Updated on: November 21, 2016

Facility Guidelines and ICD-10 Implementation

By Laurie Johnson, MS, RHIA, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer
Original story posted on: August 31, 2015

And so it begins….

It appears that ICD-10 implementation is moving forward on Oct. 1, 2015. It is important to have facility guidelines in place for ICD-9-CM as well as for ICD-10-CM/PCS at the time of implementation.

These guidelines frequently are requested by auditors and should be maintained by version and applicable dates of service. This concept is supported by pages 15-16 of the first-quarter 2014 edition of Coding Clinic as well as page 14 of the second-quarter 2014 edition and page 24 of the first-quarter 2000 edition.  

Specific facility guidelines must not conflict with official ICD-9-CM or ICD-10-CM/PCS Coding and Reporting Guidelines. These internal guidelines also cannot interpret abnormal findings and/or replace physician documentation. Another reason to have guidelines in place is that they will provide direction to the coders regarding what conditions/procedures should be coded. Where does one start, now that the framework of facility-specific or internal guidelines has been addressed?

The beginning…

The development of internal or facility-specific guidelines should not be an overwhelming project.  The first step may be to write down whatever known guidelines already exist. Most facilities have undocumented guidelines, which creates inconsistency among the coders. Here are a few items that should be considered in this documentation:

  1. For documentation that can be used for coding, include where the body mass index, wound stage, mechanical ventilation, blood transfusion, official discharge disposition, etc. information is located.
  2. Family history – Identify if the facility captures all family history or perhaps only family history for significant conditions.
  3. Personal history – Identify if the facility captures all personal history (e.g., stroke, previous MI, cancer, embolism/thrombus, etc.) or perhaps only if such history is clinically significant.
  4. Smoking status – This impacts meaningful use data. These guidelines should address how the facility determines what constitutes a “former smoker” (patient who quit last week, last month, etc.), plus how to utilize the tobacco use code (Z72.0) for ICD-10 (e.g. social smoker). Pages 108-109 of the fourth-quarter 2013 Coding Clinic indicates that there is no definition of “uncomplicated,” “in remission,” and “with withdrawal,” and that this terminology is based on provider documentation. The facility’s definition of these terms should be discussed in this area after discussion with the medical staff.
  5. Allergies – Identify if the facility captures the patient’s allergy status (food, drugs, latex, etc.).
  6. Long-term drug use – Identify if the facility captures the patient’s long-term drug use and which drugs (e.g., anticoagulants, steroids, antibiotics, insulin, antibiotics, antithrombolytics, etc.) were administered. It should be noted that these codes can impact APR-DRG assignment.
  7. Procedure status – Identify if the facility captures the patient’s previous procedures or organ absence and which procedures (e.g., CABG, coronary stents, joint replacements, amputations, etc.) were performed.
  8. External cause codes – Identify which portions of external cause codes the facility captures (place of occurrence, how accident/injury occurred, and external cause status) and the frequency of that capture. Some states require that organizations report the external cause codes every time the patient presents for an injury and not just for the initial presentation, which is specified in the Official Coding Guidelines for ICD-10-CM.
  9. Procedures – Identify which procedures the facility captures (e.g. infusions, injections, vaccine administration, hearing screening, physical therapy, occupational therapy, BiPAP, radiology portion of cardiac catheterization, blood transfusion, TEE, CTs, EKGs, Dopplers, etc.). It is important to identify the emerging technology in use at the hospital so that the additional reimbursement is captured at the organization.

The guidelines can be specified by patient type (inpatient, outpatient surgery, inpatient rehabilitation, ancillary services, etc.) as well.

Maintenance Matters

This document should be a living document, meaning that it changes as the need presents. It is important to keep a version for each year, any of which can be provided to auditors/coding quality reviewers so that the organization can be reviewed based on their coding guidelines. Remember that reviews can occur up to four years post-reimbursement, based on lookback periods. This also increases the efficiency of any coding review, because revision of results is not necessary due to the fact that the review was completed based on the organization’s specific coding guidelines.

The guidelines may be modified as new service lines are added or as coding advice changes. It is important to remain open about making changes to these guidelines as necessary.

In Conclusion

The task of developing facility-specific guidelines can seem daunting. There is so much to think of and so little time! The best first step is to begin writing down your facility’s unspoken or undocumented rules. Know why specific conditions or procedures are coded. Do not be satisfied with the “we have always captured this information” excuse. Achieving results may involve some research, but increased efficiency will be worth it! So get started!

About the Author

Laurie Johnson, MS, RHIA, FAHIMA is the director of health information management (HIM) consulting services for Panacea Health Solutions Inc. She has conducted ICD-10 education sessions and documentation reviews for multiple organizations. Prior to working for Panacea, Laurie worked for Peak Health Solutions and Optum.

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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.

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