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Guest Post: ICD-10 delay provides CDI teams time to find hidden documentation solutions

kelli(new photo)

Kelli Estes

Taming the ICD-10 Extraneous Query Beast!

By Kelli Estes, RN, CCDS

Whether ICD-10-CM/PCS implementation is six or 18 months away, the code set expanding from 14,000 to 73,000 codes will create a query volume of epic proportion if we don’t bring things down to a 10,000-foot view and get some much needed perspective. It is simply not the intent of a CDI program to query providers for everything from soup to nuts considering such code volumes.

CDI specialists cannot possibly be productive if they are expected to be the gatekeeper for capturing all clinical documentation drilling down to the deepest level of ICD-10 specificity with an exponential growth in code volume. It just won’t happen in the real world.

I think we have to remember ICD-9-CM already provides “some” specificity in certain conditions that many physicians never tap into resulting in the use of unspecified codes, as things currently stand today. There will still be unspecified codes available in ICD-10. While I am certainly not suggesting we brush off the urgent need for being more specific, I do caution against getting stuck in some apocalyptic thought process that workflow will gridlock once ICD-10-CM/PCS goes live in all hospitals across the country. There will still be a learning curve that lingers after the “go live” date for ICD-10.  We prep and plan, but we have to actually “go there” before we can get a realistic grasp on all of this.

CDI Tip: Besides educating providers with issues common to their practice, we need to also take a collaborative approach and start developing smart assessment tools to be used within or as an adjunct to the EHR (electronic health records). This will help providers improve documentation specificity pro-actively by providing choices that lead to the necessary words for depicting a really accurate clinical picture useful for ICD-10 code selection.

For example, the following choices are necessary for drilling down to the most specific fracture code:

  • Traumatic, Pathologic, Stress
  • Anatomical specificity
  • Laterality:  Right, Left
  • Open, Closed
  • Displaced, Nondisplaced
  • Initial encounter, subsequent encounter, sequelae
  • Gustilo-Anderson Fracture Scale

Changes to note from ICD-9-CM to ICD-10-CM include:

  1. Fractures not indicated as displaced or non-displaced in documentation will be coded as displaced
  2. Fractures not indicated as closed or open in documentation will be coded as closed

With the delay of ICD-10-CM/PCS implementation it only makes sense for CDI teams to embrace the additional time to fine tune strategies for educating providers and develop useful tools to enhance documentation improvement. Learn ICD-10-CM/PCS now. Practice ICD-10 CDI now. That way, when everybody else is scrambling at the last minute, you’ll be ready.

Editor’s Note: Estes has spent more than a decade as a clinical documentation specialist and consultant, presently with DCBA Inc., in Atlanta. She holds the CCDS certification through ACDIS and was in the first group of participants to sit for the exam. Since joining DCBA in 2005, Kelli has assisted with project management in dozens of CDI program implementations. She is highly skilled in the overall process of CDI program start-up and enjoys guiding the decision-making required to implement and sustain longevity in any viable program. Estes has also been involved in CDI program follow-up assessments and has written several articles for DCBA’s monthly newsletter, CDI Monthly, where this article was originally published. To subscribe to CDI Monthly, click here.

ACDIS Advisory Board releases new ICD-10 timeline

Time flies so try to make the most of it.

Time flies so try to make the most of it; check out the latest ICD-10 implementation advice from the ACDIS Advisory Board.

Not sure where you should be in your ICD-10 implementation? The ACDIS Advisory Board created a revised training timeline specifically for CDI professionals. And “stay the course” is its overarching message.

The revised ICD-10-CM/PCS training and implementation timeline which includes quarter-by-quarter and then month-by-month recommendations for preparedness activities. It makes recommendations such as emphasizing PCS coding and record reviews during the fourth quarter of 2014, developing organizational strategies to identify and prioritize documentation risks by January 2015, and incrementally increasing the scope of coders’ and CDI staff members’ dual coding and communication efforts.

Although the ACDIS revised timeline includes many recommended actions, one of the most important elements is fostering facility-wide communication, says Michelle McCormack, RN, BSN, CCDS, CRCR, ACDIS advisory board member and director of CDI for Stanford Hospital & Clinics in Palo Alto, California.

