December 9, 2013

“See One, Do One, Teach One…” Implications for ICD-10

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Paul L. Weygandt, MD, JD, MPH, MBA, CCS, CPEMany individuals working within the healthcare arena will recognize the above phrase, as it is extracted from the legacy of surgical training. While perhaps overstating a surgical resident’s ability to assimilate information, the principle does, in fact, describe the process of learning within many surgical and medical specialties.

As an orthopedic resident, I recall observing certain surgical techniques (such as the double-needle technique to percutaneously approach a lumbar intervertebral disc) many times before being allowed to actually perform the procedures – and even then, only under the watchful eye of my attending physician. There was simply no way I could learn from a book or a lecture the nuances of patient positioning, multiplanar fluoroscopy, manual technique, and the patient interaction necessary to safely perform the procedure.

Today we do indeed have greatly improved educational tools, such as computer simulations, online education, remote observation, etc., which can enhance the educational experience. However, the vast majority of physicians are still most comfortable learning from those who are most experienced in performing highly technical procedures – that is, those physicians who already possess the relevant knowledge and experience.

The above observations, however, apply to a much broader physician audience than just surgeons. Education for those in non-surgical fields also relies on the principles of learning from more experienced peers. To a large extent, education regarding inpatient care of medical patients occurs not from reference sources, but rather from interactive communication between residents and attending physicians during clinical rounds.

So, what is the relevance of the above to physician education for ICD-10? I have been asked to provide my perspective on the best model with which to apply ICD-10 education for physicians. My response is this: “Let’s use the one that will work.”

Please understand that my recommendation is based on pragmatic considerations. I have been involved in physician education for at least the past 20 years and have observed multiple challenges and proposed solutions. In addition to being a physician, I am also a certified coder and an American Health Information Management (AHIMA)-approved ICD-10 trainer. What does this mean? First, let me explain that there are many, many coders who are far more knowledgeable about the nuances of coding than I. I appreciate all the knowledge that they have been willing to share. Coding is truly a different language, a different process, and has markedly different implications than the language I learned to utilize in clinical practice.

What is ICD-10? For many coders, ICD-10 requires additional education regarding anatomy, pathophysiology, current clinical terminology, and so on, as a prerequisite to applying a new coding methodology. But what does it mean to physicians? First, the new coding system represents a “catching up” to current clinical care. Many of the revisions, such as the introduction of “new” terminology such as STEMI and NSTEMI acute myocardial infarctions, represent the inclusion of diagnostic terms that previously have been uncodable, but used nonetheless by physicians for the past couple decades. It’s new to coding, but not to physicians. Also, it would be an insult to a cardiologist to begin education regarding ICD-10 by teaching them about the four chambers of the heart. If your cardiologist doesn’t already know about that, ICD-10 is not the problem. So, for physicians, ICD-10 is really an extension of the clinical lexicon that finally is catching up with changes we have experienced in clinical medicine during the past 35 years.

So, let’s get back to the question of who should deliver physician education for ICD-10. Coders clearly typically have a superior handle on coding conventions, coding guidelines, and the technical detail necessary for accurate coding. But how many coders have a strong understanding of the specialty-specific clinical issues underlying day-to-day clinical decision-making, which provides the foundation for accurate clinical documentation? Expecting such knowledge would be unreasonable, as it typically lies beyond the scope of education for a coder.

ICD-10 diagnosis coding is driven by fundamental structural hierarchies that are constructed in a clinically logical manner. The hierarchical structure includes such attributes as etiology, manifestation, anatomic specificity, morphology, biochemical mechanisms, and laterality. Physician education specific to the transition to ICD-10 does not need to focus on anatomy or pathophysiology at all; those are prerequisites for the practice of medicine. It needs to translate physician knowledge into meaningful (and codable) terminology.

Ultimately, I believe that we have to look at the relative efficacy of various methodologies for physician education. However, what has worked historically and still works today is physician-to-physician, peer-to-peer education regarding a wide variety of clinical concepts, including ICD-10. Remember that ICD-10 is, at its core, a clinical documentation system as well as a coding system.

It is unreasonable to put coders in the position of carrying the load to educate physicians regarding accurate and complete documentation under ICD-10. We, as physicians, have a responsibility to teach our colleagues. Physicians are trained to listen to their peers, and my experience is that ICD-10 is not much different, in that regard, from sharing information on new surgical techniques, devices, or drugs. Would a physician rather learn about a new surgical technique from a colleague or a device salesman?

Let me conclude with one last caveat. Physician educators teaching ICD-10 need to work in close collaboration with our coding colleagues. We may deliver the message, but all educational content should be reviewed by coding experts. “See one, do one, teach one” may still work… but we need to be very cautious to deliver the message correctly the first time.

About the Author

Paul Weygandt, MD, JD, MPH, MBA, CCS, CPE, is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel, and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Paul is vice president of physician services for J.A. Thomas & Associates (a Nuance company). He is also an AHIMA-approved ICD-10-CM/PCS trainer.

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Paul Weygandt, MD, JD, MPH, MBA, CPE