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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.

ICD-10 Tip of the Week: Brush up on combination codes

Learn how new technologies will affect CDI efforts in this week's free webinar.

Start figuring out now when to use multiple codes, and when to use a combination code.

One of the biggest differences CDI specialists and coders face with the switch from ICD-9-CM to ICD-10-CM is the addition of combination codes. A combination code is a single code used to classify two diagnoses, a diagnosis with an associated secondary process (manifestation), or a diagnosis with an associated complication.

In the ICD-10-CM Official Guidelines for Coding and Reporting combination codes are identified by referring to subterm entries in the alphabetic index, and by reading the inclusion and exclusion notes in the tabular list. CDI specialists identify any linkage of diagnoses, or the absence thereof in documentation, when drafting a query for the physician.

Combination codes should only be used when the code fully identifies the diagnostic conditions involved, or when the alphabetic index requires the coder to do so. Multiple codes should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis.

Here’s an example: When it comes to coronary artery disease (CAD) or arteriosclerosis, coders often have to use two codes to fully describe a patient with CAD and angina in ICD-9-CM. If the patient does have angina in the setting of CAD, coders will choose a combination code in ICD-10-CM that identifies CAD and the presence of angina pectoris as well as its type, if specified.

CDI specialists should query the physician when two conditions associated with a combination code are documented to establish if there is a relationship between the two conditions, allowing the use of the combination code when appropriate. Yes/no queries can be used when attempting to establish a cause-and-effect relationship, according to the 2013 ACDIS/AHIMA Query Practice Brief. When a combination code lacks the necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code.

Use of combination codes can affect DRG assignment. For example, if the provider lists only diagnoses such as foot ulcer and diabetes, the coder would assign one code for the diabetes, and another for the foot ulcer, which would map to DRG 594: Skin ulcers without a CC or MCC. However, if the provider documented “diabetic foot ulcer,” this would allow the use of a diabetes combination code that captures both the type of diabetes and its manifestation. The tabular list requires an additional code to capture the site of the ulcer. The codes associated with the site of the ulcer are classified as CCs. Therefore, these codes would map to a different DRG assignment, 638; Diabetes with a CC with a relative weight of .08218.

Editor’s Note: The previous information was compiled from a variety of ACDIS resources. For additional information, check out:

If at first you don’t succeed: New bill aims for ICD-10 delay again

If nothing else, Rep. Ted Poe, R-Texas, is consistent. He again introduced legislation to kill ICD-10. (The bill is H.R.2126 if you are interested.)

Poe has tried this trick before. He introduced an almost identical bill April 24, 2013. That bill, H.R. 1701, was never even discussed in committee.

Members of the House Energy and Commerce Committee’s Subcommittee on Health seemed to agree that we need ICD-10 during the February 11 ICD-10 implementation hearing. So it seems unlikely that this bill would make it very far.

Six fellow Republicans signed on as cosponsors of the bill, but the Democrats seem to be staying away. More indication that this bill is a non-starter.

With less than five months to implementation, we don’t need this kind of distraction. What we need are assurances that another delay won’t happen. Sadly, we probably won’t get the date written in stone and most of us will probably remain skeptical. It’s okay to be a skeptic. Just don’t slow down your ICD-10 implementation work because you think Poe might get a bill heard.

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

ICD-10 Tip of the Week: Follow a timeline for preparation

Don't delay! Start preparing for ICD-10 now.

Don’t delay! Start preparing for ICD-10 now.

We get it: It’s been a challenge to maintain a proper ICD-10 education and preparation schedule with the delays, the doubts, and the everyday challenges that already exist without the stress of a new code set. But, as CMS insists that ICD-10 is a go, it’s time for facilities to nail down a plan of action. There are a lot of changes, and the best way to ensure a smooth transition is organization.

This is why ACDIS, with the help of director, Brian Murphy, and the ACDIS advisory board, created a sample ICD-10 training and implementation timeline for CDI specialists. It includes recommended courses of action, the most important element being fostering facility-wide communication. Facilities throughout the country are also used as case studies, so you can see what’s worked—and what hasn’t worked—for existing CDI departments that are already preparing for the October 1, 2015 implementation date.

The biggest challenge many facilities face is, “where to begin?” With open communication at the center of any preparation plan, the first step is ensuring organizational understanding of the impact of ICD-10, says Michelle McCormack, RN, BSN, CCDS, CRCR, ACDIS advisory board member and director of CDI for Standard Hospital and Clinics in Palo Alto, California. Include hospital and departmental leadership in meetings and related educational sessions. Or set up ICD-10-focused committees in charge of coordinating education, evaluating preparedness, and the like. All in all, it should be a hospital-wide effort.