Stanford Hospital & Clinics, for example, has a number of ICD-10 focused working committees that meet regularly, on separate schedules, then come together monthly with organizational leadership to review key activities and accomplishments and jointly tackle barriers to progress.

While dual coding is a big component of the revised ACDIS timeline, if you haven’t begun dual coding, McCormack says that you can make significant  progress by simply revising your electronic templates and query forms for ICD-10.

Editor’s Note: ACDIS members received an exclusive first look at the new timeline via email July 14. Click here to download the timeline and related article.

Tip: Brush up on heart anatomy as related to ICD-10-CM/PCS

image505

You’ve got heart, kid! Don’t let A&P get you down.

Go to your local bookstore, pick up a copy of Gray’s Anatomy (the book, not the television show), and flip though the illustrations. Alternately, you can Google “Gray’s anatomy illustrations.” They are in the public domain. Some of them are pretty good, especially considering it was first published in 1858.

Not surprisingly, anatomy hasn’t really changed since then. Our understanding of certain things–like what parts of the brain are involved in which functions—has changed, but the structures themselves have stayed the same for the last many thousands of years.

So why do you need to brush up on anatomy and physiology before ICD-10? The best reason I’ve heard so far comes from Gerri Walk, RHIA, CCS, senior manager of technical training for HRS in Baltimore.

“The vessels of the heart are like roads in Texas,” Gerri says. “Turn a corner and you’re on a different road or in a different vessel.”

ICD-10-CM and ICD-10-PCS both require specific vessels for cardiac conditions and procedures. For example, a patient suffers an acute MI. Where was the infarction? ICD-10-CM includes specific sites, such as:

  • Left main coronary artery
  • Left anterior descending coronary artery
  • Diagonal coronary artery
  • Other coronary artery of anterior wall
  • Right coronary artery
  • Other coronary artery of inferior wall

Some of those are easy (if the physician documents it). Some could be a little trickier. Do you know which smaller arteries are on the inferior wall and which are on the anterior wall?

For Dilation procedures (balloon angioplasty and stents) in ICD-10-PCS, you only need to know the number of coronary sites treated. For Bypass procedures, you need to know the number of sites bypassed from and where the bypass is going:

  • 3, coronary artery
  • 8, internal mammary, right
  • 9, internal mammary, left
  • C, thoracic artery
  • F, abdominal artery
  • W, aorta

Although some coders and CDI specialize to particular units or concentrations of care, you still need to know arteries even if you don’t focus on cardiac cases. For a procedure involving an artery, for example, you will need to know which artery is involved, where it is located in the body, what approach the physician used, what type of repair he or she performed, and whether the physician used a device.

Consider a patient with septic thrombosis of the choroid vein. If you know that the choroid vein is an intracranial vein, you’re all set. You can report ICD-10-CM code G08 (intracranial and intraspinal phlebitis and thrombophlebitis). You’ll notice all of the intracranial veins and sinuses are lumped into this one code. If you don’t know where the vein belongs and your physician simply documents septic thrombosis of the choroid vein, you’ll need to research the vein. This decreases productivity, which slows down cash flow and so on and so forth.

You don’t need to take a full-blown anatomy course. Figure out what anatomy you already know well. Odds are you know some of it very well. Identify areas where you aren’t as strong and do some focused training. It can be as simple as looking at Gray’s Anatomy (again, the book, not the TV show).

Find ways to make it fun. An anatomy version of Jeopardy! could be interesting. You can find a lot of free resources online, just make sure you choose ones from a reputable source.

Editor’s Note: This article first published on the ICD-10 Trainer Blog.

 

Fabulous Fourth of July ICD-10-CM coding

Be careful out there this 4th! Whether you are coding, querying, or enjoying the holiday.

Whether you are coding, querying, or enjoying the holiday, be careful out there this 4th!

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.

Ralph, apparently did not pay attention to the “do not try this at home” warning. He attempted to create his own backyard extravaganza and ended up blowing off two fingers. Ralph immediately traveled to the Acme ED for initial treatment by Dr. Boom and with a follow-up by Dr. Sam.

