The American Medical Association (AMA) has pushed to defeat the ICD-10 code set transition since 2012. During its recent House of Delegates meeting, this November, the AMA reinforced its position that ICD-10 implementation should be delayed by two years. It initially put forth that resolution in June.
The AMA’s stance was a contributing factor in the implementation delay implemented in 2012–the one that pushed the “go-live” date from October 1, 2013, to October 1, 2014. That may not have been a great thing for physicians, according to Paul Weygandt, MD, JD, MPH, MBA, CCS, vice president of physician services for J.A. Thomas and Associates in Atlanta.
“The worst thing for physicians was that the AMA delayed ICD-10 by one year,” he told AHIMA Convention attendees in October. Why? Because it provided physicians a convenient illusion that the AMA could stop ICD-10 implementation again. And why should physicians bother understanding the documentation needs of ICD-10 if they think the change will never actually come to pass?
The question for CDI specialists is how to get physicians on board for ICD-10 when the AMA is not? Remind them that ICD-10 doesn’t change the way they practice medicine. They will still treat patients the same way they do now. We’re just asking them to document a little more specifically.
Physicians are likely documenting much of the necessary information already, such as laterality, because it’s good patient care. The physician wants to know where an injury occurred so when the patient comes back for a follow up, he or she is checking the correct area.
ICD-10 is also written in more clinical terms and less coder speak, which means docs will need to learn less than coders. For example, many pulmonologists already describe asthma as:
- Mild intermittent
- Mild persistent
- Moderate persistent
- Severe persistent
ICD-10-CM now uses those terms.
For myocardial infarctions, physicians have been documenting STEMI and non-STEMI for years, Weygandt says. In ICD-10-CM, coders will be able to report it that way.
Don’t tell physicians what they need to document. Tell them what they aren’t documenting. Give them a (figurative) pat on the head for the things they are doing correctly. And ask them if they would accept their documentation if it came from a resident.
“Good documentation for ICD-10 is what we should be teaching residents because it’s good clinical care,” Weygandt says.
ICD-10 is coming, whether the AMA wants it to or not. Work with your physicians now so you are all ready for the change.
Editor’s Note: This article was originally published on The ICD-10 Trainer Blog.
A feral flock of wild turkeys has invaded New York City. Seriously. And with them, they bring all sorts of code-ready diseases and mishaps.
First, turkeys can transmit fun infections such as chlamydiosis, salmonellosis, arizonosis, and colibacillosis.
When we look up chlamydiosis in the ICD-10-CM Alphabetic Index, we are directed to see chlamydia. That doesn’t sound good.
On a clinical note, however, chlamydiosis in birds is different from the human venereal disease chlamydia. Patients who contract chlamydiosis from birds often experience fever, headache, and loss of appetite. They may also experience painful or difficult breathing.
Chlamydiosis in birds, such as our Big Apple party crashers, is caused by a bacterial organism, Chlamydophila psittaci. And it just so happens we have a specific ICD-10-CM code for it: A70 (Chlamydia psittaci infections).
We all know not to eat raw eggs and I certainly don’t want to fight a wild turkey for one (the grocery store ones come with much less hazard to my hands). Odds are, we won’t contract salmonellosis from the NYC flock.
Colibacillosis is caused by our old friend Escherichia coli. E. coli can cause all sorts of unpleasant conditions, including:
- A04.0, enteropathogenic Escherichia coli infection
- A04.1, enterotoxigenic Escherichia coli infection
- A04.2, enteroinvasive Escherichia coli infection
- A04.3, enterohemorrhagic Escherichia coli infection
- G00.8, meningitis due to Escherichia coli
- J15.5, pneumonia due to Escherichia coli
- P36.4, sepsis of newborn due to Escherichia coli
Those all sound like awesome reasons to avoid the meandering turkeys and their droppings. So if you’re flocking to New York for the holidays, watch out for those wild birds.
Editor’s Note: This article was originally posted on the ICD-10 Trainer Blog.
As you know, ACDIS regularly asks for assistance with industry and product related insight. Many of these surveys are then shared with the membership in special benchmarking reports or used to design more useful products and services for you. We currently have a few surveys outstanding and hope you will take a moment or two to participate. Surveys include:
- A 10-question survey regarding ICD-10 query preparation. Your responses will help founding ACDIS Advisory Board member Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, tailor her 2014 ACDIS conference presentation on the subject.
- A 10-question survey regarding online training for CDI professionals. Your responses will help ACDIS provide more useful tools and programs for your CDI department.
- A 19-question survey regarding ICD-10 implementation and preparedness for HIM directors/managers. Your responses will help our sister publication, Medical Records Briefing, compile a benchmarking report in its upcoming edition.
Guidelines for assigning principal diagnosis (PDX) remain exactly the same after the change to ICD-10-CM/PCS. UHDDS guidelines define the PDX “as the condition determined by the physician, after study, to be chiefly responsible for the patient’s admission to the hospital for care.”
