October 17, 2011

ICD-10 and DOCs: Greater Interaction Needed with Coders


I had the pleasure of attending both the ICD-10 Clinical Modification (CM) and Procedure Classification System (PCS) AHIMA academies in September, and I strongly urge physicians to attend a coding program designed for ICD-10.

The CM, or diagnosis, portion of ICD-10 has changed significantly, but not as significantly as the PCS, or procedure, section. The driving force behind both is the added requirement of significantly enhanced documentation and the need for increased interaction between coding staff and physicians.


For the physician community, some of the CM changes are for the better.

For example:

1. Sepsis has replaced septicemia throughout the book.
2. There is only one code for HTN I10 (no need to worry about type).
3. OB coding specificity now is designated to trimester.
4. With HIV+ status, provider confirmation is sufficient to code.
5. Diabetes has been expanded to reflect manifestation, replacing the original process of using an additional code to identify complications (as seen with type 2 DM with diabetic peripheral angiopathy with gangrene). The I-10 code is E11.52. Controlled/uncontrolled is not a factor in ICD-10, and the new terminology denotes hypo or hyperglycemia.

Changes that will require additional physician documentation include the following:

1. Laterality;
2. Anatomy site specificity;
3. Initial and subsequent encounters;
4. Time frame for MI (no longer eight weeks, but four weeks or 28 days);
5. Abortion vs. fetal death has been changed from 22 weeks to 20 weeks;
6. A new consideration for infection: is it drug-resistant? There is a new code assignment for the resistance, Z16;
7. Big push on adding exposure to tobacco, whether perinatal or even if a child was exposed prior to developing OM. There are several codes to identify tobacco exposure: examples include exposure to environmental tobacco smoke (Z77.22), exposure to tobacco in the perinatal period (P96.81) and occupational exposure to environmental tobacco smoke (Z57.31);
8. Coma now requires three codes for levels of consciousness: eye, verbal and motor response, with a terminal digit identifying where the assessment was done;
9. Ulcers: one code says it all, but the “all” is comprised of site/laterality and stage; and
10. Newly added is underdosing to the poisoning chapter, meaning patient noncompliance.

If at this point you are thinking that the new guidelines will increase how much time you need to spend documenting, ”you ain’t seen nothing yet!” I must stop and ask a rhetorical question: why did we not just adopt the AMA’s CPT, which was developed by the physician body and certainly makes more sense to me than ICD-10? The ICD-10 Procedure Coding System (ICD-10-PCS) is an American system of medical classification used for procedural codes.

The National Center for Health Statistics (NCHS) received permission from the World Health Organization (WHO), the body responsible for publishing the International Classification of Diseases (ICD), to create ICD-10-PCS as a successor to Volume 3 of ICD-9-CM and as a clinical modification of the original ICD-10. The final rule did state that CPT would remain the coding system for physician services. So in the aftermath we are left with a convoluted schema in order to code a facility procedure. I have pondered the idea that the same folks who sit in the corner coming up with the next nuance to the DRG formula also must have had a hand in the very intricate way of coding in PCS.

Most physicians are used to writing Billroth I or II and Whipple to describe procedures, and for the most part coders now are used to coding these procedures to their respective ICD-9 codes. The ICD-10 book does not contain eponyms for procedures. Yes, gone are the Billroth and the Whipple procedures; I hope that Drs. Christian Billroth and Alan Whipple are not turning over in their respective graves. You still can look up Roux-en-Y in the index, but the entry says “see bypass” and additionally you are given the three-character root procedure.



PCS presents intricate ways of classifying procedures. For example, a thrombectomy now falls under “extirpation.” Extirpation by definition means complete excision or destruction of a body part, but in PCS the definition becomes taking or cutting out solid matter within a body part (whereas excision means cutting out or replacement of some of a body part, such as in a lumpectomy). If I look up the word “thrombectomy” in the PCS, I am given a direction to see “extirpation.” If I look up “lumpectomy,” I am given a direction to see “excision.” If a physician performs a BKA below-knee amputation, now we are guided towards the word “detachment,” and if a herniorrhaphy is performed using a mesh, PCS steers us to use the entry “supplement” to find the correct code (but if the repair is without mesh, it still is considered a “repair”). Seems a little schizophrenic to me, but there is a code for that too.

A “revision” now refers to the correction of a malfunctioning or displaced device, and a vein stripping is now an “extraction.” An exploratory laparotomy is now an “inspection.” Thank God a CABG is still a bypass and a fusion still a fusion.

My advice is to start a dialogue between physicians and the coding staff about the changes to come. And start small! Run a query on your data’s top 20 diagnoses and procedures. Use the GEMs (General Equivalent Mappings) to crosswalk and see how things translate from ICD-9 to ICD-10 (and look at the additional wording in the new codes). From there develop a plan for the specialists as well as the internists. For the surgical procedures, share the tables of the codes with the surgeons. This gesture in itself is bound to start a conversation. Fortunately or unfortunately, because of the non-adoption of the CPT procedural coding PCS does not affect how a surgeon currently documents in order to get his or her procedure paid.

With ICD-10, a physician performing a biopsy will need to add the word “diagnostic” and will need to distinguish the body part. Also, per the new rules a converted laparoscopic cholecystectomy to open is coded twice to percutaneous endoscopic inspection and open resection. For the BKA referred to earlier, physicians can help coding staff by designating whether it was a high-, mid- or low-level amputation for code specificity selection.

What I have addressed above deals only with the root operations of this complex system, and there is so much more to consider before actually rendering a code such as body part, approach, device and qualifier (see example below from the AMA) to eventual submission of a UB/1500 form and receiving payment.

Remember that there is no grace period for implementation, and that Oct. 1, 2013 is looming on the horizon.



Read 196 times Updated on March 16, 2016
Denise M. Nash, MD, CCS, CIM

Denise Nash, MD has more than 20 years of experience in the healthcare industry. In her last position, she served as senior vice president of compliance and education for MiraMed Global Services, and as such she handled all compliance and education needs, including working with external clients. Dr. Nash has worked for the Centers for Medicare & Medicaid Services (CMS) in hospital auditing and has expertise in negotiation and implementation of risk contracting for managed care plans. Dr. Nash is a consultant on coding/compliance audits at physician practices and hospitals, and has worked for insurance plans conducting second- and third-level appeals. Her past experience also included consulting for the Office of the Inspector General of New Hampshire in its Fraud and Abuse Division. Dr. Nash is a member of both the RACmonitor and the ICD10monitor editorial boards.