We know that Ralph suffered a traumatic amputation. In order to code his accident we also need to know:

  • Was the amputation complete or total?
  • Which hand was involved?
  • Which specific fingers were involved?

Dr. Sam documents he is seeing Ralph for a follow-up visit for complete traumatic amputation of the right index finger and partial amputation of the right middle finger caused by exploding fireworks.

That gives us codes:

  • S68.110A, complete traumatic metacarpophalangeal amputation of right index finger, initial encounter
  • S68.122A, partial traumatic metacarpophalangeal amputation of right middle finger, initial encounter

This is a follow-up treatment for Ralph’s injuries, so why are we calling it an initial visit? Because the ICD-10-CM Official Guidelines for Coding and Reporting tell us to add the seventh character of A when a patient is receiving active treatment including:

  • Surgical treatment
  • ED encounter
  • Treatment by a new physician

Dr. Boom saw Ralph in the ED, today Dr. Sam is treating him at the clinic. An initial visit with a doctor means you append A as the seventh character.

And with that, we will close the clinic for the day and hope you all stayed safer during your holiday celebrations.

Editor’s Note: This article originally published on the ICD-10-Trainer Blog. Read the complete collection of tales from the “Stitch ‘Em Up Hospital” and “Fix ‘Em Up Clinic” in the new book ICD-10 Trainer: Top Coding Scenarios for CM and PCS.

Coding Clinic to review advice highlights

The AHA will begin to collect and respond to limited questions regarding the ICD-10 code set.

The AHA published its final Coding Clinic for ICD-9-CM recently.

The AHA recently published its first issue of Coding Clinic for ICD-10-CM and ICD-10-PCS along with its final edition of Coding Clinic for ICD-9-CM. In it, the editorial board reiterated that it has no plans to translate all previous issues of Coding Clinic for ICD-9-CM into ICD-10-CM/PCS.

Additionally, this issue reminds readers that clinical information previously published in Coding Clinic—whether for ICD-9-CM or ICD-10-CM/PCS—does not constitute clinical criteria for establishing a diagnosis, substitute for the provider’s clinical judgment, or eliminate the need for provider documentation regarding the clinical significance of the patient’s medical condition. CDI staff may still find it helpful to know what signs and symptoms are integral (or not) to a condition; however Coding Clinic cautioned that ICD-10 has new combination codes as well as instructional notes that may or may not be consistent with ICD-9-CM.

The forthcoming edition of the CDI Journal takes a deeper look at the most recent Coding Clinic advise, but for those who cannot wait for July 1st, the AHA presents a review of ICD-10-CM Coding Clinic advise to-date, tomorrow, Wednesday, June 18, noon to 1 p.m., Central.

ICD-10 Trainer says: Too much sun is no fun

Ah, Memorial Day, the unofficial start of summer. And the day after Memorial Day is the unofficial start of summer injury season at Fix ’Em Up Clinic.

Sweating sun

Holidays are no fun unless your using ICD-10 codes to account for Memorial Day mayhem!

Jackee took advantage of the long weekend by heading to the beach. She packed plenty of water, munchies, and books to read, but didn’t pack her sunscreen. As a result, she ended up with a nasty sunburn.

The only information we really need to code Jackee’s sunburn is the degree:

  • L55.0, sunburn of first degree
  • L55.1, sunburn of second degree
  • L55.2, sunburn of third degree
  • L55.9, sunburn, unspecified

The physician does need to specify the degree; you can’t just guess or default to first degree.

We can also add some External Cause codes:

  • X32.XXXA, exposure to sunlight, initial encounter
  • Y92.832, beach as the place of occurrence of the external cause
  • Y99.8, other external cause status

Gina also headed to the beach for the weekend, but she was a little less prepared than Jackee. Gina forgot to pack her water but spent the day anyway. She came into the clinic complaining of nausea, vomiting, vertigo, and muscle cramps. Her temperature was 104°F and her heartbeat was fast and weak.

Dr. Sunni Daze diagnosis sunstroke. That’s pretty easy to code. We have one choice: T67.0 (heatstroke and sunstroke).

