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October 2013 seems like a long time away, and it is too early to begin to actually learn the new coding system. However, there are areas in which radiology practices can work now to be ready then. IT departments already are working on the 5010 transaction standard, while managers are planning budgets for the transition and collaborating with vendors. But it’s not too early for the rest of the staff to prepare.

The move to ICD-10-CM will allow for greater specificity than we have now with ICD-9-CM. This will provide better data for measuring care furnished to patients, designing payment systems and processing claims, among other actions. 

Potential Problem Ahead

However, this greater specificity is a potential problem for radiology, and something practices should begin to examine now. Most radiology claims currently are coded with non-specific diagnosis codes because complete information either is not provided or does not make it through the system to the final dictated report. While there still will be non-specific codes available for use, using them on a regular basis will negate the benefits of ICD-10-CM. In addition, the advent of ICD-10-CM may bring with it more specific medical policies. It is possible that claims will be denied if a non-specific diagnosis is coded.

Hospital radiology departments, radiology practices and imaging centers should begin to train (or re-train) both clerical and clinical staff immediately to make sure the most complete and appropriate clinical information and/or diagnosis codes are obtained and documented, respectively. 

Work for Process Improvement Now

Often a complete diagnosis is given at the outset but does not make it through from front desk to coder. Or, for an inpatient the hospital system only allows the admitting diagnosis to appear on the ordering form. Practices should be looking at all of the points where diagnosis coding can be impacted and begin now to work to improve the entire process.

Scheduling or other intake personnel also should ask for additional information if a non-specific indication is given. For instance, if a physician’s office calls to schedule a test and cites a clinical indication of “hypertension,” the scheduler should ask if the patient has benign or malignant hypertension. If an uncertain diagnosis such as “ruled-out pneumonia” is given as the clinical indication, radiology personnel should ask what patient symptoms are leading toward that possible diagnosis. ICD-10-CM contains many more codes for signs and symptoms than ICD-9-CM for use with encounters for which definitive diagnoses often are not known, but we must have the symptoms to code them.  
If the patient gets past scheduling or front-desk personnel with a non-specific or uncertain diagnosis or clinical indication, technologists may ask the patient for additional information. As long as this is documented in the medical record, it can be used for coding. For example, if the clinical indication is “abdominal pain,” ask the patient for a more specific location. There are codes (in both ICD-9-CM and ICD-10-CM) for right upper quadrant, left upper quadrant, epigastric, right lower quadrant, left lower quadrant, periumbilic and generalized abdominal pain. This is in addition to codes for acute abdominal pain, abdominal tenderness, rebound abdominal tenderness, colic and pelvic pain. 

The Final Report and the Coder

Assuming that a complete diagnosis or clinical indication gets through the clerical system, the radiologist should be responsible for dictating it in his report. The ACR practice guideline for communication of diagnostic imaging findings indicates that the final report should include relevant clinical information and both the clinical indication and any positive findings necessary for appropriate diagnosis coding.

The final step in this process is the coder. Many coders have a “cheat sheet” with common (and usually non-specific) codes to use, meaning they rarely open an actual diagnosis code book. This will not be feasible with ICD-10-CM, and coders immediately should begin to get used to looking up the more specific codes that are available even now with ICD-9-CM. All coders should be familiar with the official guidelines that are revised and published annually on the NCHS website (http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm). If possible, coders also should have access to “AHA Coding Clinic For ICD-9-CM,” and when the time comes, the ICD-10-CM publication. “Coding Clinic” is the official publication for guidelines and advice concerning diagnosis coding. Coders may need additional training in anatomy and physiology between now and October 2013 because of the increased specificity in ICD-10-CM. 

New features in ICD-10-CM that will impact radiology in particular include:

•    Coding for laterality (right, left, bilateral) and encounter. For example: S52134D, Non-displaced fracture of neck of right radius, subsequent encounter for closed fracture with routine healing.
•    Combination codes for certain conditions and common associated symptoms and manifestations. For example: I83202, Varicose veins of unspecified lower extremity with both ulcer of calf and inflammation.
•    Obstetric codes identifying trimester. For example: O26841, Uterine size-date discrepancy, first trimester.
•    An “X” placeholder for 5th and/or 6th characters when a 6th or 7th character is required. For example: T198XXA, Foreign body in other parts of genitourinary tract, initial encounter.

With just these few examples, the required level of documentation and pending changes in coding practices should be very clear. My favorite example, though, is current ICD-9-CM code 733.82, Non-union of fracture. In ICD-10-CM, this one code will be replaced by more than 2,500 codes! Just a few of the possible new codes are:

•    S32432K, Displaced fracture of anterior column [iliopubic] of left acetabulum, subsequent encounter for fracture with nonunion;
•    S32451K, Displaced transverse fracture of right acetabulum, subsequent encounter for fracture with nonunion;
•    S32443K, Displaced fracture of posterior column [ilioischial] of unspecified acetabulum, subsequent encounter for fracture with nonunion; or
•    S32444K, Non-displaced fracture of posterior column [ilioischial] of right acetabulum, subsequent encounter for fracture with nonunion.
By getting staff accustomed to obtaining the most specific clinical indication possible now, your team will be ahead of the curve when October 2013 rolls around.  



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