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ICD-10 Tip of the Week: Staffing considerations

CDI programs need to work across disciplines to advance documentation efforts into areas of medical necessity and severity of illness, risk of mortality.

The more functions a CDI specialist is expected to perform, the higher the staff ratio should be.

An experienced CDI specialist should have an average daily census of 12-15 new patients and five to 10 established/follow-up cases. A good rule of thumb is one CDI specialist for every 1,200-1,500 discharges per year. The more functions a CDI specialist is expected to perform, the higher the staff ratio should be. Smaller CDI staff should focus on condition clarification only. However, many CDI programs are understaffed—some only employ one CDI specialist. Such staffing will become even more problematic once ICD-10 implementation begins.

Reviews are going to take more time and require more resources. While CDI staff ratios and productivity expectations depend on the program’s mission, CDI programs need to evaluate whether or not their program’s focus is realistic for their staff size. More importantly, they must start considering whether or not they need to bring on additional staff to bridge those anticipated productivity gaps.

Most programs query to identify incomplete, vague [more]

News: AMA/CMS join forces while Congress misses the ICD-10 memo


No time to wait.

Those following the episodic turns of the ICD-10-CM/PCS implementation saga witnessed another dramatic plot twist in the narrative this week when the American Medical Association (AMA) and CMS made a joint announcement essentially prioritizing physician ICD-10 education and allowing some flexibility in claims auditing and quality reporting.

“ICD-10 implementation is set to begin on October 1, and it is imperative that physician practices take steps beforehand to be ready,” said AMA President Steven J. Stack, MD, in a joint statement with CMS Monday morning, July 6.

Stack’s statement not only marks a sea change in opinion from the AMA. Yet those hoping the agreement might also resolve years of debate and back-room political attempts to delay ICD-10 implementation may just have to keep on hoping until the actual implementation date comes to pass. Last week (July 10) Reps. Marsha Blackburn, R-Tenn., and Tom E. Price, R-N.C., introduced H.R. 3018, the Code-FLEX Act, to allow submission of ICD-9-CM and ICD-10-CM codes for 180 days after implementation.

W. Jeff Terry, MD, a Mobile, Alabama, urologist, sounded off on the problems of ICD-10-CM/PCS implementation in a HealthLeaders Media article, “AMA Delegate Blasts ICD-10 Implementation Requirements,” on Friday, July 1. And previous AMA leaders described ICD-10-CM/PCS’ detriments in Star Wars terms, Healthcare IT News pointed out this week, recalling that past-AMA President Robert Wah, MD, indicated the group wanted to essentially freeze the code set in carbonite.

Despite the new Code-FLEX Act proposal, the AMA and CMS seem to be moving forward with ICD-10 education. Although the details of their agreement seem simple enough, many news headlines seems to state that CMS gave physician practices permission to code incorrectly. When actually, CMS for its part said Medicare review contractors “will not deny physician… claims …based solely on the specificity of the ICD-10 diagnosis code as long as the physician used a valid code from the right family.” (Emphasis added.)

The problem comes, as Michelle Leppert points out in an an article on the ICD-10 Trainer Blog, that CMS does not define a family of codes. Is it a category of codes, such as 500, superficial injury of head? “That could be interesting,” Leppert writes, since the category includes nine subcategories which each also have further subsections.

While those entrenched in ICD-10-CM/PCS drama may say that these concessions read more like snip-its from the Official Guidelines for Coding and Reporting, getting the AMA to effectively bury its opposition is, for once, a welcome shift in the ICD-10-CM/PCS implementation storyline.

Editor’s Note: Portions of this article originally published in eNewsletter CDI Strategies. Subscribe now, for free.

ICD-10 Tip of the Week: No more excuses

Now that you have the extra time...

There’s no more room for excuses. ICD-10 is coming.

By now, we’re sure you’ve heard the news. CMS and the AMA made a joint announcement on Monday, stating that ICD-10 is a go, with a hard deadline of October 1, 2015. What’s the catch, you ask? For one year after implementation, CMS will not deny or audit claims just for specificity, as long as the code is from the appropriate family of ICD-10 codes.

To gain cooperation from the AMA, CMS also agreed to a number of other policies involving claim denials, quality reporting, and the like. (For information on the changes, click here.)

So, what does this mean for CDI? Well, for starters [more]

Guest Post: Happy Fourth of July, ICD-10 style

We hope everyone had a safe 4th! Whether you were coding, querying, or enjoying the holiday.