However, we do see a note to use additional code(s) to identify any associated complications of heatstroke, such as:

  • coma and stupor (R40.-)
  • systemic inflammatory response syndrome (R65.1-)

Since Dr. Daze didn’t document any complications, we don’t need to report any additional diagnosis codes. We could report the same External Cause codes as we did for Jackee.

Our final post-Memorial Day patient skipped the beach and went camping instead. That also turned out to be a less-than-perfect way to spend the weekend.

Geoff ran afoul of some ticks in the woods, who decided to tag along for his ride home. They also left him with what he thought was a summer cold. Instead, he contracted Lyme disease.

We have five codes for Lyme disease, depending on what condition results from the disease:

  • A69.20, Lyme disease, unspecified
  • A69.21, meningitis due to Lyme disease
  • A69.22, other neurologic disorders in Lyme disease
  • A69.23, arthritis due to Lyme disease
  • A69.29, other conditions associated with Lyme disease

We can still assign External Cause codes for Geoff’s illness. One thing to watch out for is the first code. You may be tempted to assign a code for bitten by an insect. However, ticks are not actually insects. They are arthropods, like spiders. It turns out that we will still report W57.XXXA (bitten or stung by nonvenomous insect and other nonvenomous arthropods) because ICD-10-CM lumps insects and arthropods into one code.

Our additional External Cause codes would be:

  • Y92.821, forest as the place of occurrence of the external cause
  • Y93.01, activity, walking, marching and hiking (camping doesn’t have its own code, but Geoff was also hiking during his trip)
  • Y99.8, other external cause status

So when you head out this summer remember your sunscreen, drink plenty of water, and watch out for small arthropods.

Editor’s Note: This article was originally published on the ICD-10 Trainer Blog.

News: IPPS contains language for new ICD-10 implementation date

CMS says new date for ICD-10-CM/PCS implementation set for 2015.

CMS says new date for ICD-10-CM/PCS implementation set for 2015.

The new ICD-10-CM/PCS implementation date looks like it could be October 1, 2015—that is, if CMS’ Inpatient Prospective Payment System (IPPS) Proposed Rule becomes the law of the land. In anything but an overt revelation, the Proposed Rule includes three mentions of October 1, 2015—on p. 684, p. 1065, and p. 1074. Each section merely mentions that the transition is “scheduled to take place,” and “officially [will] be implemented,” on the new date.

The original implementation date of October 1, 2014, was delayed by the surprise inclusion in legislation in HR4302 “Protecting Access to Medicare Act of 2014” which, although it aimed to address problems with the Sustainable Growth Rate (SGR) formula for physician Medicare reimbursement, included the delay and other “add-on” amendments.

Many in the healthcare industry—including AHIMA, ACDIS, AHA, and others—quickly voiced opposition to the delay. CMS itself indicated that the delay came as a surprise having adamantly endorsed its professed 2014 implementation.

Since the Congressional vote on March 31, the mantra from many in the industry has been to “stay the course” with ICD-10-CM/PCS training and implementation efforts. During AHIMA’s ICD-10-CM/PCS Summit at the end of April, Denise Buenning, MsM, acting deputy director for CMS’ Office of E-Health Standards and Services, told the group the agency was “close” to having a new official implementation date for the industry.

Regardless of whether the date in the Proposed Rule is simply a clerical error (on p. 121 it also lists October 1, 2014 as the implementation date), a suggestion of what the new hoped-for date may be, or an actual Proposed Rule, facilities should not be distracted by date debate, says ACDIS Director Brian Murphy. “Clarifying documentation in the medical record is what CDI is about. Continuing with documentation improvement efforts in ICD-9-CM will only help when the ICD-10-CM/PCS transition does finally come,” he says.

Editor’s Note: Gloryanne Bryant, RHIA, CDIP, CCD, CCDS, a founding ACDIS Advisory Board member and the National Director of Coding Quality, Education, Systems and Support for the National Revenue Cycle of the Kaiser Foundation Health Plan, Inc. and Hospitals, joins CDI Education Director Cheryl Ericson, MS, RN, CCDS, CDIP, Associate Director, Education for ACDIS, and Trey La Charité, MD, University of Tennessee Hospitalists at the University of Tennessee Medical Center at Knoxville (UTMCK), for a special panel discussion regarding the ICD-10 delay during the ACDIS Conference on Wednesday, May 7, at 4:30 p.m., in Las Vegas.