Even though the definition remains the same, the healthcare environment has changed dramatically since this definition was first implemented, and accurately assigning the PDX can be complex. MS-DRGs based on a symptom PDX typically have a low relative weight (RW) and therefore lower reimbursement. These types of MS-DRGs are also highly scrutinized by external auditors because diagnostic workups, often associated with a symptom PDX, typically do not meed requirements for inpatient hospital care.
Coders and CDI specialists need to consider medical necessity of setting when assigning the PDX. Typically, medical necessity requires documentation of an acute disease process or an exacerbation of a chronic condition. Capturing PDX documentation is also needed to ensure that what the hospital reports matches what the provider bill.s
Signs or symptoms of an underlying condition should be coded only if no definitive diagnosis is determined, according to the draft ICD-10-CM Official Guidelines for Coding and Reporting. Sign and symptom codes are identified in Chapter 18 of the coding manual, codes R00 through R99.
However, inpatient hospital coding guidelines allow the reporting of uncertain diagnoses if they remain uncertain at the time of discharge. As such, the CDI specialist should review the health record for clinical indicators and query the provider of the “probable,” “suspected,” or “likely” cause of the symptom to avoid defaulting to a symptom PDX. Keep the following two important definitions in mind:
- A sign is objective evidence of a disease that the examining physician can observe
- A symptom is a subjective observation that the patient reports but that the physician does not confirm objectively
- Use available resources. When revising query templates, refer to the ICD-10-CM/PCS manuals as well as the joint ACDIS/AHIMA 2013 query
practice brief, Guidelines for Achieving a Compliance Query Practice. As Coding Clinic begins to publish ICD-10-related questions and answers, be sure to review this information as well. ACDIS Advisory Board member Cheryl Ericson, MS, RN, CCDS, CDI-P, CDI Education Director, for HCPro, Inc., in Danvers, Mass., reviews each AHA Coding Clinic for applicable ICD-10 and CDI insight in each edition of the quarterly CDI Journal.
- Team up. It may be challenging for coders to translate some of the clinical details of ICD-10-CM/PCS into query templates without leading physicians, says Cheryl Robbins, RHIT, CCS, director of remote coding operations for Precyse in Dallas. “The query will need to be written very clearly and with more clinical detail. If it’s not done well, it could potentially be leading,” she says. Coders should work with CDI specialists and/or a physician champion when revising templates, she adds.
- Take it slowly. “Consider looking at a diagnosis or procedure a week,” says Sandra L. Macica, M.S., RHIA, CCS, coding content manager at Elsevier in Atlanta. “As coders are currently assigning codes, they can be on the lookout for problem areas. The challenge is that if that are not very familiar with ICD-10-CM/PCS, they don’t know what those problem areas are yet.”
- Plan ahead. Finding the time and resources to devote to this effort may be challenging as well, says Gloryanne Bryant, RHIA, CCS, CDIP, CCDS, HIM professional in Fremont, Calif.. “Lack of resources is usually the number one issue. Set aside time with your own staff or hire external resources to assist with this effort,” she says. “You don’t want to have massive volumes of queries being generated and sent to physicians on October 1, 2014, and through the first two or three months following go live. You want to be proactive rather than reactive, so use the coming months to get ready.”
The Association for Clinical Documentation Improvement Specialist (ACDIS) 2013 ICD-10 Preparation Survey provides a compelling snapshot of where CDI departments stand regarding the impending Oct. 1, 2014 implementation date of ICD-10. More than 180 CDI specialists answered questions on their overall readiness for ICD-10, their biggest areas of concern, their anticipated additional volume of physician queries, and their staff and physician training timetables.
The data in the ACDIS ICD-10 Preparation Survey contains important and surprising results. For example, 61% of respondents indicated they have an ICD-10 implementation committee in place, yet only 39% indicated that their CDI manager/director is a “key leader” in implementation efforts, and only 55% indicated that their facility HIM manager plays such a role.
Poor Mr. Frank N. Stein, he’s literally falling to pieces. Not to worry, though, Dr. Shelly at the Stich ‘Em Up Hospital will have him back together in no time.
Frank’s most obvious problem is that his right hand has come off. Apparently whoever sewed it on the first time didn’t do a very good job. Dr. Shelly documents that she reattached Frank’s own right hand. Her operative note is full of details about the procedure, but for coding purposes, we need to know the objective of the procedure.
ICD-10-PCS root operation Reattachment (M) is defined as “putting back in or on all or a portion of a separated body part to its normal location or other suitable location.” Examples include reattachment of hand and reattachment of avulsed kidney. Dr. Shelly is reattaching a hand, so we know our root operation.
Before we can find the correct table, we need to determine the body system. ICD-10-PCS does not include a body system value for the arm or hand separately. They are rolled into the anatomical region Upper Extremity (X).
Now we can get to the correct ICD-10-PCS table: 0XM. We have lots of choices for specific body parts being reattached, so we need to carefully read the operative report to make sure we choose the correct one.