We hope everyone had a safe 4th! Whether you were coding, querying, or enjoying the holiday.

By Michelle A. Leppert, CPC

Ah, the Fourth of July, picnics, parades, and pryotechnics. What could be better? Well, not having your family and friends end up at Fix ‘Em Up Clinic the next day would be a good start. Alas, holidays here in Anytown never go off without a hitch, so let’s see who has wandered in with a holiday malady.

Doug was running around with a lit sparkler and one of the sparks flew into his eye. So what kind of injury does Doug have? If the little metal shaving from the sparkler is still in his eye, he may have a foreign body in the cornea (T15.0-) or a foreign body in the conjunctival sac (T15.1-). Alternately, he could have a corneal abrasion without a foreign body (S05.0-).

The code we choose will ultimately depend on the physician’s documentation [more]

ICD-10 Tip of the Week: Prepare for procedure codes 

If you are thinking about taking the CCDS exam the first step to take is to review the CCDS Candidate Handbook.

Both CDI specialists and coders should make sure their own training includes the ins and outs of PCS.

Traditionally, CDI specialists do not query regarding procedures. They may query to clarify excisional and nonexcisional debridement, but many CDI programs tend not to focus on MS-DRG assignment, since it typically bears little effect on CC and MCC reporting. However, with ICD-10-CM/PCS implementation, organizations may task CDI staff to ensure that the documentation necessary for accurate PCS coding is available. This means CDI specialists may require extensive PCS training, similar to the training offered to coding staff.

The PCS classification system is independent of ICD, even though it will be used alongside ICD-10-CM. Therefore, it’s difficult to say how much or how little PCS will effect CDI and coder productivity. Both CDI specialists and coders should make sure their own training includes the ins and outs of PCS.

Similar to ICD-10-CM, PCS is composed of seven alpha (non-case sensitive) or numeric characters. Unlike ICD-10-CM codes, PCS codes will always be seven characters, and there are no placeholders. The numbers 0 through 9 are used, and O and I are not used to avoid confusion with the numbers zero and one. PCS codes also do not contain decimals.

ICD-10-PCS has its own set of coding guidelines [more]

Guest Post: Wrapping your CDI arms around ICD-10-CM/PCS

Broaden the scope of your CDI efforts by looking for medical necessity indicators and increasing proactive efforts to protect the record against audit risks.

ICD-10-CM/PCS doesn’t have to be met with apprehension in your CDI department.

by Karen Newhouser, RN, BSN, CCDS, CCS, CCM

ICD-10 CM/PCS.  To some, the utterance of this classification system produces much trepidation. I hope to dispel some concerns as I recount the undertaking of ICD-10 implementation at one CDI program.

First, please understand that I am not here to de-emphasize the seriousness of ICD-10-CM/PCS, but rather to equip you with a roadmap of tips and hints as you embark on this journey.

Yes, CDI specialists’ productivity will likely decrease, mostly due to the sheer volume of queries needed for the added specificity vital for correct code assignment. The act of query writing, no matter how experienced one may be, takes time. I feel, though, that with preparation and open channels of communication, the impact on productivity can be assuaged, however.

This case example CDI program is housed within the HIM department of a large Midwestern hospital [more]

ICD-10 Tip of the Week: Assess your readiness

Regulatory changes make CDI and coding accuracy more important than ever

Be honest with yourself, and assess how prepared your CDI program is for ICD-10.

It’s pretty uncommon for a facility to feel they are over-prepared for ICD-10. However, it is common for facilities to think they are more prepared than they actually are. With less than 100 days before ICD-10 implementation, CDI specialists need to be honest with themselves, and accurately evaluate their program’s readiness. This is no time to underestimate your abilities to adapt to ICD-10-CM/PCS.

So, assuming you’re educational efforts have already begun, how do you assess how far along your facility is in terms of ICD-10 readiness? First, try breaking down ICD-10 preparation into sections, or specific items that facilities should address before implementation. For example [more]

ICD-10 Tip of the Week: Practice makes perfect

Look for all the clinical indicators in the medical record to ensure appropriate sequencing.

Coders are basically going to have to re-learn their jobs. CDI can help.

