April 6, 2011

NPPs and ICD-10-CM/PCS: Bridging the Gap in the Transition from ICD-9 to ICD-10


The use and acceptance of non-physician practitioners (NPPs) in healthcare settings such as the private physician practice, outpatient clinics and the inpatient hospital milieu has become commonplace and widespread.

For many patients, it is no longer unusual to be evaluated and treated by a highly skilled physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS) and/or certified nurse midwife (CNM). The utilization of such professionals for the economic delivery of healthcare services has sustained and even allowed for an expansion of primary care and specialty services in a climate of growing uninsured patient populations and dwindling third-party payer reimbursements.   

The framework of duties performed by any particular NPP can be rather diverse and dependent on certain variables. Outside of the typical, clinical medicine “scope of practice” laws enforced by each state, the NPP can find him/herself acting in quite unique roles in a physician practice, at an outpatient clinic or within a hospital’s medical floor or emergency department. The NPP has become a key component of the clinical and administrative operations of the healthcare entity, at times facilitating the flow of clinical data from the physicians to targeted practice coders and facility health information management (HIM) staff.

In many cases, employing the NPP to the fullest advantage now also includes his/her involvement in coding workflow and procedures. Even at the lowest threshold of service, NPPs must be aware of coding protocols – as must physicians – that enable their own medical record (MR) documentation to be “translated” into the appropriate ICD-9-CM codes. Above and beyond that, deciphering physician MR documentation, providing clarification on clinical issues buried in diagnostic statements and assessing treatment nuances lying outside the purview of the typical coder are just some of the adjunct duties the NPP may be called upon to do.

Bridging the Gap

Savvy HIM staff long have known that when a physician is unavailable for general queries, the NPP can be an invaluable and more easily accessible “bridge” in elucidating routinely gray areas – helping out with tasks such as discerning from the treating physician’s MR documentation, for example, whether a patient has systemic inflammatory response syndrome (SIRS) or full-on sepsis, whether pneumonia was ventilator-associated in etiology, or whether specific signs and symptoms are the usual late-effect manifestations of a former condition or illness. The NPP doesn’t substitute for the treating physician’s clarification of MR documentation when such data is incomplete (or illegible) in these instances, but the NPP often can provide answers to queries when such documentation is not fully understood by the coders or HIM staff.   

Many NPPs have taken steps to obtain basic coding education and some even have advanced to securing coding credentials, either as a Certified Procedural Coder (CPC) via the American Academy of Professional Coders (AAPC) or as a Certified Coding Specialist - Physician Based (CCS-P) via the American Health Information Management Association (AHIMA). Diagnosis coding, specifically within ICD-9-CM and post-Oct. 1, 2013 within ICD-10-CM, is the language with which the healthcare industry communicates illnesses, injuries and conditions as well as reasons for clinical patient presentations. Under ICD-9-PCS, hospitals code and communicate procedures performed.

Getting Up to Speed

To become familiar with and speak the language of these coding systems is much like making preparations for an extended stay in Italy by taking and mastering a course in conversational Italian. This analogy also is applicable to the imminent transition from ICD-9-CM to ICD-10-CM (and ICD-10-PCS for procedure coding). Both the essential increased familiarity with anatomy and physiology as well as the heightened coding skill level required to be successful in applying ICD-10-CM/PCS protocols are immediately recognizable when reviewing the publicly available ICD-10-CM/PCS code indices and tabular sections approved to date (note: the Centers for Medicare & Medicaid Services (CMS) provides ICD-10-CM and ICD-10-PCS information as well as links to coding resources such as the National Center for Health Statistics [NCHS]).  

Physician Query Process

The NPP’s role in the physician query process will be immensely valuable during the transition from ICD-9-CM to ICD-10-CM, and this can be exploited to everyone’s benefit. The NPP will be able to facilitate dialogue between practice coders and the treating physicians, plus provide insight and guidance when the expanded coding detail in ICD-10-CM requires clear, specific and comprehensive MR documentation to support the appropriate assignment of codes.  

Prominent on the lengthy “to-do” list for the crucial preparations in migrating from ICD-9-CM to ICD-10-CM/PCS will be hosting education and training (E&T) programs. By all means, the practice, clinic and hospital NPPs should be included in these E&T initiatives, and if adroit hospital and practice executives plan their ICD-10-CM/PCS curricula correctly, NPPs will be at the forefront among staff receiving baseline and higher-level training in the new system.

By placing NPPs in a prominent role in such efforts, these professionals will be able to assist physicians and coders/HIM staff more effectively during a potentially sticky and protracted transition period. In many cases, healthcare entities will be operating parallel systems of both ICD-9-CM and ICD-10-CM before, during and after the official implementation date of Oct. 1, 2013.

The Bridge Between Physicians and HIM

The NPPs can play a vital role in the changeover by taking part and sharing in real-life patient treatment scenarios per their usual scope of duties, thereby assisting physicians during the process of understanding why meticulously detailed MR documentation is such a critical component of the ICD-10-CM/PCS experience. Also, the NPPs can provide expert guidance to coders/HIM staff in translating MR documentation into ICD-10-CM/PCS codes.

NPPs also will be able to help coders/HIM staff understand various subtleties of anatomy and physiology, the comprehension of which will be necessary for correct code assignment under the ICD-10-CM/PCS structure.


Leveraging the unique clinical and administrative position of a non-physician practitioner such as a practice PA, a clinic NP and/or a hospital CNS during the transition from ICD-9 to ICD-10 ultimately can help facilitate what promises to be an enormous undertaking by all healthcare entities. These highly skilled professionals, many of whom are already knowledgeable and trained in ICD-9-CM coding, can potentially assist in this transition by acting as informational “bridges,” closing the gap between physicians and coding/HIM staff.      

About the Author

Michael G. Calahan, PA, MBA, is the director of physician services at KForce Healthcare, Inc. Michael has more than 25 years of experience in health care, beginning as a physician assistant with the USN. He has served as an administrator for several physician practices and has enjoyed a varied career in healthcare consulting, being affiliated with Ingenix, CGI, Navigant, PWC and Parente-Randolph. He has authored numerous industry publications and articles in physician, IP/OP/ASC, DMEPOS, ESRD, HHA, ambulance, HIPAA and in Medicare Parts C & D for Medicare Advantage.  

Contact the Author

Read 33 times Updated on September 23, 2013
Michael Calahan, PA, MBA

Michael G. Calahan, PA, MBA, is the vice president of hospital and physician compliance for HealthCare Consulting Solutions (HCS). Michael lives and works in the Washington, D.C. metro area, specializing in compliance, revenue cycle management, CDI, and coding/billing in the facility inpatient/outpatient and physician arenas.