Last month I wrote about how important it is to get ready for dual coding. That is critical for any successful transition to ICD-10. This month, let’s focus on physicians, who are another driving force in this area.

One of the issues that keeps cropping up when working with hospitals and physician groups is that physicians are asking “what’s in it for me?” That is quite an obstacle to overcome. Granted, there is no monetary return associated with ICD-10 for the practitioners, but they need to understand that the diagnoses and the conditions they are treating need to be supported by medical necessity – and according to the Centers for Medicare & Medicaid Services (CMS) medical necessity is the “overarching criterion.” Without evidence of medical necessity, it does not matter what CPT/HCPCS code is submitted; the claim will not be paid. 

One suggestion is to show the practitioners denials based on medical necessity. Many times we leave practitioners in the dark as to what type of denials they receive. Work with your physicians on their documentation. In many cases, the current level of documentation is a problem as it pertains to supporting complexity. For example, when the physician performs a H&P during a subsequent visit in the hospital (or during an office visit) and he or she is documenting an evaluation and management service, in the assessment the practitioner usually does a pretty good job of identifying the diseases and/or conditions being treated. However, in many cases the coded diagnoses are generic, meaning limited  specificity is evident. Terms that are important are “mild,” “moderate,” “severe,” and “laterality,” just to name a few. In addition, for OB/GYN services the trimester of the pregnancy must be documented (which is not always the case). The evaluation and management service guidelines require documentation of the status of the condition treated, which is currently problematic.

As it relates to auditing medical records, I always tell physicians in our education meetings that they need to document statuses of conditions (stable, improved, failing to change, worsening, etc.) We don’t always see that in documentation. Also, another issue that often arises is simply this: What are you thinking? What if you have a patient with chronic sinusitis, and you feel the patient may have a growth or tumor, prompting you to order an MRI. Are you documenting the fact that you suspect a potential tumor? We have told physicians over the years not to report “suspected,” “probable,” and “possible” conditions, and that if a confirmed diagnosis cannot be determined, to only document signs and symptoms. 

In the outpatient setting, only code and report signs and symptoms when a confirmed diagnosis cannot be determined. In the inpatient setting, report potential conditions as they are confirmed. 

However, practitioners need to tell us what they are thinking. How can this benefit the practitioner? Here’s how: If the physician orders an MRI for a patient with a headache and he or she suspects a seizure disorder, even if the history and examination is comprehensive, the headache might only equate to a Level 2 or maybe a Level 3 patient visit, based on medical necessity. But if the physician documents in the assessment and plan of care that the MRI was ordered because the practitioner feels the patient may have a seizure disorder, the complexity of the patient changes – and it potentially could equate to a Level 4 patient visit. 

Another example is the following: consider a scenario in which a physician orders an echocardiogram and the rationale is not documented; how can the practitioner support medical necessity? We see this type of documentation quite routinely. But if the physician indicates that the patient has a history of coronary artery disease of the native artery with angina, now we can support medical necessity for the test ordered and code to the level of specificity necessary.

So saying there is nothing in it for the physicians when it comes to ICD-10 is a false statement.

Complexity, severity, and the associated documentation directly impact practitioner reimbursement. When I explain this to physicians, they understand, creating a basis to obtain buy-in. This will also help with hospital coding.

Every organization needs to work toward clinical documentation improvement (CDI). The idea of CDI is to support a clear picture of the condition the practitioner is treating, to support quality of care, and to get paid for the work being done. Many times when we audit records, we find that physicians “under-document” for the conditions they treat. This creates a loss of revenue. So I tell practitioners it is not more documentation they need, but the quality of the documentation that counts. ICD-10 will achieve this goal by providing us with more information, more specificity, and ultimately, accurate reimbursement.

So start working with your physicians and get them on track with ICD-10.

About the Author

Deb Grider, a Clinical Documentation Improvement Practitioner, is an AHIMA-approved ICD-10 trainer and an American Medical Association coding author. She is a senior healthcare manger for Blue & Co., LLC, and has more than 30 years of experience in coding, reimbursement, practice management, billing compliance, accounts receivable, revenue cycle management and compliance across many specialties. Her specific areas of expertise include medical documentation reviews, accounts receivable analysis and coding and billing education. She is the president of the Indiana Health Information Management Association.

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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.