A couple of weeks ago, CMS and the American Medical Association (AMA) released a series of questions and answers regarding the July 6, 2015 joint announcement on ICD-10-CM/PCS implementation flexibilities. CMS answered 13 questions that a lot of CDI specialists and coders had been asking.
For the first year of ICD-10 use, CMS will not deny or audit physician claims based solely on the specificity of diagnosis codes, as long as the codes on such claims are from the correct family of codes. What is family of codes, you ask? According to CMS, a “family of codes” means any code from the same ICD-10 three-character category.
Here’s an example: Take category H25 (age-related cataract): this category, according to CMS, is a family. The family contains a number of specific codes that capture information on the type of cataracts, as well as information on the eye involved.
If a coder were to report H25.9 (Unspecified age-related cataract) when the patient really suffered H25.031 (Anterior subcapsular polar age-related cataract, right eye), CMS would not audit or deny this claim because a valid code was reported within the correct family.
What does this mean for CDI? Well, for one, CMS never said it wouldn’t deny claims for medical necessity. Additionally, this “deal” with the AMA only pertains to private physician practice, not hospital claims. This means CDI needs to work especially hard to make sure the documentation is as specific as possible, and clearly supports why the patient required the treatment they received. Some things you can do to ensure specific and accurate documentation include:
- Make sure the documentation includes all conditions that were clinically evaluated, that were therapeutically treated, that were studied, that extended the length of stay, or that increased nursing care or monitoring.
- Ask questions and query—if something isn’t clear to you, or if you think it can be documented to a higher specificity, do not hesitate to get a second opinion from a CDI or coding peer, and/or query the physician.
- Try to review every piece of the record, including, but not limited to, physician assessments and orders, ER nursing assessments, EMT records, history and physical, other physician orders, nursing admission assessments, consulting physician documentation, operation reports, diagnostic testing, ancillary staff reports, and progress notes.
- Confirm the principal and any secondary diagnoses, symptoms relating to these diagnoses, surgeries or treatments, and any change in care level.
- Take the time to verify the correct code assignment/sequencing and clinical indicators.
With specific, detailed documentation, coders will be able to report the most specific code. While this may seem basic, these tips could help your facility defend against denials, which are still very possible even if the code is within the correct family.
Editor’s Note: This post was compiled using a variety of ACDIS and HCPro resources. For more information, check out:
- The Clinical Documentation Improvement Specialist’s Guide to ICD-10
- The Clinical Documentation Improvement Specialist’s Complete Training Guide
- family,” originally published on the JustCoding ICD-10 Trainer blog
- “CMS clarifies ’family of codes,’” originally published in CDI Strategies
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]
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.
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]
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]
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]
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]
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]
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]
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]