February 1, 2016

Making ICD-10 Documentation Interesting

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ICD-10 training is rapidly becoming the sort of buzzword that gets everyone rolling their eyes and having nightmarish visions of death by a thousand PowerPoints. It’s true that the subject matter can be dry, and people are rapidly transitioning into training fatigue. That fatigue will lead to complacency and finally to apathy. With the news that there can be hundreds of new ICD-10 codes coming in the next year, the unfortunate truth is that we can’t really let up off the gas pedal. In 2016, the prospect of educators facing burned-out and uninterested audiences will be more of a reality than any time I can remember in the last 20 years. The challenge will be to find presentation styles and strategies to continue engaging audiences in a manner that increases information retention, interest, and attendance.

Challenge Accepted.

By now you have seen the standard ICD-10 PowerPoint education, which covers the history, format, organization, and philosophy of ICD-10. We have seen the numbers of codes and the slides covering the character count, and numerous talking points regarding specificity and code shifts. At this point we still don’t have good data regarding the true impacts of these code shifts, and more importantly, the DRG shift patterns and percentages. Analytics experts tell me not to hold my breath waiting for that firm data to come in any time soon. Nonetheless, most of us are not interested in hearing those same old talking points parroted yet again in another presentation. We get it. Those daily/weekly/monthly “here is the ICD-10 code for this injury or circumstance” were great to generate early interest, and while we continue to look forward to seeing them, I have started to notice a decreased interest in even that.

So now what?

Let’s highlight strategies you absolutely should employ when building your ICD-10 education.

  1. Refer to Coding Clinic. Surprisingly, there is not as much Coding Clinic discussion in current ICD-10 education as you might expect. Not surprisingly, there are some genuinely interesting and paradigm-shifting pieces of information included in both the coding guidelines as well as the Coding Clinic I covered here.
  2. Highlight subtle documentation changes that change a DRG. It is always interesting to an audience when a very subtle turn of phrase (which may or may not clinically mean the exact same thing) changes the code and the DRG – and as a result, the severity, the relative weight, and the expected length of stay. Above all, coders are intimately familiar with these issues, while clinical documentation specialists and physicians often just presume that x documentation always means y ICD-10 code. Hint: no, it often doesn’t. Use this strategy with every ICD-10-related topic of discussion for a guaranteed perk in your audience. Don’t be afraid to open with this.
  3. Check the literature. Take the time to find out what standard literature source is most popular among your hospital’s staff and go directly to the medical literature to determine what indicators may or may not be relevant to a code or a diagnosis. It’s true that sometimes there is disagreement among doctors as to which sources are best, or even how to interpret the same source. Congratulations, you have just identified an interesting topic of discussion for a classroom audience hungry for information regarding the potential pitfalls of documentation for ICD-10 coding.
  4. Go beyond only looking at what is documented. A good documentation audit should always begin with a review of not what the doctor lists as his differential diagnosis, but of the signs and symptoms, lab values, response to treatments, radiology reports, and vital signs. Try thinking about what diagnosis you think makes sense before reading what the physician suspects. This is a great exercise in critical thinking that surely will open new doors of discussion and learning. If you were way off-base (and you sometimes will be), then you have identified a great educational opportunity for yourself. If you came up with a diagnosis that makes sense but has not yet been clinically identified, you may have a query opportunity. If the coding itself presents opportunities for clarification of data not yet documented, you may have a query opportunity. What didn’t you do?  Use a direct quote already written in the chart as your only basis for seeking discussion and clarification. You can use this thought process to walk your audience through hypothetical case scenarios and brainstorm about what the documentation issues might be. This is not only interesting to the audience, it might be just the sort of interactive exercise that you were looking for as an ice-breaker – or a way to illustrate the issues with a particular diagnosis, such as NSTEMI versus ischemia with a troponin leak (be sure and check future issues for my writeup on that topic).
  5. Tackle the most confusing and controversial issues head-on. Encephalopathy, malnutrition, functional quadriplegia, demand ischemia, renal failure, etc. If your educational agenda reads like the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) work plan for fraud investigation or the local Recovery Auditor’s “top ten” list, then more than likely you will be hosting a documentation educational session that truly matters to your audience. 
  6. Use real case examples – obviously, not case examples that include protected health information, but examples of documentation issues that speak to the topic at hand. These examples can be a combination of exerts of documentation that have the PHI removed or mock cases that you custom-build based on actual documentation issues that have created confusion. I have a story about a family member with aplastic anemia that has been known to simultaneously produce both tears and smiles.
  7. Presentational style does not require you to speak with an overabundance of poise. Whatever the circumstance, do not read from slides. You should be intimately familiar with the content enough to freely speak on these topics. The slides are only there to remind you of the progression of the content or the next topic. The information should come directly from you. This prevents anyone from feeling like you could have just emailed the file and they could have read it themselves. You want to give the kind of information that compels people to pick up a notebook or a copy of the slides and make notes. Work a joke in every six or seven slides and a relatable story that makes the content more real at about the same frequency, in alternating fashion.
  8. Lastly, demand that the audience participate in the discussion (assuming an audience of less than 50) by seeking out responses or opinions on key ice-breakers at the beginning of various topics. The smaller the group, the more interactive it should be. Use one of the controversial or Recovery Auditor audit target issues as the setup for a question that should generate disagreement or differing opinions from the attendees.
Allen R. Frady, RN, BSN, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

With 20 years in healthcare, Allen R. Frady provides clients assistance in the areas of documentation, program implementation and compliance. His background includes critical care nursing, coding, auditing, utilization review, and documentation improvement.

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