All Entries in the "ICD-10" Category
The clock strikes twelve…
Now that you have the extra time...
…and the documentation coach will turn into a pumpkin if you’re not on time. As a CDI specialist, what has been your approach to ICD-10? Are you hoping it will go away? Are you waiting for 2014? Are you preparing now?
Although the official start date for ICD-10 CM and ICD-10 PCS is expected to move out to October 1, 2014, the start of fiscal year 2015, most hospitals should be, and are, preparing now.
AHIMA has produced an ICD-10 checklist, with a detailed timeline and suggestions as to who should be involved at what stage of the process. CDI specialists aren’t specifically mentioned until the very end, as one group of the many users who will need ICD-10 education, but their role will be critical.
According to the timeline, you should have already looked at your physicians’ documentation to see if it will stand up to ICD-10 coding requirements, and should be developing and implementing strategies to address any weaknesses in that documentation. You can’t do that if you don’t know ICD-10. If you are not expert in anatomy and physiology (A&P), get refresher training now. While you are likely not coding the chart, you are ensuring that the documentation is sufficiently detailed to meet ICD-10 (especially PCS) coding requirements, and that means having expert understanding of A&P.
If your hospital hasn’t decided what changes to it needs to make in its electronic documentation processes, get involved. (See related articles CDI input helps EHR implementation succeed and E-nvolved: The case for planning EHR implementation available in the CDI Journal archives.) You are the experts on documentation requirements. It will be much easier to work the documentation requirements into your electronic system before implementation than to try to retrofit a process into an existing system later.
You may think it is too early to learn about ICD-10, or that if you learn it now, you will forget it by the implementation date because you are still using ICD-9. Think back to when you first learned the MS-DRG system and ICD-9-CM codes. How long did that take? Aren’t you still learning? Don’t you have to give yourself time to become competent so that you could educate your doctors?
Consider this: Everything you teach physicians about documentation for ICD-10 will improve their documentation under ICD-9. Your coders are not going to complain that you enabled the physician to be too accurate. When you send a query, physicians generally doesn’t know or care about the coding rule or the classification system that triggered the query. They just know they have to answer to the level of detail you’re asking, so start sending questions that generate ICD-10 compliant answers. When you learn ICD-10, you can start guiding your physicians in the right direction, and the official transition in 2014 will be much less painful.
I liken the preparation for ICD-10 to that, a little more than a decade ago, for Y2K. Some people feared disasters including nuclear holocaust, and when nothing happened on 1/1/2000, they were almost disappointed. In reality, the preparation had been impressively thorough and left nothing to chance. Although the world might not end if we aren’t ready for ICD-10, getting all the details covered before the official implementation date can make the actual conversion more like distant thunder clap than an Armageddon explosion.
Training seminars, boot camps, and books abound. Take advantage of everything that’s offered, and ask for training if you haven’t received any. If you’re just starting to train, review CMS’s overview of ICD-10. The World Health Organization offers an ICD-10-CM online training tool that’s free and easy to use.
As a CDI consultant, I knew that at some point I would be required to provide ICD-10 documentation education to new CDI specialists. So I decided to pull out the ICD-10-CM official guidelines and actually compare them side by side with the ICD-9 CM guidelines. Not only did I learn about ICD-10-CM, but I refreshed my knowledge of ICD-9-CM.
Then I began putting together a presentation on ICD-10-PCS, and by working my way through the definitions and the rules, I educated myself. By the time I finished creating my PowerPoint, not only did I have a greater understanding of the complexity of the documentation requirements, but I was able to code a simple procedure. I was very proud of myself, too! Now, I didn’t become an ICD-10 expert that day, but by challenging myself to work with it, I found it much less frightening and much less mystifying.
Please don’t wait for education to come to you. Please don’t wait for someone else to tell you what your CDI process should be. Put the “special” in CDI specialist.
ACDIS advises members to ‘stay the course’ despite potential ICD-10 delay
ACDIS Advisory Board recommend facilities continue with ICD-10 preparations.