Identifying weaknesses in documentation efforts is also something to be looked at early on, says Laurie Prescott, RN, MSN, CCDS, CDIP, CDI education specialist with ACDIS/HCPro in Danvers, Massachusetts. For example, many facilities struggle with procedure codes (ICD-10-PCS), in part due to the increased specificity. However, if there is a larger focus on PCS codes now, CDI specialists can provide targeted education regarding top procedures and current documentation practices.

The ACDIS timeline focuses on dual coding practices, which Prescott says is critical to a successful transition. There should be a feedback loop between coders and CDI specialists to communicate what information is missing and what is required. CDI specialists should also identify specific documentation needs for specific physicians.

Query policies should also be reviewed, Prescott adds. They should reflect the fact that more queries will be asked in ICD-10, and should include how queries will be prioritized, how long queries are allowed to be unanswered, and how to differentiate between queries for reimbursement, and those that provide more specificity but do not affect reimbursement.

When designing a timeline for your own facility (we recommend using the ACDIS timeline as a guide), start by listing the remaining months before implementation, and creating goals and to-do lists for each month. Once you have a plan in place, circulate it throughout your facility, and make sure hospital leadership is aware of your plans, as well as any scheduled training sessions or meetings.

Here’s an example of what May ICD-10 preparations might look like. Keep in mind, this timeline begins at the end of 2014. If your facility has not yet started its ICD-10 prep, take a look at the timeline as a whole, and figure out a reasonable schedule that works for your team.

May 2015

  1. Full dual coding scope, use external vendors to supplement staffing as needed. Solidify and execute staffing plan (internal and external) to meet ICD-10 productivity and quality standards, and maintain accounts receivable.
  2. Continue analysis of dual coding outcomes. Task CDI with tailoring and presenting service-specific education based on the findings.
  3. Develop “go-to” team with coding counterparts in preparation for go-live.
  4. Provide fact sharing and status update to ICD-10 transition teams; adapt as needed.

Editor’s Note: The previous information was compiled from a variety of ACDIS resources. For additional information, check out:

ICD-10 Tip of the Week: Know the basics

Got a question? Ask us!

The problem many facilities face with ICD-10 prep is that they don’t know where to begin.

It might seem pretty obvious that, with a new code set and code structure, your team should probably understand what’s going to change. The problem many facilities face is that they don’t know where to begin.

Practicing with the new code set could make all the difference to CDI and coding success post-implementation. As CDI specialists, knowing some of the code set basics can help you understand what is needed in the documentation, and can help prevent claim errors. So let’s go back and review some of the ICD-10-CM basics.

ICD-10-CM (diagnosis codes) far exceeds ICD-9-CM in the number of concepts and codes available. Here are some key differences:

  • ICD-10 codes will be 3-7 characters in length, as opposed to 3-5 characters for ICD-9
  • 69,000 codes available in ICD-10, as opposed to 13,500 codes in ICD-9
  • ICD-10 is flexible for adding new codes, very specific, and has laterality, while ICD-9 has limited space for new codes, lacks detail, and lack laterality

The additional characters allow for more specificity particularly anatomically and in regards to laterality. If the diagnosis does not have such a code, both right and left codes for the condition should be reported.

As far as the code structure goes, under ICD-10, codes will no longer begin with a letter “E” or “V,” as they did in ICD-9. The first character is always a letter, the second and third are numbers, and the fourth through seventh characters can be either or. CDI specialists and coders will also need to avoid confusing the letter “O” with the number zero (0), and the letter “I” with the number one.

Some other things that CDI specialists will need to be aware of include the location of the characters—this now matters, specifically for the 7th character which can indicate additional information such as the episode of care (Learn more about this in the forthcoming May edition of the CDI Journal, as the AHA Coding Clinic for ICD-10-CM/PCS covered this in some depth during a recent volume.

ICD-10 also uses the letter “X”, for codes that require a 7th character, but which have less than seven characters as a placeholder. Read more about placeholder use in the CDI Specialist’s Guide to ICD-10.

This might seem a bit rudimentary, especially for those facilities that have been incorporating ICD-10 education into their ongoing training already, but having a strong foundation of ICD-10 knowledge is critical. Knowing the basics will allow CDI specialists to assist physicians in ensuring their documentation is specific enough for proper coding, and to facilitate coders in retrospective reviews.