Reports from the AHIMA ICD-10 Summit

Which countdown to ICD-10 calendar will you use?

Which countdown to ICD-10 calendar will you use?

The AHIMA ICD-10-CM/PCS and Computer Assisted Coding Summit took place this week April 22-23 in Washington D.C., and I was fortunate enough to attend. As you may expect there was a lot of hubbub about the ICD-10-CM/PCS delay. Here is a brief summary of what I learned and you can always read more on the ICD-10 Trainer Blog.

Steven Stack, MD, immediate past chair of the AMA Board of Trustees, gave the keynote address during which he admitted that, yes, the AMA still wants to kill ICD-10 implementation but, no, it was not the motivating factor behind the inclusion of the ICD-10 delay within the bill to patch the Sustainable Growth Rate (SGR). The AMA wants a permanent fix to SGR and actually lobbied Congress to defeat the bill it its entirety, he said. During his presentation, Stack described how physicians struggling to use complex electronic health record systems and referred to the oft repeated line that physicians just want to take care of the patient and don’t want to worry about the documentation piece.
Although CMS has not released a new ICD-10-CM/PCS implementation date, (according to Donna Pickett, MPH, RHIA, medical classification administrator for the CDC) Denise Buenning, MsM, acting deputy director for CMS’ Office of E-Health Standards and Services, told the group at the closing session that the agency is close to having a new official implementation date for the industry.
Meanwhile, AHIMA president Angela Kennedy, EdD, MBA, RHIA, reminded attendees that nothing has changed in terms of the underlying need for ICD-10 implementation–the new code set will provide better data, she says. However, those working in the field can (and need to) do a better job of telling the public why better data is so important. As Deborah Neville, RHIA, CCS-P, from Elsevier explained facilities which do not have a firm grasp of coding and documentation requirements in ICD-9 will need to get that documentation set before ICD-10.
Looking on the bright side, Buenning expects the delay will provide more time for end-to-end testing and give CMS a more robust group of providers to pull from for its testing process.
If anything, the latest delay “eliminates the excuses to not transition to ICD-10,” Buenning said.

 

Hoppy Holiday: Watch out for gopher holes

Here comes Peter Cottontail, hopping down the bunny trail—and right into a gopher hole. Stupid rodents.Poor Peter limped his way into the Fix ‘Em Up Clinic to see Dr. Hop A. Long for an initial visit. After a thorough exam and some x-rays, Dr. Long diagnosed Peter with a broken right foot. That’s a big foot on that bunny, Dr. Long. Can you be a little more specific?

Easter bunny

Be safe hunting Easter eggs and don’t hop on into the wrong hole.

Actually, we need Dr. Long to be a lot more specific. If we look up Fracture, foot in the ICD-10-CM Alphabetic Index, we find the following choices:

  • astragalus—see Fracture, tarsal, talus
  • calcaneus—see Fracture, tarsal, calcaneus
  • cuboid—see Fracture, tarsal, cuboid
  • cuneiform—see Fracture, tarsal, cuneiform
  • metatarsal—see Fracture, metatarsal
  • navicular—see Fracture, tarsal, navicular
  • talus—see Fracture, tarsal, talus
  • tarsal—see Fracture, tarsal
  • toe—see Fracture, toe

So before we can even get to any code, we need to know which bone Peter broke. After consulting the x-rays, Dr. Long documents fractures of the cuboid, lateral cuneiform, and medial cuneiform.

For these injuries, we need three different ICD-10-CM codes—one for each bone. We also need to know whether the fractures are displaced or non-displaced and open or closed.

We do have some defaults, though, for coding fractures. If the physician does not document displaced or nondisplaced, code it as displaced. If the physician does not document whether the fracture is open or closed, code it as closed. (Of course you could always query for the additional specificity, too.)