As I’m sure most of you are aware, The Department of Health and Human Services (HHS) has proposed a one-year delay of ICD-10-CM and ICD-10-PCS. You can read the complete release here http://www.gpo.gov/fdsys/pkg/FR-2012-04-17/pdf/2012-8718.pdf. The go-live date for which most of us were preparing—October 1, 2013—is now extended to October 1, 2014, barring any last-moment changes.
According to CMS, many provider groups had expressed serious concerns about their ability to meet the initial Oct. 1, 2013 compliance date. The proposed change in the compliance date for ICD-10 will give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition to these new code sets.
ACDIS would like to offer the following guidance for our members:
Stay the course with ICD-9 and ICD-10 documentation education. Hospitals continue to struggle with documentation and coding requirements under ICD-9; the best way to prepare for ICD-10 is to perform ICD-9 correctly and negotiate the differences between it and the new coding system. Regarding the best time to begin ICD-10 training: We’ve heard anecdotal evidence of hospitals moving out their ICD-10 training dates for their coding staff, which is understandable. However, an industry-wide recommended first step is ensuring that additional required physician documentation is in place for HIM/coding staff. Getting the additional specificity necessary under ICD-10 now is a good way to ensure a seamless transition to October 1, 2014. CDI specialists should use this time to improve their core competencies and knowledge base of ICD-10.
Provide commentary to CMS. Commentary on the proposed rule is open for 30 days starting on Tuesday, April 17. If you feel strongly that the one-year delay should not be implemented, or if you believe that the one-year delay will benefit your hospital, let CMS know by providing your comments at regulations.gov. CMS reviews all provider comments, and who better to hear from than CDI specialists, for whom the change to ICD-10 will be of the greatest impact. To comment on the proposed delay to ICD-10, click the following link to the Federal Register http://www.regulations.gov/#!documentDetail;D=CMS-2012-0043-0001 and click the “Submit a Comment” button. Comments are due on May 17, 2012 by 11:59 p.m. ET.
CMS offers ICD-10 Report on the State of the Union
A one-year delay in ICD-10-CM/PCS isn’t a slam dunk. “We’re recommending it, but it’s not [guaranteed],” said Denise Buenning, group director CMS Office of E-Health Standards and Services. Buenning delivered CMS ICD-10 Report on State of the Union at the AHIMA ICD-10 Summit on April 17 in Baltimore.
“The absolute worst thing you can do is stop working toward implementation,” Buenning added. “Follow our lead and stay the course.”
A series of events made CMS consider delaying ICD-10-CM/PCS implementation. One of the largest centered on problems providers and payers experienced when implementing HIPAA Version 5010. Many vendors did not have software updates in place in time to meet the January 1, 2012, implementation date. As a result, CMS has twice delayed the enforcement of HIPAA 5010.
Implementing HIPAA 5015 was supposed to be the easier transition, so CMS officials became concerned about potential problems with ICD-10-CM/PCS implementation.
HHS received many unsolicited comments regarding the delay with a number of different recommendations, Buenning said.
During the discussions about a possible delay, many wondered whether CMS might skip ICD-10-CM/PCS completely and move straight to ICD-11. That would result in huge economic losses and might not be feasible given the configuration of ICD-11, Buenning said.
CMS proposed the one-year delay after much consideration. A delay of longer than two years would be a waste of resources for those who have already spent a lot toward the implementation, Buenning said. A one-year delay balances the industry’s need to know when ICD-10-CM/PCS will be implemented, gives those who need it more time, but doesn’t penalize those who have already begun implementation.
“Use any additional time to your best advantage,” Buenning said, adding “I’m sure testing will be a big part of that conversation.”
CMS offered up a 30-day comment period “because we want to put out the final rule as soon as possible,” Buenning said. Normally, CMS provides a comment period of 60 days or more.
“We take feedback very seriously,” she said. “Positive and negative, we need all of it.”
Editor’s Note: This article first published on the ICD-10 Trainer Blog.
