May 2, 2011

NPPs and ICD-10: It’s Time to Get to Work!


About 11 years ago, in January 2000, I wrote an urgent news flash entitled “What’s the scoop on the release of ICD-10-CM?” This article, appearing in a non-physician practitioner (NPP) newsletter published by Ingenix, surmised an imminent release of the ICD-9 diagnostic and procedural coding systems and a subsequent conversion to ICD-10, because the Centers for Medicare & Medicaid Services (CMS) (then called the Health Care Financing Administration, or HFCA) had decided not to release any annual changes to the 2000 ICD-9-CM codes pending full implementation of Y2K compliance initiatives.

Remember Y2K? Rumors were swirling; the industry was abuzz. Both “Y2K” and “ICD-10” were on the lips of nearly everyone. So we’ve come full circle: the more things promise to change, the more they stay the same.

Again, that was in the year 2000. The switchover from ICD-9-CM/PCS to ICD-10-CM/PCS finally now is assured. No longer a rumor, the hard-and-fast implementation date of Oct. 1, 2013 is right around the corner, and there are laundry lists of tasks to accomplish: let’s face it, there are mountains to move. And moved they will be … thus we will arrive at the threshold of that implementation date prepared, knowledgeable and set to go.

At the (specifically under my byline), we’ll be bringing you relevant how-to articles from the NPPs’ perspective (note: NPPs include physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and nurse midwives) exploring various concerns related to ICD-10-CM/PCS, covering topics including preparation, knowledge base fortification and tips for easier and more effective ICD-10 implementation.

Many of the ICD-10 issues to be tackled are provider-driven and squarely in the purview of the NPP; that is, in order for ICD-10 to work properly the physicians and NPPs must be an active part of the conversion process from ICD-9 to ICD-10. Take, for example, medical record (MR) documentation: ICD-10 codes will be generated from, substantiated by and/or validated through this critical aspect of each and every provider’s patient care efforts.

MR documentation represents the beginning, middle and end of the current ICD-9-CM/PCS life cycle; it is foundational to the entire process of diagnosis coding, and there is nothing currently indicating that this promises to change with ICD-10.

Provider documentation will continue to initiate the derivation and assignment of codes, drive the assessment of medical necessity for payment of services and serve to validate those services upon review by oversight entities such as Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs) and Comprehensive Error Rate Testing (CERT) reviewers, just to name a few (and there are more to name). Federal oversight entities loom like specters on the horizon, hovering around the ICD-10 implementation date. With recovery monies now budgeted into the government’s appropriations on the front end (not simply seen as “found” money or additional funds added on the back end), the advent of ICD-10 will not slow down or alter the fed’s plans to audit, audit, audit.

How does the typical practice NPP, one employed by several physicians and working with several other NPPs, begin to get ahead of the curve when it comes to assisting in the ICD-10 conversion process? What can be done now as a first step without fancy new IT systems, without any particular depth of knowledge about ICD-10 and without emptying the patient schedule to free up huge blocks of time? Start at the foundation: a baseline MR documentation assessment.  

A baseline MR documentation assessment will enable physicians and NPPs within any specialty or any-sized practice or clinic (or outpatient department) to recognize where its incumbent providers need to strengthen their MR documentation so that ICD-10-CM, with its heightened requirements of specificity and attention to detail (for example, in aspects of anatomy and physiology) can be implemented successfully.

The practice administrator or manager should initiate this project and set the scope of work. The practice NPPs, using their clinical insight and established history of mastering adept techniques in MR documentation, easily can bridge the gap between physicians and coders, and will be invaluable in this process.  

To begin the baseline assessment, a “review sample” of medical records must be selected. Criteria in this selection must be stratified to include, by frequency and volume, at least the top 25 ICD-9-CM diagnosis codes currently being assigned by the practice. The practice administrator should generate a report from the billing system highlighting these claim details.

Several documentation standards then should be assessed while reviewing the assigned ICD-9-CM diagnosis codes derived from the MR documentation completed for each patient visit. These standards include legibility, authentication (i.e. signature requirements), patient identifiers, timeliness and presentation of the diagnostic data within the body of notes, delineations between old (past) diagnoses and current (new or continuing) diagnoses, details of each diagnostic statement when unconfirmed (such as “rule out” or undifferentiated signs/symptoms), and more.   

Next month, we will present the final portion of this timely article on performing a baseline MR documentation assessment as part of your preparations for converting to ICD-10. Look for it!        

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

To comment on this article please go to


Read 30 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.