (HIM) technology and services company.

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.