For now, we can use those defaults to code Peter’s fractures as:

  • S92.211A, displaced fracture of cuboid bone of right foot, initial encounter
  • S92.221A, displaced fracture of lateral cuneiform of right foot, initial encounter
  • S92.231A, displaced fracture of intermediate cuneiform of right foot, initial encounter

Dr. Long also notices that Peter suffered a dislocated right ankle. That was some hole he hopped into. For an ankle dislocation, we need to know whether the injury is a dislocation or subluxation, laterality, and encounter.

We know all of that information—dislocation, right ankle, initial encounter. That gives us ICD-10-CM code S93.04XA, dislocation of right ankle joint.

Notice that we do need a placeholder X so our seventh character ends up in the seventh spot.

Dr. Long also documented a sprained right ankle. In order to code the sprain, we need to know which specific ligament is involved.

In case you are not up on your ankle anatomy, we could be coding for the:

  • Calcaneofibular ligament
  • Deltoid ligament
  • Tibiofibular ligament
  • Internal collateral ligament
  • Talofibular ligament

The internal collateral and talofibular ligaments are grouped into one code for other ligaments. Dr. Long thankfully documented that Peter sprained the anterior tibiofibular and calcaneofibular ligaments. That leads us to codes:

  • S93.431A, sprain of tibiofibular ligament of right ankle, initial encounter
  • S93.411A, sprain of calcaneofibular ligament of right ankle, initial encounter

Dr. Long puts a cast on Peter’s foot, gives him some crutches, and tells him to avoid hopping on that foot for six to eight weeks.

Now it’s time for us to hop on out of the clinic to enjoy a long weekend!

Editor’s Note: This article was originally published on the ICD-10 Trainer Blog.

Take it from the King: ACDIS conference has much to offer

ACDIS Director Brian Murphy poses with Elvis during last year's conference in Nashville. Word on the street is he might don an Elvis costume at some point during this year's show in Vegas!

ACDIS Director Brian Murphy poses with Elvis during last year’s conference in Nashville. Word on the street is he might don an Elvis costume at some point during this year’s show in Vegas!

“Man, I really like Vegas.” ~Elvis Presley

After the big news about the ICD-10 delay, you may be wondering what it means for the 7th Annual ACDIS Conference. Perhaps you may even be debating whether it’s still worth coming to Vegas at all.

If so, I urge you to think again. As Elvis (patron saint of Las Vegas) might have said, “We can’t build our dreams on suspicious minds.”

CDI remains critically important, regardless of the code set being used. You’re still faced with difficult clinical discussions with your physicians, interrogating the record for a host of reasons—those related to code set and those regarding how the codes relate to so many quality improvement, healthcare research, and reimbursement reform efforts.

ACDIS continues to be the only association for CDI specialists—focused on the variety of ways documentation improvement efforts help address these concerns.

This year’s conference includes sessions such as “SOI/ROM Queries: Why is that “Healthy” Patient Dead in the Bed?” Where you’ll learn how to improve your quality metrics, along with “Integrating Quality into Your CDI Program: The Case for All Payer Review.”

To get physicians on board, we’re offering sessions like “Physician Partners for CDI: Strategies for Goal Alignment,” a case study of Novant Health’s successful techniques for engaging physicians. In “Changing Medical Culture and Influencing New Ideas: CDI for Medical Students” you can join the Mayo Clinic CDI team for a presentation on how it partnered with its medical school to create a CDI training program.

On top of sessions like these, it would be a mistake to forgo the ICD-10 sessions we’re offering. You still have to be ready for the (projected) Oct. 1, 2015 compliance date, and attendees will get that information straight from one of the nation’s foremost authorities on ICD-10, Nelly Leon-Chisen of Coding Clinic.

As of today we have our largest ever turnout with more than 950 attendees already registered. What better way is there to learn than from your peers? As always, ACDIS remains the go-to event for dedicated CDI networking.

Despite our large numbers, Vegas is a very big place and Bally’s Hotel still has vacancy. We’d love to have you out to enjoy our first-ever pre-conference cocktail reception on Tuesday evening, May 6, where we’ll be presenting the 2014 CDI Professional of the Year awards and starting out the conference in style.

To close with one final quote from the King: “The joint is always crowded, but you still can find some room.”