It has been an ongoing struggle to keep physicians, hospitals, and others motivated in the ICD-10 implementation process.

From my experiences with my own clients, I gauge that about 50 percent of providers are continuing to forge ahead with their implementation projects, while the other 50 percent have completely stopped and allocated their resources elsewhere. When I ask the 50 percent who have stopped why they have suspended their efforts, the answer typically seems to be that they don’t think ICD-10 will be implemented – so why spend the time and effort?

 

I understand these frustrations and concerns, but I still advise clients to stay on course and to make sure not to lose momentum. Those with many larger hospitals understand the need to stay on track because there is so much to do, but critical access hospitals and physicians have had a tendency to veer off course, thinking that ICD-10 might either be delayed again or never become a reality.

So, how can we help physicians document better while becoming more proficient and familiar with ICD-10?

Dual coding might be the answer. It would benefit every hospital and physician to begin this process now. We know that hospitals have the capability in their electronic health records (EHRs) to dual code, and some physicians using EHRs will have the capability to dual code as well. 

What is dual coding, anyway? It is the process of coding in ICD-9 and then either converting the ICD-9 codes to ICD-10 codes or actually coding in ICD-10 using a coding lookup tool or a code book (which I know is old fashioned, but it is time now to get back to the basics and learn to code all over again).

Every coder, hospital, and medical practice should invest in an ICD-10 code book. It is very helpful when dual coding without all the electronic tools. Also, one key advantage is that you actually can look at all the options to find the most specific code. What I am finding is that unspecified ICD-9 codes map to unspecified ICD-10 codes when using the Centers for Medicare & Medicaid (CMS) General Equivalency Mappings (GEMs). That can be a real problem if the goal is to achieve specificity.

Why should we dual code?  The purpose is to build proficiency and keep our productivity up. The industry is estimating that productivity will be reduced by at least 50 percent due to the complexity of the coding – documentation and even keystrokes will take more time. How long productivity will be an issue is really unknown, as we are the first industrialized country with the complexities in healthcare we face (such as multiple payers, more codes, coding inpatient services, and a brand new coding system) to implement ICD-10.

If you begin dual coding now and start building proficiency, it is possible that productivity will not be affected so dramatically. Hospitals are planning to dual code, but many physicians and physician groups are unsure if there is value to it for them. But there is always value when productivity losses are mitigated.

First of all, if you are using certified coders, you are in a good position. Coders can take the majority of the coding burden off of practitioners as long as the documentation is there. Get your coders trained in ICD-10. Make sure coders attend in-depth training lasting at least 3-5 days. Online training is fine, but by not having an instructor to answer questions, it could be confusing – and as we all know, coding is not always black and white. I strongly recommend in-person training. Make sure the instructor has the knowledge to teach ICD-10, too; taking an instructor course and winging it does not validate expertise. Investigate who is providing the training. 

If you utilize coders, once your coders are trained, it is time to train the physicians on ICD-10 documentation for their specialties. It is important that physicians document quality, not quantity. I hear all the time from other healthcare colleagues that they are teaching physicians to document for their specificity, which is good, but it is not more documentation that is needed, but rather the right documentation. Many times physicians think we understand what is in their notes, but many times the notes are not clear. With the right documentation, the provider will be in compliance, but a specific ICD-10 code also can be selected. I also recommend workshops, seminars or 2-4-hour training for practitioners.

My team and I have been training physicians of all specialties since January, and I can tell you from experience that they have many questions – and how can they get answered without guidance from an instructor? Webinars are great, but sometimes practitioners do not get his or her questions answered.

If your medical practice cannot afford certified professional coders and the physicians perform their own coding, they will need in-depth coding training, and documentation training as well. It will be a bit more difficult to dual code without coders, but you might want to consider getting other staff members (clinical staff, billing staff, or some other staff members) trained in coding. It might be an excellent investment.

You cannot begin dual coding without offering coding training for the coders and/or billers and documentation training for the practitioners. Once the training is completed, perform a test drive. Don’t make the decision to start dual coding all claims immediately. You might want to dual code one day per week, or even take one morning per week and dual code. Yes, you will need to code with ICD-9 to submit your claims in addition to selecting ICD-10 codes. Even if your practice has an EHR or code lookup tools, you still will need to look at all codes in the classification to determine if you have the most specific code. What you might find is that 20-25 percent of the time, the only code you can select in ICD-10 is an unspecified code (because the documentation supports only an unspecified code).

The overall goal is to reduce the number of unspecified codes that we use, and to code to a greater level of specificity, which supports medical necessity for more complex patients and paints a more complete picture of the patients’ medical conditions. With that being said, there are times that the only choice you have, based on the patient’s condition or the uncertainty of the condition, is an unspecified code.

By dual coding you also will be able to query physicians for potentially more detailed documentation that will support ICD-10 codes.

I was talking to a doctor just this week about his documentation; out of 10 records, only one supported the level of service the practitioner selected. After sitting down and having a discussion about documentation, I discovered that these patients were considerably more complex than many others, but the practitioners were not documenting the entire conditions clearly – which in turn reduced the levels of evaluation and management (E/M) services the practitioner reported. Physicians must realize that they are paid based on the diagnosis codes, as the diagnosis supports medical necessity for the CPT/HCPCS they report. No, there are no RVUs attached, but without supporting medical necessity, how will the practitioner get paid? Most likely he or she will not, so we must talk to our physicians about making sure the documentation supports the complexity of the patient – which in turn validates quality of care and reduces malpractice risk.

So my advice is to begin the preparations for dual coding now. It is a process and cannot be accomplished overnight.

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.
Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner

Deborah Grider has 34 years of industry experience and a recognized national speaker, consultant and American Medical Association Author who has been working with ICD-10 since 1990 and is the author or Preparing for ICD-10, Making the Transition Manageable, Principles of ICD-10 and the ICD-10 Workbook, Medical Record Auditor, and Coding with Modifiers for the AMA.  She is a senior healthcare consultant with Karen Zupko & Associates.  Deborah is also the 2017 American Health Information Management Literacy Legacy Award Recipient. She is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.