Book Excerpt: Coding guidelines for diabetes under ICD-10
The age of a patient is not the sole determining factor for the type of diabetes, although most Type 1 diabetics develop the condition before reaching puberty. For this reason, Type 1 diabetes mellitus is also referred to as juvenile diabetes. If the physician does not document the type of diabetes mellitus in the medical record, the default category of codes is E11 (type 2 diabetes mellitus).
If the physician does not document the type of diabetes but does indicate that the patient uses insulin, assign a code from category E11; also report code Z79.4, long term (current use insulin to indicate that the patient uses insulin. Do not report code Z79.4 if a Type 2 patient is given insulin temporarily to bring his or her blood sugar under control during an encounter. In situations where diabetes occurs during pregnancy and for cases of gestational diabetes, refer to the ICD-10 Official Guidelines for Coding and Reporting Section I.C.15, Diabetes mellitus in pregnancy and gestational (pregnancy-induced) diabetes.
The codes under category E08 (diabetes mellitus due to underlying condition) and E09 (drug or chemical induced diabetes mellitus) identify complications/manifestations associated with secondary diabetes mellitus. Secondary diabetes is always caused by another condition of event (e.g., cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drugs, poisoning.)
The sequencing of the secondary diabetes codes in relation to codes for the cause of the diabetes is based on the tabular instructions for categories E08 and E09. For category E08, first code the underlying condition. For category E09 first code the drug or chemical (T36-T65). For a patient with diabetes ketoacidosis without coma due to cirrhosis of pancreas, report K86.8 (cirrhosis of pancreas) and E08.10 (diabetes mellitus due to underlying condition with ketoacidosis without coma).
Editor’s Note: This post is an excerpt from The Clinical Documentation Improvement Specialist’s Guide to ICD-10.
Happy Friday the 13th
Don't be scare of ICD-10 codes for phobia.
Editor’s Note: Sure, most CDI professionals won’t be submitting queries to physicians about what scares their patients most. Nevertheless, this post from our friends over at the ICD-10 Trainer Blog raised the hairs on the back of our necks, so we thought you might enjoy a little Friday the 13th, ICD-10 coding fright, too.
Do you suffer from triskaidekaphobia, paraskevidekatriaphobia or friggatriskaidekaphobia? In other words are you afraid of the number 13 or Friday the 13th? More importantly, can you code for those fears?
Surprisingly, ICD-10-CM does not have a specific code for the fear of the number 13 (triskaidekaphobia) or fear of Friday the 13th (paraskevidekatriaphobia or friggatriskaidekaphobia). If your physician documents any of these phobias, you would report ICD-10-CM code F40.298 (other specified phobia). So even though the code doesn’t specify the phobia, the documentation does.
If the physician documents a generic phobia, but doesn’t say what the patient is specifically afraid of, you would have to default to the unspecified code F40.9 (phobic anxiety disorder, unspecified). Of course before you do that, you should query the physician. Maybe you’ll find out your patient is really afraid of injections and transfusions (F40.231), small spaces (F40.240), or spiders (F40.210).
So don’t break any mirrors or walk under any ladders today and absolutely, positively avoid black cats. If you believe in that bad luck stuff that is.
Will CDI staff take on larger role in querying physicians?
More CDI reviewers could be needed once ICD-10 implementation occurs. Will facilities be able to look past the simple CC/MCC, financial incentives for reviews?
By Shannon E. McCall
Physician queries are considered communications between coding (or coding-related) professionals and physicians to clarify or increase specificity in the documentation to ensure good clinical documentation as well as to support code assignment for the billing process. Queries are technically not limited just to inpatient coding and in some cases can also be done for outpatient or professional services. For the moment, I’d like to focus more on the previous than the latter.
Currently, queries can be performed concurrently or retrospectively to the inpatient admission/discharge. Concurrent queries, which are generally preferred, are posed while the patient is still “in-house” and the physician is readily available to provide clarification while the information is new in his or her mind. Verbal queries are generally included with the concurrent queries. Retrospective queries are performed after the patient is discharged, typically prior to the billing or post-billing. The query responsibility is generally shared by the coding staff as well as clinical documentation improvement (CDI) staff members.