Dr. Shelly documented reattachment of the right hand, which gives us J as a fourth character. The rest of the characters are easy. We only have one possible approach (open) and no device or qualifiers. That gives us a final code of 0XMJ0ZZ (reattachment of right hand, open approach).
Editor’s Note: Read the complete details of how Frank’s other body part replacements were coded on the ICD-10 Trainer Blog.
Happy Halloween! Death smiles at us all. All a man can do is smile back. (Kudos if you know that’s appropriated from the movie Gladiator.)
History is full of weird circumstances and odd injuries that lead to death. Let’s look at some of history’s more (in)famous deaths and see how we would code the injuries that caused death in ICD-10-CM.
Going way back to the 600s B.C., Athenian lawmaker Draco was smothered to death when happy citizens of Aegina showered him with gifts of cloaks. His cause of death was likely asphyxiation. You’ll find the codes for asphyxiation in the T71- series, which covers both mechanical suffocation and traumatic suffocation. Note that all of the codes under T71 require a seventh character to denote the encounter.
T71 also has an Excludes1 note, which means not coded here. You should never report the excluded code with the code above the Excludes1 note. Be sure to check the Excludes1 note before selecting a code from T71.
In Draco’s case, we would look for a code in the T71.1- (asphyxiation due to mechanical threat to breathing) series since the weight of the cloaks smothered him. T71.1 includes codes for suffocation by:
- Smothering under pillow
- Plastic bag
- Bed linens
- Another person’s body
- In furniture
- By hanging
- Other causes
For Draco, it’s other causes since gifts of cloaks aren’t covered. We also need to know if the asphyxiation was accidental, intentional self-harm, assault, or undetermined. I’m going with accidental, because I don’t think the citizens were trying to kill him, so our code is:
- T71.191A, asphyxiation due to mechanical threat to breathing due to other causes, accidental, initial encounter
Editor’s Note: Read more about coding for strange deaths through history on the ICD-10 Trainer Blog.
Q: I have heard many people talk about preparing for ICD-10 implementation by looking at their facility’s top 25 principal and secondary diagnoses. Right now we’re looking into creating tools and cheat sheets for providers and maybe looking into how they map in terms of DRGs. How are other people examining documentation for their top diagnoses in preparation? I want to make sure we’re not missing anything now that could help ease the transition down the road.
A: We’re taking a look at these diagnoses and seeing how they’re coded in ICD-10-CM. We need to see what the documentation looks like currently right now. We know we will have a code for the level of specificity of congestive heart failure (CHF) and one for highest level for dementia. If your hospital has a lot of cerebrovascular (CVA) patients or myocardial infarction patients, your team has to be really fluent in understanding the extent of that disease, anatomy, and associated diagnoses.
There are certain diagnoses that your CDI team will need to concentrate on depending on your location, your population of patients. For example, one of our hospitals doesn’t have moms and babies and pediatric. So those coders and CDI specialist shouldn’t waste their time learning those codes. That’s really why everyone says look at your top diagnoses first and concentrate on documentation improvement efforts there.
Let’s go back to that CVA patient’s documentation. CDI specialists would look to see if the physician specified the cause as whether it was a thrombus, an embolism, or due to stenosis. They would look to see if a CAT scan or MRI finding specified which cerebral artery. If that documentation isn’t there, the CDI team may need to conduct some outreach to the radiologists to ensure they understand the importance of documenting to such specificity.
With cardiac catheterization procedures, we look at the current documentation and then look to what will be needed to code for these procedures in ICD-10. We found that sometimes the cardiac cath reports weren’t available at the time the CDI staff members performed their reviews so if they had questions as to where the MI took place, what coronary artery, they would have to query rather than just code the specificity and move on. So there was another opportunity to streamline the process.
The real reason for this behind the scenes work is to know your facility, its top diagnoses, and the foibles, or bad habits if you will, of the documentation. It is really important to focus your training on anything related to ICD-10 for those diagnoses because there are more than 68,000 codes for ICD-10-CM. Focus and education will definitely be important.
Editor’s Note: This question was answered by Adelaide M. La Rosa, RN, BSN, CCDS, system director for HIM, CDI, and CDM for Catholic Health Services of Long Island, during the July audio conference “Auditing Documentation for ICD-10: Steps Prepare Physicians and Staff.”
OptumInsight and ACDIS host a free webinar Wednesday, October 16, 1-2 p.m., (ET), featuring Shely O’Laughlin, Vice President, National Solution Leader for ICD-10 and Clinical Documentation Improvement and Cecilia Guardiola JD, RN, Associate Director, CDI Consulting. During the webinar the speakers will discuss the impact that CDI technology has on the role of the CDI specialist in the hospital environment, with an emphasis on case-finding, coaching and education, physician interventions, data analytics, and performance metrics. Additional agenda items include:
- Description of technology solutions for CDI
- Influence of technology on traditional CDI processes
- CDI specialist as coach: A role in evolution
- CDI metrics: Quantifying improvement in CDI process and documentation practices
- Practical implications for organizations considering investment in CDI technology
- Brief CDI Module demo