January 19, 2015

Ten Minutes per Week for ICD-10 Documentation Proficiency

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Unfortunately, chiropractic physicians have a reputation as the providers with the worst documentation.

According to the 2013 CERT Annual Improper Payment Report, chiropractic services were paid improperly 51.7 percent of the time. Of those improper payments, reviewers determined that 92.5 percent of them were due to insufficient documentation. As a certified professional medical auditor and a chiropractor, I have performed chart audits and provided expert witness testimony on documentation issues. As such, these numbers don’t surprise me.

 

Chiropractors are terrific clinicians and they care deeply about their patients, yet documentation seems to be the last thing on their minds. However, auditors and reviewers will look at the documentation first, perhaps in part because they know it is a chiropractic weak point.  

When ICD-10 kicks in on Oct. 1, chiropractors will have to work even harder on their documentation. ICD-10 presents new challenges involving documentation because the codes are more detailed. For many of the codes used by chiropractors, the new detail will include laterality or anatomical location.

Most doctors probably already document “right” or “left.” They also probably already specify anatomical details such as “cervical” or “lumbar.” They don’t need that information for ICD-9 code selection, but it is documented because that is just good practice. For example, they may already state “degenerative disc disease of the mid-cervical region.” The ICD-9 code denoting this is:

722.4  Degeneration of cervical intervertebral disc

The ICD-10 codes are similar, but there are more choices. The new level of detail specifies the anatomical region. Using the same notation, a coder could select:

M50.32 Other cervical disc degeneration, mid-cervical region

Therefore, the doctor could get by without making any changes to his or her documentation. But he/she will need to know what the new codes are in order to submit a clean claim.

Alternatively, many codes specify details that chiropractors may not routinely consider. For example, most headache codes include options for headaches that are intractable or not intractable. The first time I saw these terms in the code set, I had to pull out my medical dictionary to make sure I fully understood them. Intractable means “hard to control or deal with,” and it is often used in the medical world to describe a condition that does not respond readily to medication. 

The code for a headache that is not intractable includes the designation NOS, which means “not otherwise specified.” Therefore, if the doctor does not document whether the headache is intractable, this option would still work. However, since the codes now offer this level of detail, doctors should consider using this new term in their documentation. It will make code selection easier, and it will also make it easy for a reviewer or auditor to recognize that the correct code was chosen. For example, an ICD-9 record could say “tension headache” and the code might be:

307.81 Pain disorders related to psychological factors; Tension         headache (psychalgia)

But in ICD-10, the record might say “tension-type headache, intractable,” and the code would be:

         G44.201 Tension-type headache, unspecified, intractable

Upon closer examination, the ability to code episodic or chronic tension headaches is still available in ICD-10, but each designation now has an “intractable” and a “not intractable” option. Avoiding unspecified codes is always a good idea unless there are no better options. A more complete note would therefore include not only the type of headache, but whether or not it is episodic or chronic. And it would also need to include information about whether or not the headache responds to medication (intractable or not).

These examples may seem manageable, but how can a provider figure this out for all of the new codes that need to be considered? Getting used to the codes and their documentation requirements could be overwhelming if a provider waits until Oct. 1 to make changes. However, some simple strategies and 10 minutes a week can make all the difference in the world. Here is one strategy to consider:

1.  Pull out a recent patient note.
2.  Locate the ICD-9 codes reported for the service(s) provided.
3.  Search for the appropriate ICD-10 code(s) using one of these three methods:
           a.  Code mapping (i.e. general equivalency mappings, or GEMs, tables)
           b.  Finding a “commonly used ICD-10 code” list for your specialty
           c.  Searching for keywords in the alphabetic index
4.  Look for the final code(s) in the tabular list and review the information required to report that code at the highest level of specificity possible. Is there a fourth, fifth, sixth, or seventh character required?
5.  Review in-column instructions at the level of each character. Pay particular attention to inclusion, excludes 1, and excludes 2 notes.
6.  Compare the required information with the detail contained in the patient note. Is there enough detail in the documentation, or is more information needed?
7.  Recreate the note to ensure that it supports the newly selected ICD-10 codes.
8.  The next time a patient presents with that condition, document in this new way.

Repeat this process with one record, every week, until Oct. 1, 2015. By then you will have become an expert on the codes and documentation requirements that are most important to your practice. Though it may take longer than 10 minutes at first, this method can probably be completed in a relatively short amount of time each week. With a little bit of consistent practice, any provider can become completely ready and trained long before it becomes necessary for reimbursement.

According to reviewers, chiropractors need to work on documentation improvement. ICD-10 only adds to this challenge, but a simple plan can ensure preparedness for the day that your reimbursement depends on it.

Ten minutes per week for ICD-10 documentation proficiency!

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Evan M. Gwilliam, DC, MBA, BS, CPC, CCPC, CCCPC, NCICS, CPC-I MCS-P, CPMA

Evan M. Gwilliam, DC, MBA, BS, CPC, CCPC, CCCPC, NCICS, CPC-I MCS-P, CPMA, executive vice president of ChiroCode and Find-A-Code LLC, graduated from Palmer College of Chiropractic as valedictorian and is a certified professional coding instructor, medical compliance specialist, and professional medical auditor, among other things. He provides expert witness reports, medical record audits, consulting, and online courses for healthcare providers. He also writes books and articles for trade journals and is a sought-after seminar speaker. He has a bachelor’s degree in accounting and a master’s of business administration, and he is one of the few clinicians who is a certified ICD-10 Instructor and certified MACRA/MIPS healthcare professional.