Now on to why I am bringing this up.
Queries performed by CDI specialists traditionally have been mostly limited to diagnoses (and in many cases ones that affect the overall reimbursement), such as complications/comorbidities (CCs and MCCs). But some of these queries have no financial bearing on the case and are simply posed to obtain added specificity to reflect true severity of illness.
We know that with all the added details in the ICD-10-CM diagnosis codes, there very well may be many more opportunities for queries to be posed. But, my cause for concern is that the ICD-10-PCS codes will require a very thorough understanding of how physicians actually perform the procedures and the anatomy involved, which may go beyond the clinical knowledge of coder.
So, will CDI specialists become more involved in the query process as it relates to procedure coding? Procedures can certainly have an impact on the overall MS-DRG assigned, and incorrect assignment can lead to improper overpayments (or underpayments). If a question arises regarding a procedure, would it make more sense for the coder or the CDI specialist to pose it to the surgeon? CDIs are in many cases spread very thin (as coders are as well) and may even find it hard to even touch all the cases more than once or twice from a diagnosis standpoint.
So will it present problems in the future if we add to their workload additional clarifications needed for operative reports? All seven characters must be assigned to qualify as a complete ICD-10-PCS code, so there is no way out by using a vague code with digits/characters identifying “unspecified.”
Editor’s Note: Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, is director of coding and HIM at HCPro, Inc. Shannon serves as the director over the Certified Coder Boot Camp ® programs. Contact her at smcall@hcpro.com. This post was originally published on the ICD-10 Trainer Blog on February 22.
Refresh your awareness of combination codes
The JustCoding.com Virtual Summit for ICD-10 takes place next week.
Coders have been seeing more and more combined procedures in recent years in the CPT® Manual. For example, in 2011, AMA combined CT of the abdomen and CT of the pelvis into a single code. So the thought of combination codes for diagnoses shouldn’t be that scary.
Some of the combinations will make life easier. In ICD-10-CM, coders will only need one code to report type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema instead of three in ICD-9-CM. The single ICD-10-CM code includes the type of diabetes mellitus, the body system affected, and the specific complications affecting that body system.
Some of the combinations may come as a surprise, though. Codes in categories T36–T65 are combination codes that include substances related to adverse effects, poisonings, toxic effects and underdosing, and external causes (e.g., T39.011A, poisoning by aspirin, accidental [unintentional], initial encounter).
Combination external cause codes identify sequential events that result in an injury, such as a fall that results in striking an object (e.g., W01.111A, fall on same level from slipping, tripping, and stumbling with subsequent striking against power tool or machine, initial encounter).
Start now by reviewing some of the categories with combination codes: diabetes, coronary artery disease, pressure ulcers, and poisonings and adverse effects. Review the documentation you currently have and try coding the record in both ICD-9-CM and ICD-10-CM. That will help you determine what’s missing, then share that information with physicians.
You can even start querying them for the additional information now. Hopefully, they will be in the habit of documenting the additional information by the time October 1, 2013 rolls around.
Editor’s Note: This article first published on HCPro’s ICD-10 Trainer blog. The JustCoding.com Virtual Summit for ICD-10, two tracks of courses regarding the new coding systems, begins tomorrow February 29 through Friday, March 2. ACDIS will be “virtually” present and available to chat with participants throughout the Summit.
Maybe, possibly, definitely: Stay informed regarding ICD-10 delay
Which countdown to ICD-10 calendar will you use?
On February 14, CMS acting administrator Marilyn Tavenner told American Medical Association (AMA) meeting attendees that CMS would “reexamine” the timeline for ICD-10-CM/PCS implementation. Tavenner offered no details, just the vague possibility of potential reconsideration.
The healthcare industry jumped with the news.
American Health Information Management Association (AHIMA) immediately published a release urging healthcare professionals to move forward with their ICD-10 implementation and training plans, and downplayed the announcement, pointing its vague language.
