December 18, 2012

ICD-10: Sharing the Burden

By

As we progress toward the Oct. 1, 2014 implementation deadline, some differences in opinion are arising regarding who bears the burden of knowledge relevant to ICD-10.

Clearly, the coding industry is rapidly gaining the requisite education to transition to ICD-10, and numerous IT solutions are developed or under development, but can coders really “Do it all?”

Some in the coding community itself have suggested that physicians need not learn more than very high-level, superficial information about ICD-10 – and that with sufficient effort (and loss in productivity), coders will be able to ferret out what the physician actually meant in their documentation. Additionally, some have suggested that with new tools such as computer-assisted coding, anticipated decreases in coder productivity may in fact not be as significant as anticipated.

We have a couple of complicating factors to consider. Between now and the implementation, most hospitals in the United States (other than those on a completely integrated EHR) will be accelerating their IT infrastructure development. For those who routinely review the medical records, such as documentation specialists and coders, the explosion of information within the records actually slows down efficiency of review. It can, in some records, make it more difficult to review nursing, PT, OT, RT, dietary, consultant and other notes to identify the existence of appropriate or inadequate documentation.

Some have entertained computer-assisted coding as a solution to retain efficiency of coders. However, if the wrong terminology is entered by the physician, will it not lead computer-assisted coding down the wrong rabbit hole?  Since I’ve opened with this cliché, let me throw in another:  Garbage in, garbage out.

So why are we hearing arguments even from coders that physicians need not learn ICD-10? It is most likely due to the anxiety coders themselves experience when trying to wrap their heads around the scope and scale of ICD-10. With the amount of time most coders spend learning ICD-10, they recognize there is little likelihood of getting physicians to commit the same time and effort – so educational efforts are viewed as essentially futile. But wait! There is a critical difference between coders and physicians. Coders must embrace the entire breadth of ICD-10; physicians do not. And that is a key distinction.

Let’s begin with a “rabbit hole” example for computer-assisted coding. Identifying a root operation is probably the most difficult task for most coders as it pertains to coding cases under ICD-10-PCS. Consider two closely related terms: excision and resection.

While used interchangeably by many physicians, the terms have specific meanings. Resection is the “cutting out of off, without replacement, all of a body part,” and excision is defined as “cutting out or off, without replacement, a portion of a body part.” If a physician writes excision but actually means resection, how will that impact computer-assisted coding? Is there not a likelihood that it will map to excision codes rather than resection codes (which are entirely separate in the ICD-10-PCS system)? How difficult would it really be for an intelligent physician to grasp this simple distinction quickly, and use the terminology correctly in the first place?

Let me also address the issue of scope of knowledge. For medical and surgical procedures, there are seven identified approaches. However, an interventional cardiologist only has to learn three of those approaches at most. It is very unlikely that a cardiologist ever is going to use a “natural or artificial opening” such as the mouth, nose, ear, anus or urethra to reach the heart, so they don’t really need to learn those approaches (this eliminates three of the designated approaches, and procedures on the heart cannot be performed through an external approach either). Such considerations fundamentally decrease the scope of education physicians require. However, this solution creates challenges as well.

Physicians require applicable ICD-10 education specific to their practice specialty or sub-specialty, and it would, in fact, be a mistake to expose them to materials irrelevant to their practice. This demands subspecialty education covering critical parameters for each field of expertise. Generally speaking, physicians agree that it makes more sense to do it right in the first place than to go through a lengthy process of iterative queries.

I recently had the experience of providing an ICD-10 overview to a large group of surgeons. I was pleasantly surprised with their aggregate response, which could be summarized as “We are glad to cooperate with the hospital and coding staff to provide accurate, compliant documentation. We just ask that at the time we begin the go-live preparation for ICD-10, someone actually tell us what we need to document.” This peer-to-peer attitude becomes pervasive when physicians are informed about the realities of the transition to ICD-10.

We need to integrate physicians into ICD-10 implementation collaboratively by providing the knowledge necessary to document elements required for ICD-10-CM and ICD-10-PCS coding.

About the Author

Paul Weygandt MD, JD, MPH, MBA, CPE, CCS, is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Dr. Weygandt is vice president of physician services for J.A. Thomas & Associates and is a partner in the firm.

Contact the Author

To comment on this article please go to

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.
Paul Weygandt, MD, JD, MPH, MBA, CPE