December 19, 2012

ICD-10-CM: What about the Radiologist?

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Clinical documentation improvement (CDI) specialists and coding educators nationwide have started looking at the need for additional detail that will be required when ICD-10-CM and ICD-10-PCS are implemented on Oct. 1, 2014.

But there is a possible problem connected to these activities. The issue is simply that not every detail required for sufficient documentation will come from the history and the examination. What many tend to forget is that some of the vital details come from radiology studies such as plain films, CT, and MRI evaluations. It is the attending physician who looks to the radiologist for details that eventually can lead to the diagnoses assigned to the case. So, what about the radiologist?

Unfortunately, little has been said about plans to include radiologists in the ICD-10-CM documentation discussion. If you haven’t thought of it, however, now is the time to start including them and discussing the details. We are well aware that the attending physician is responsible for documenting these important details in the medical record, but the specifics of many conditions won’t be known if they aren’t provided by the radiologist. The following are some areas to focus on during CDI discussions.

Fractures

One key area of focus is fractures. The physician’s only view of a potential closed fracture often comes from the X-ray image. Even if viewing the images themselves, many physicians still welcome information about the specific type of fracture – information that can be provided by a skilled radiologist. A good example is fractures of the radius and/or ulna. Monteggia’s fracture of the ulna and Galeazzi’s, Colles’, Smith’s and Barton’s fractures of the radius are all individually classifiable in ICD-10-CM. Even without these specific fracture names, however, different types are classifiable, such as torus, transverse, oblique, spiral, comminuted, segmental and greenstick.

Dislocations

Dislocations can raise similar problems. Radial and ulnar dislocations no longer are classified as open or closed under ICD-10-CM. With the new code set they retain the previous classifications of anterior, posterior, lateral and medial, but specifically they are coded with indications as to whether the ulnohumeral joint or the radial head was affected. In ICD-10-CM, the coder also will code any associated open wound separately in order to indicate that an open dislocation occurred. The same detailed description of the fracture or dislocation used in determining the treatment plan will be valuable in diagnostic coding as well. And yes, the attending physician needs to document the details, but they can’t document details they don’t have. And again, the radiologist is key to obtaining these details.

CVA

Another not-so-obvious area in which greater detail will be required is cerebrovascular accidents and non-traumatic brain hemorrhages. Without sufficient details, there are only unspecified codes to assign for CVA, intracerebral hemorrhage or intracranial hemorrhage. With information about the presence or absence of thrombosis, embolism or other occlusion of the specific precerebral or cerebral artery, plus whether any of these resulted in an infarction, a very specific code can be assigned. Yet, again, the details of the specific precerebral or cerebral artery would be provided best by the radiologist. An issue here is that many reports indicate the “lobe of the brain” or the “general area of the cerebrum that has the infarction,” not the specific artery that caused the infarction. That’s not surprising, because in ICD-9-CM, specific arteries aren’t named. The classification system only identifies thrombosis, embolism or unspecified occlusion, plus whether there is an associated infarction.

The fact that ICD-10-CM is on the horizon should be no secret to radiologists. This new diagnosis coding system will be required on all claims, including professional fee claims for the interpretation of imaging studies. In many cases, payment for imaging studies is covered by local or national coverage determinations when claims are submitted to Medicare. Because of this, the need for specific information and specific codes should come as no surprise. In fact, the industry has yet to see how the local and national coverage determinations will be affected by the specificity of the new ICD-10-CM system. Only time will tell.

All things considered, though, now would be the time to begin discussions with the radiologists. Their interpretation of images, using specific information, may be the only source the attending physician has to satisfy the need for specific documentation. Involving radiologists in ICD-10-CM training and helping them understand how valuable specific information is to the code assignment process will help in your quest to assign more specific codes in ICD-10-CM.

And at the end of the day there will be better data for analysis and quality outcomes – and, hopefully, facilities will be better armed to achieve the optimal reimbursement to which they are entitled.

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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Read 8 times Updated on September 23, 2013
Maria Bounos, RN, MPH, CPC-H

Maria T. Bounos, RN, MPM, CPC-H, is the practice lead for coding 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.