One of the main pain points CDI specialists stress for ICD-10 preparation is physician education. But what about preparing the coders? After all, it is the code set that’s changing. Coders are basically going to have to re-learn their jobs—they’re going to have to adapt their daily routines to an entirely new, more specific set of codes and rules. The physician could have the most complete and accurate documentation in the world. But if the coder isn’t up-to-speed with ICD-10, all of the physician education will have been for nothing.

As CDI specialists, you can help get coders in tip-top shape for implementation by facilitating and encouraging dual coding practices. If your facility hasn’t begun to do so, start by revising electronic templates and query forms for ICD-10, and revising query policies. From there, encourage coders to begin dual coding to help identify risk areas and coding familiarity. You can start by having coders begin dual coding on a smaller scale, such as high-volume and/or high-dollar DRGs.

After coders [more]

ICD-10 Tip of the Week: Have a plan in place for queries

Take a look at your emergency room records to ensure that E/M efforts are appropriately captured

Do yourself a favor: plan out an updated ICD-10 query process and policy now.

The ICD-10 code set is complex. The volume of codes and required increased documentation specificity alone is enough to overwhelm even the most sophisticated CDI programs. Do yourself a favor: plan out an updated query process and policy now.

The number of queries associated with a given health record will likely increase post-ICD-10 implementation. If you haven’t already, start educating CDI and coding staff on documentation needs associated with the new code set, and prevent future documentation woes before they occur. Likewise, programs should begin including ICD-10-CM/PCS elements in targeted queries for high-volume diagnoses, specific to your facility. Practice documenting and querying for ICD-10 now, and CDI, coders, and physicians alike will be better prepared.

CDI departments also need to review their query policies [more]

Latest AMA ICD-10 proposals get it half right, in my opinion


ACDIS Director Brian Murphy

The American Medical Association (AMA), aware that the national tide has turned in favor of ICD-10, has made what seems to be one final, desperate push for delay–not of the implementation of the new code set, but its impact. Physicians at the 2015 AMA Annual Meeting this week passed policy calling for CMS to put a two-year moratorium on payment penalties for physicians as a result of ICD-10 coding mistakes. You can find the full article here:

Alongside this policy is to me a more interesting policy promulgated by the AMA, which wishes to join CMS, the National Centers for Health Statistics (NCHS), the American Hospital Association (AHA), and the American Health Information Management Association (AHIMA) as a 5th Cooperating Party. The Cooperating Parties, as most know, are the group in charge of updating and managing the ICD code set.

I’ve been asked by several people what my take is on the AMA’s proposal for an ICD-10 payment grace period, and here it is: I do not support the concept of implementing a code set half way. While the AMA policy is an interesting proposal and not a completely unreasonable compromise, holding hospitals accountable to the ICD-10 codes they report, but not physicians, only deepens the divide between these two parties at a time when CMS is attempting to unify the professional/facility divide through bundled payments and other initiatives. It would also likely result in bad statistical data that would have a ripple effect for years to come.

ICD-10 has already been delayed several times at the behest of the AMA. There are a number of free ICD-10 training resources available at the disposal of physician practices from CMS and others. Early claims testing has proven remarkably successful. And as many have pointed out, the ICD-10 code set is not the monster it is made out to be: The rhetoric of “four times as many codes” is a smokescreen, as most physician practices will be using a far smaller subset of codes. Hospitals, at the behest of CMS, have been preparing for years, at enormous cost. The time is now to implement ICD-10 to the hilt, including for claims processing and payment.

However, the AMA’s case to become a 5th Cooperating Party to me is a much stronger one. Physicians deserve an equal voice at the table when new codes are developed. Codes need to be 100% clinically congruent to the practice of medicine, not the other way around, as is frequently the case with anyone familiar with the quirks of ICD-9. In fact, I’d like to eventually see ICD replaced by a truly clinical language like SNOMED. But that’s a battle for another day. While there are physician representatives among the four current Cooperating Parties, they seem to be a minority. More to the point, the critical work of the Cooperating Parties lacks transparency—try to find a website detailing their work or membership roster, for example—and there is no readily available method for groups affected by ICD changes to have their voices heard.

In summary, let’s move forward with full implementation of ICD-10 on Oct. 1, 2015, both for hospitals and physicians. But let’s also see a more transparent application process for the Cooperating Parties, allowing physicians/clinicians full representation at the table. While that physician group may not ultimately be the AMA, the time has come for more input on the ICD codes from those at the center of healthcare delivery.