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Contrary to public opinion, ICD-10 is not a coding problem. Clinical documentation improvement (CDI) will be as affected as coding, if not more so. The true challenge in the transition to ICD-10 is ensuring that documentation meets the level of specificity and granularity required to achieve optimal reimbursement, meets all regulatory and reporting requirements, and accurately reflects the level of care provided.

Documentation practices will be the No. 1 driver for success in ICD-10. There will be significant changes required in clinical documentation, specifically in the areas of disease specificity, anatomical site and laterality, complication and manifestations, obstetrics, and correct use of medical terminology and naming. Providers must adhere to these changes to increase the specificity of the codes as well as decrease the potential for coding errors and unpaid claims that could impact reimbursement or quality of care.

Interestingly, in some cases this additional specificity in ICD-10 allows for less coding, or an increased use of combination codes. A common example that our team cites is diabetes with retinopathy. ICD-9 required two codes for this, one for the diabetes and one for the retinopathy. In ICD-10, there will be a combination code for diabetes with retinopathy. Another common example would be pressure ulcers. In ICD-9, you would code the pressure ulcer site and then use an additional diagnosis code for the stage. In ICD-10, there is a combination code.

Being aware of changes such as these – specifically for our most common diagnoses – will allow our CDI specialists to work efficiently while adhering to all of the new guidelines associated with ICD-10.

Here are nine focus areas for CDI specialists to concentrate on:

  1. Laterality: A renewed emphasis on laterality within documentation under ICD-10 is intended to enhance communication between providers as they formulate each patient’s story; all of the complexities and factors affecting the care of the patient are expected to be recorded. The goal is to improve the quality of care provided to the patient.
  2. Disease pathophysiology: Disease pathophysiology, or the study of ongoing changes in the disease state, is much more detailed in the ICD-10 disease descriptions. Documentation must reflect the highest level of known pathophysiology for diseases so that CDI specialists can identify the most accurate level of severity.
  3. Combination codes: Combination codes have been created to merge two diagnoses that typically are related to one another. In ICD-10, this means some codes now have six options, whereas they had one or two options previously under ICD-9.
  4. Encounter timing: ICD-10-CM requires documentation of the type of treatment that is rendered for specific conditions, such as injuries, signs and symptoms, and external causes of morbidity. Stage of care is also a critical element of this documentation.
  5. Identification of trimester in ICD-10: For obstetrics clinicians, new definitions of trimesters have been introduced. In addition, each episode of care must be reported along with the patient’s trimester.
  6. Increased disease specificity: ICD-10-CM has expanded many code descriptions to connect complications and manifestations with conditions.
  7. Alcohol and drug abuse: ICD-10 has clarified the way alcohol and drug abuse and dependence should be documented to mitigate confusion when attempting to accurately represent the patient’s condition. This will include effects, aspects, and manifestations of substance abuse.
  8. Expansion of injury codes: Documentation of the sites and types of injuries will be required in ICD-10.
  9. Post-procedural disorders: ICD-10-CM requires documentation to indicate if a condition or disorder is caused by or follows a procedure. Every physician needs to clearly state if a procedure caused a negative impact to a patient’s condition.

Training is key to preparing CDI specialists for ICD-10. There are a number of companies, including Precyse University, currently providing ICD-10 education within the healthcare marketplace. This education can be provided one-on-one, via online e-learning platforms, or with self-paced reading on ICD-10 changes. It is important to commit to providing the same level of ICD-10 preparedness education to CDI colleagues and coders alike. This includes Web training and one-on-one guidance by certified ICD-10 trainers. CDI specialists and coders should learn the same playbook and be able to work collaboratively throughout the training process, so when they hit game time, they will be ready to tackle ICD-10 as a team.

Physician queries also are being affected. Right now, the provider community is frustrated with the number of provider queries they have to respond to on a daily basis, and this is based on a set of rules that has existed for more than 20 years. The challenge is that providers are receiving questions about the same record from CDI specialists, UR nurses, case managers, and coders. With ICD-10, we can expect up to a 40 percent increase in provider queries. This will only increase the frustration levels of our providers. We need to prepare our entire patient care community now. If your organization has not updated your query templates to reflect looming changes associated with ICD-10, you should start today. Updating queries can launch the process of educating providers, CDI specialists, and coders on the level of specificity and granularity needed. Providers will begin to understand the documentation guidelines going forward, meaning they can incrementally change their documentation habits to adhere to the new principals and guidelines – before the reimbursement consequences kick in on Oct. 1.

After reviewing the ICD-10 changes, the following issues should be your areas of focus:

COPD, anemia, AMI, sepsis, acute renal failure, chronic kidney disease, pneumonia, hypertension, heart failure, and skin ulcers.

Every area needs some degree of focus, but these areas will provide a solid starting point for education and documentation improvement. Prior to ICD-10, educating physicians regarding the top 10 documentation issues within your practice could provide meaningful data to ensure the production of good clinical documentation with October 2014 arrives.

Through thorough understanding and practical use of the ICD-10 guidelines, CDI specialists will accurately reflect each patient’s severity of illness, thereby achieving optimal reimbursement in addition to improving quality measures, reporting, and regulatory compliance. I believe this is something we can all get behind to improve the health of our patient population.

About the Author

Krista Jaroszewski, product manager at Precyse, has more than 20 years of experience in healthcare operations and technology, specifically in the areas of product management, project management, implementation, accounts, and management. She has served as director of product management and product manager for Precyse since 2006, with specific focus on the CDI, transcription and coding product suites. Krista also has served as the director of transcription operations for Precyse from 2004-2006. Prior to her work at Precyse, Krista served a variety of operational and product roles at Matria Healthcare, WebMD, Emory, and the New Image Orthodontic Group. Krista received her Bachelor’s degree from The Ohio State University and performed graduate work at DePaul University. 

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