Editor’s Note: The previous information was compiled from a variety of ACDIS resources. For additional information, check out:

I said what I meant and I meant what I said

Rumors upon rumors keep ICD-10 prep from progressing. Don't let the hearsay stop your efforts

Rumors upon rumors keep ICD-10 prep from progressing. Don’t let the hearsay stop your efforts

We want physicians to be very clear in their documentation about what’s wrong with the patient and what the physician did to make that patient better. CDI Specialists spend their professional lives working to get more precise, detailed, accurate, no-room-for-interpretation documentation.

Why all the fuss about specificity? Different people interpret things different ways. My colleagues sometimes hate me for playing devil’s advocate and saying, someone could take that to mean Y instead of X.

Relevant case in point: Earlier this week, AHIMA emailed its members imploring them to call members of Congress to oppose an ICD-10 delay. AHIMA’s Margarita Valdez, senior director of Congressional relations, heard that Chairman of the House Rules Committee Pete Sessions, R-Texas, was drafting (or looking to draft) language for another ICD-10 delay.

My colleague Steve Andrews reached out to Sessions’ office asking for verification. In very short order, a member of Sessions’ staff replied that the Congressman is meeting with physicians about their concerns regarding ICD-10, but no legislation has been drafted.

I also heard from a blog reader who told me she had spoken to a staff member for Rep. Rob Woodall, R-Ga. That staff member had spoken to Sessions’ staff, who told him that Sessions has no plans at present to introduce legislation for another delay of ICD-10. (That’s a massive amount of hearsay, because it’s at best fourth-hand information, but still, we’ll take what we can get for now.)

At first glance, that looks like a win. No legislation, no delay, right? Not exactly. Here’s where playing devil’s advocate comes in.

Sessions had not drafted legislation and has no plans to introduce legislation. However, no one claimed Sessions isn’t looking to add language to an existing (or future) bill to delay ICD-10. It’s nitpicking, but we are talking about politicians.

The whole discussion may have started with a letter that the AMA and 99 specialty societies sent to Andrew Slavitt, acting administrator of CMS, detailing a “number of concerns that do not appear to be addressed” by CMS’ current transition plan.

Fair enough, we’re all worried about certain parts of the transition.

The medical groups want CMS to release more detailed end-to-end testing results broken out by:

  • Type and size of providers who tested
  • Number of claims tested by each submitter, percentage of claims successfully processed
  • Specific details about problems encountered

That seems reasonable to me. The more we know about what worked and what didn’t, the better we can prepare.

Things get a little murkier near the end of the letter when it talks about code specificity. The AMA has been beating this drum for a while now because the increased specificity requires more detailed documentation. The detail, though, is one of the main strengths of ICD-10. We can get a better picture of the patient’s health, and with ICD-10-PCS, we’ll actually know what specific procedure the physician performed.

According to the letter:

CMS officials have stated that, absent indications of potential fraud or intent to purposefully bill incorrectly, CMS will not instruct its contractors to audit claims to verify that the most appropriate ICD-10 code was used. There is also general concern about how physicians will be audited as they learn to use the new code set. We urge CMS to: 1) confirm and broadly educate stakeholders and contractors that claims will not be audited simply for code specificity; and 2) to instruct contractors that they are prohibited from engaging in audits that are only predicated on code specificity.

I was kind of appalled by the apparent unconcern for specificity. Then I reread it and found it’s not so much appalling as it is vague. Then I went back to the source of the “no audit” statement, the Government Accountability Report on CMS’ preparation for ICD-10 implementation. According to that report:

CMS officials stated that the submission of valid ICD-10 codes is a requirement for payment; however, when the presence of a specific diagnosis code is not required for payment then the claim would be paid even if a more appropriate ICD-10 code should have been used on the claim.

In a way that makes sense. You could go to the physician’s office for a cold or a bad cut or just for your annual physical. In order to use the CPT® code for an office visit, you don’t need a particular ICD-10-CM code. You just need the code that will support medical necessity for that service. So if a patient is seen for S50.311A (abrasion of right elbow, initial encounter), you probably won’t get away with reporting CPT code 99215 (level 5 established patient visit).

The GAO report further stated:

Additionally, CMS officials indicated that, absent indications of potential fraud or intent to purposefully bill incorrectly, CMS will not instruct its contractors to audit claims specifically to verify that the most appropriate ICD-10 code was used. However, audits will continue to occur and could identify ICD-10 codes included erroneously on claims which could lead to claims denials, according to CMS officials.