Surgical Revenue Predicted to Plummet Post-ICD-10

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January 2014 marked one of the coldest months on record for many states. Below-zero temperatures, mountains of snow, and blustering winds shut down airports and closed classroom doors. Similarly, ICD-10 is predicted to be healthcare’s “storm of the century.” And lost surgical service revenue may pack the nastiest punch.

Major MS-DRG Shifts Ahead

The biggest differences between ICD-9 and ICD-10 coding lie within the Procedural Coding System (PCS); hence the high probability of significant MS-DRG shifts for surgical cases.

The majority of ICD-9-CM procedure codes map to multiple ICD-10-PCS codes. Coders must determine the correct root operation for each and every step within each operative procedure versus assigning a single code for the entire surgery (as is commonly the case in ICD-9-PCS). ICD-10-PCS also requires a deeper review of each operative report. Detailed documentation is a must. One-paragraph operative reports won’t suffice under ICD-10.

Finally, there are new terms to describe many surgical procedures in ICD-10-PCS. Coders must be trained, encouraged, and empowered to assign the correct ICD-10-PCS root operation based on the clinical documentation provided — even if the surgeon uses traditional, ICD-9-CM procedural terminology. The first step is to master root operations.

Tackle Root Operations

Many ICD-10-PCS root operations have very similar definitions and can be confused or incorrectly assigned easily, causing the MS-DRG to shift. Consider the root operation “excision,” which implies that a portion of a body part is cut out or off using a sharp instrument. This is similar to the ICD-10-PCS root operation of “resection,” which implies that all of a body part (or any subdivision of a body part that has its own body part value in ICD-10-PCS) is cut out or off using a sharp instrument.

The easiest way to understand these new operative terms is to separate the 31 root operations into nine groups. Each group’s definition describes the goal or outcome of the individual surgical procedure. Once mastered, coders should learn the finer nuances of each group.

A simple table listing specific procedures included within each main surgical grouping may be coders’ best reprieve from the ICD-10 storm. Flash cards also may re-emerge to offer quick reminders of new root operation definitions.Using crosswalk tip sheets for the most common surgical procedures is another simple but valuable tool for coders to learn ICD-10-PCS root operations.

Empower Coders

The finer nuances of each operative step are critically important in ICD-10. Coders must take the time to read operative reports and interpret the specific surgical documentation, finding details not currently needed in ICD-9.

Guideline A11 further explains that it is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. Physicians are not expected to use PCS code descriptions. Instead, again, coders should be trained, encouraged, and empowered to translate OR documentation into defined PCS terms, freeing them from having to query surgeons when correlations are clear. For example, if the surgeon documents a partial resection, the coder must translate that into the term excision.

Coders must embrace this new responsibility and achieve a higher comfort level in interpreting physician documentation, or queries will surge and surgical revenue will plummet.

Include Operative Reports in CDI Efforts

In the past, CDI teams have been focused on improving physician documentation to support a clinical diagnosis. In ICD-10, these teams must shift efforts to also include operative report audits and reviews. Physicians must provide timely and thorough OR reports for effective coding in ICD-10-PCS. Five lines are not sufficient for an operative report.

Health information management (HIM) directors and clinical documentation improvement (CDI) teams should work together in 2014 to ensure that surgeons, who are rarely queried in ICD-9, are aware of new documentation requirements.

Shore Up Defenses Now

Procedures are much more difficult to code than diagnoses in ICD-10. Additional coder training and documentation analysis are essential to prevent significant MS-DRG shifts and subsequent revenue loss. To effectively prepare, the following seven steps should be taken.

Define what percentage of discharges includes a procedure.
Determine whether outpatient surgical cases will be assigned an ICD-10-PCS code.
Estimate coder productivity, physician query, and overall staffing impact for surgical coding in ICD-10.
Create and begin using tables, crosswalks and flash cards to help coders master the new terms.
Rely on surgical technicians (instead of surgeons) for coder lunch-and-learns or procedure-specific knowledge sharing.
Empower coders to translate ICD-9-CM procedural terms into ICD-10-PCS root operations.
Give coders plenty of practice in reading OR reports, translating terms, and assigning accurate ICD-10-PCS codes.

Solid training, preparation, and communication regarding ICD-10-PCS will help ensure that January 2014 trumps October 2014 for the time in which healthcare’s stormiest weather hits.

About the Author

Gerri Walk, senior manager of technical training for HRS, is a nationally recognized speaker and author on the topic of clinical coding, and an approved ICD-10-CM/PCS trainer by the American Health Information Management Association (AHIMA). She has an extensive background in clinical coding and auditing at large academic, pediatric, and teaching institutions. Gerri has been with HRS for more than 20 years and currently serves as senior manager of technical training.

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