May 4, 2015

ICD-10: Need for New Codes Apparent


Many of electronic medical record (EMR) programs have an add-on that is supposed to help physicians in the hospital setting with ICD-10 coding. It often is composed of dropdown menus that allow physicians to pick a word pattern with an associated code. 


It’s a great concept, but it was tough in ICD-9 and is even tougher in ICD-10. A plain dropdown menu for a fracture of a wrist can have over 200 entries, and what doctor, who is rounding on patients or seeing patients in the office, is going to rummage through all of these? None. 

So, what do they often do? They select the first one on the list to get the undesired process finished. And the information that comes out of the first diagnosis on the list is often the least specific. Some of the ICD-10 programs also started featuring selections listed in a particular order so that all of the choices don’t appear at once, allowing the physician select the most specific code possible. Now that’s better! Or is it? When they use coder logic to present the breakdown, it’s often a waste of time. Doctors don’t think that way. And with the new wave of complexity of management of patients with several diseases, the ability of a program to help the physician just isn’t there (well, one is).

Interface functionality of electronic health records is lacking, and as long as the inpatient EMR doesn’t talk to the physician’s EMR, the support the physician needs in ICD coding for personal professional services is severely limited – as is the capability of the physician to manage his discharged patient.

Physicians in the office setting are used to having a superbill – a listing of diseases they see frequently that allows them to select one that will accompany their bill for services. Some companies have provided services to modify a physician’s superbill to accommodate ICD-10 codes so that the same diseases are in the same order on the piece of paper or on the computer screen. That’s cool – but they don’t (can’t) provide the doctor with the support needed to ensure that all of the correct codes are there, with all of the needed expansion. And again, the help the physician needs to provide the additional information that will show that payment is justified isn’t there.

This thing called an electronic health record is truly a joke. It’s a great format for a factory, where yes/no drives processes. But people aren’t yes/no. And diagnoses often aren’t yes/no. Taking care of patients is a lot more complex than that, and without help, doctors will have trouble – probably for years – to justify the payments that they are used to getting.

Studies have been done regarding physician preparedness for ICD-10. The American Academy of Professional Coders reviewed 20,000 cases and found that an average of 68 percent of physicians, across all specialties, were providing documented information adequate for the needs of ICD-10.

What’s interesting is that the most prepared field is plastic surgery, which takes care of the fewest diseases. The worst field is gastroenterology, which traditionally describes portions of the intestinal tract in a standard way – whereas now, different classifications are required.

On the other hand, there are some issues with the current version of ICD-10-CM, and I have been communicating with the cooperating parties for the past five years to see if they might be corrected. A couple of them did manage to garner some attention and are on the way to being corrected. 

Hypertensive emergency and hypertensive urgency were once listed under malignant or accelerated hypertension, but not in the way that doctors refer to the condition. The newer verbiage is more intuitive to physicians, and we will probably have I16 codes to cover malignant hypertension with organ failure, known as hypertensive emergency, and malignant hypertension without organ failure, known as hypertensive urgency.

What is recommended is to code also any stable background hypertension that the patient has, or to designate those cases that might be caused by endocrine disorders or renal artery stenosis or eclampsia. What is not yet suggested is to code also the organ failure that leads to the conclusion that it is indeed hypertensive emergency. And doctors should not misuse the terms as they misused malignant hypertension in ICD-9.

The operations for congenital heart disease also have been discussed, and how to handle them is under consideration. There may well have to be a 32nd primary procedure code or a new body part identified for primitive organs that never made it to the adult counterpart.

Be on the lookout for other new code needs. Physicians have been begging for them and maybe with ICD-10 we’ll be able to get them. 


Robert S. Gold, MD

(1942-2016) The late Robert S. Gold, MD, was a nationally known physician, responsible for having championed clinical documentation with a peer-to-peer educational approach in hospital organizations. Dr. Gold was a cofounder and the CEO for DCBA, Inc., a consulting firm that concentrates on development of Clinical Documentation Improvement (CDI) programs that aid in proper data streams, proper communication within the medical records and proper reimbursement. Dr. Gold served on the ICD10monitor editorial board from 2011 through January 2016.

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