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The Centers for Medicare & Medicaid Services (CMS) has announced that the implementation of ICD-10-CM may be delayed beyond the scheduled Oct. 1, 2013 date. Inpatient Rehabilitation Facilities (IRFs) have been getting ready for the implementation of ICD-10-CM through education for hospital departments, physicians, clinicians and coders. Now is not the time to stop your educational programs. This delay, irrespective of how long it may be, provides an opportunity for additional education and could smooth the transition to ICD-10-CM.

IRFs have many of the same problems facing other facilities, including incomplete and inconsistent physician documentation. IRFs are unique in that the IRF Prospective Payment System (PPS) requires completion of patient assessment forms, and the codes reported on those forms do not always follow the Official ICD-9-CM Guidelines for Coding and Reporting.

It is sometimes difficult to assign codes, as conditions typically are reported on the Patient Assessment Instrument (PAI) required by the IRF PPS when a patient receives initial treatment for a condition causing impairment at an acute-care facility prior to IRF admission. Such information required for code assignment is not always known or documented by the IRF physician, who often must rely on the history and physical, ER report, diagnostic tests and other indicators documented in the record from the transferring facility in order to determine how the patient acquired the impairment requiring treatment. The IRF physician reviews the information from the acute-care facility, but does not always include this information in the IRF documentation. For example, consider a physician who documents that a patient is admitted for rehabilitation following surgery requiring a below-knee amputation (BKA). Code assignment for the etiology will require a physician query to determine the condition that required the BKA.

Currently, incomplete or inconsistent documentation is addressed via a written physician query performed to obtain the necessary additional information. It is anticipated that the number of queries will increase with the advent of ICD-10-CM, as the additional characters provide an opportunity to identify additional information about conditions that codes represent. The anticipated delay in implementation of ICD-10-CM provides a window of opportunity to offer more physician education on the documentation requirements for code assignment.

Physician education on a continual basis is necessary whether ICD-9-CM or ICD-10-CM codes are reported, though. One approach is to start with the impairment group with the greatest volume and/or the impairment group that currently requires the greatest number of queries. It will take multiple educational presentations per topic to obtain physician buy-in and compliance. Still, select a topic and provide education through physician staff meetings, newsletters, emails, etc. Provide education on one or two topics each month. Be consistent and query each time required information is not documented until compliance is achieved.

If the stroke impairment is selected, for example, education could focus on documented information identified by the individual characters in the ICD-10-CM codes indicating a stroke. For assignment of a detailed ICD-10-CM code, it will not be sufficient for the physician simply to document that “the patient is admitted with hemiparesis and deficits in ambulation and activities of daily living following a stroke.” When the cause of the stroke is infarction or hemorrhage, physician documentation should indicate the cause as such and also identify the location and type of infarction as a thrombus or embolism – plus the specific cerebral artery, precerebral artery or other site of occlusion that includes the laterality. The location of a hemorrhage also should be documented.

An example of an ICD-10-CM stroke code requiring specific documentation is code I63.311, for cerebral infarction due to thrombus of the right middle cerebral artery.

Education for other impairment groups should cover the information indicated by each of the ICD-10-CM characters included in a code.

Education also should focus on conditions requiring frequent queries due to documentation that does not include sufficient detail for specific code assignment. These conditions include obesity versus morbid obesity, renal failure and dysphagia.

About the Author

Patricia Trela, RHIA, is the director of HIM and rehabilitation services for Diskriter, Inc., a consulting firm offering integrated HIM rehabilitation consulting services, including HIM Interim management, IRF PPS compliance and education, coding and auditing support, dictation/transcription, and other solutions. She has more than 25 years of healthcare industry experience.  As a consultant, Pat has worked with many acute-care hospitals, rehabilitation hospitals and long-term acute-care hospitals (LTACH).  Pat facilitates the AHIMA Coding Physical Medicine Rehabilitation Community of Practice (COP).

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