December 19, 2011

Physicians and ICD-10 “Language” – What is the Real Message?


I had to chuckle. At an introductory ICD-10 seminar for physicians, one of the attendees – an emergency department physician – just had asked a rather obvious question.  We were reviewing the new “language” of the codes for diabetes, in particular the ICD-9-CM verbiage as compared to the draft ICD-10-CM verbiage for type II diabetes mellitus (DM-II). As seen in ICD-9-CM’s code classification 250, the adjectives “controlled” and “uncontrolled” (or “not stated as uncontrolled”) no longer will be employed; instead, “with hyperglycemia” will be used in ICD-10-CM under code classification E11, i.e. E11.65 Type-2 diabetes mellitus with hyperglycemia (or, as appropriate, “with hypoglycemia” among other such descriptors such as “with/without coma,” etc.).

“But why do I need to select a code for diabetes with hyperglycemia when that already describes the condition, which is an aberrant state of glucose circulating in the blood due to various etiologies? Is there any common sense to the new system’s language at all?” the frustrated ED physician asked. As a physician assistant, I completely identified with the line of questioning and thoroughly empathized with his clinical perspective. Wasn’t this particular ICD-10-CM concept a tad redundant? Well, yes and no.

Specificity of ICD-10

In context with ICD-9-CM, select codes devised to communicate DM-II in ICD-10-CM will convey “with hyperglycemia” as the descriptor for a diabetic state not squarely under control. An option for “with hypoglycemia” likewise is provided. As we well know, the DM-II state may be transient or circumstantial, or it might have more malevolent long-term implications. Overall, diabetes mellitus can be primary, secondary and/or induced, or gestational. The ICD-10-CM codes for DM-II indicate the diabetes type, body systems affected and any complications or manifestations affecting those body systems.  As many codes as can be found within a particular category, such as E11, can be used to capture all the complications of the diabetic state, per the provider’s diagnostic statements.

Controlling Ambiguity

In ICD-9-CM, “controlled” (i.e., not stated as uncontrolled) and “uncontrolled” was the language of the day; in ICD-10-CM, specific reference to hyperglycemia will denote a correlated diabetic state and whether the descriptors “controlled,” “uncontrolled,” “out of control” or “poorly controlled” apply. This relieves much of the ambiguity of some of these clinical scenarios and could eliminate the need to pin down the provider for specific documentation via a query (though some scenarios still will require this), and furthermore, it specifies a certain DM-II status at a certain point in time.

The selection of an ICD-10-CM code based on the provider’s documentation represents the patient’s status as of a particular date of service, essentially creating a “snapshot in time” of the patient’s episode of care for the DM-II. Note that, similar to ICD-9-CM guidelines, the ICD-10-CM guidelines likewise affirm that if the type of DM is not referenced in the provider’s documentation, the default will be E11 DM-II.

Medical Record Language

That brings up one of the implicit messages of ICD-10-CM/PCS and its attendant documentation requirements: ICD-10 can enrich diagnostic and procedural information while enhancing the overall communication capabilities of medical record data. Much of the former ambiguity inherent in ICD-9-CM will fall to the wayside with the implementation of the new coding system. But in no way by using ICD-10-CM/PCS is the healthcare industry stating that physicians must change their medical record “language” or learn an entirely new way of documenting patient care.  And that, after those initial chuckles, was the first part of my response to the questioning physician.

Clinical Documentation Improvement

If by chance there already is a need for clinical documentation improvement (CDI) by providers requiring remedial training or retraining, whether under ICD-9-CM or ICD-10-CM, then the bounce from one system to the other perhaps will be a bit bumpy. Engaging in CDI exercises in these cases will cause providers to lose nothing but will help them gain infinite advantages by applying specific CDI standards and techniques juxtaposed to ICD-10-CM/PCS.



Lessons Learned

The subsequent and more emphatic portion of my message to the frustrated physician was accompanied by a coding exercise. That’s correct: the physicians in this particular seminar were led through a coding exercise to experience firsthand the challenges faced by their own coding staffs. And the benefits of this exercise as well as the potential pitfalls in ICD-10-CM were immediately apparent. If or when a specific provider’s documentation is not as detailed as it should be, and particularly when the documentation is vague or even ambiguous, the coding of a patient encounter may present a problem. This often is found in cases pertaining to DM-II and its clinical state of “controlled” or “uncontrolled” during the patient’s episode of care. The lesson: knowing the documentation requirements under ICD-10-CM facilitates improved provider documentation up front and promotes more efficient physician back-office processes (namely coding, billing, reimbursement, appeals, etc.).

Ambiguous medical record documentation always will require clarification. The opportunities presented in the application of ICD-10-CM/PCS, a data-rich and highly conversant coding system, can lessen the need for such clarification without necessarily changing a provider’s approach to documenting patient care. Knowing the “language” of ICD-10-CM/PCS and what it means, bringing medical record documentation up to standards, being aware of the challenges coders face, and striking a balance between all of these aspects is a central theme in the transition from ICD-9 to ICD-10.

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 122 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.