“This is a promise from CMS to examine the timeline, not to change it,” said Dan Rode, MBA, CHPS, FHFMA, vice president for advocacy and policy at AHIMA, in the release. “But government officials are sending mixed signals that many in the healthcare community will interpret as a reason for delay.”
The AMA celebrated.
“The timing of the ICD-10 transition could not be worse for physicians as they are spending significant financial and administrative resources implementing electronic health records in their practices and trying to comply with multiple quality and health information technology programs that include penalties for noncompliance,” wrote Peter W. Carmel, MD, AMA president in a February 16 release. “Burdens on physician practices need to be reduced—not created—as the nation’s health care system undertakes significant payment and delivery reforms.”
The very next day, February 15, HHS Secretary Kathleen Sebelius said “the federal government will delay for an unspecified time the implementation date for the ICD-10 diagnostic and procedural coding system,” HealthLeaders Media reported.
Specifically, the HHS release stated that the agency “will initiate a process” to delay the ICD-10 implementation date for “certain health care entities.”
And that was pretty much it.
The rest of the release reiterates that the provider community feels burdened by the ICD-10 implementation, but also reiterates the importance of the move to ICD-10 because it will “provide more robust and specific data that will help improve patient care.”
Meanwhile, CMS confirmed to ACDIS’ parent company HCPro Inc., that the agency will use the rulemaking process when revisiting the ICD-10 implementation timeline; a process known to be lengthy, a process that does not always furnishes an expected result (meaning after the rulemaking CMS may just decide to keep the implementation date firm).
So multiple experts from ACDIS Advisory Board members to AHIMA directors repeated the refrain,; “Stay the course with ICD-10 implementation.”
I’m on their side.
In a phone conversation earlier this week, an ACDIS member told me that she was glad to hear CMS delayed ICD-10 by two years. Two years, she said.
Of course, I asked where she got her information and she cited some reputable sources which, on closer examination, actually said nothing of the sort.
All this commotion—all this maybe, possibly, definitely thinking about it—may ultimately cause serious difficulties for those in the midst of ICD-10 implementation plans. The possible delay could cause facility administrators to pull back the purse strings on training funds. Programs could decide to delay important technology purchases to save money since the implementation date isn’t imminent.
Meanwhile, we hear how far behind facilities actually are in their ICD-10 planning. CDI staff (according to a recent survey) say they do not even know if a ICD-10 implementation committee is meeting at their facility or what will be expected of them as the coming change draws near. Possibly postponing the actual “go-live” date only adds to facility procrastination on these issues.
The more advanced facilities have already evaluated their staffing needs in terms of CDI specialists’ concurrent record reviews and coding needs. These facilities have already budgeted for additional employees and charted a course for staff member training beginning with anatomy and physiology. Even more advance programs have already begun reviewing their top MS-DRGs for documentation improvement opportunities related to ICD-10.
History may prove me wrong (especially as rumors also abound about HHS opting to skip ICD-10 and jump directly to ICD-11!) but I remain convinced that ICD-10 implementation is inevitable and that the sooner facilities prepare themselves the better.
‘Stay the course’ despite suggestions that CMS may delay ICD-10 implementation
HHS confirmed its intent to re-examine the ICD-10 compliance deadline during a proposed “rule making,” session the agency announced in a press release yesterday, Thursday February 16. The release came following a statement HHS Secretary Kathleen G. Sebelius made during a presentation to the American Medical Association (AMA) meeting on Tuesday, February 14. The AMA previously announced its intention to oppose the ICD-10 implementation timeline. The group sent a letter voicing its opposition to Speaker of the House John Boehner in January, according to FierceHealthIT.
In the release, Sebelius says “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead. We are committing to work with the provider community to reexamine the pace at which HHS and the nation implement these important improvements to our health care system.”
“Since the AMA announced its intention to try and delay the implementation of ICD-10, this news does not come as a total surprise,” said Lynne Spryszak, RN, CCDS, CPC-A, CDI education director for HCPro, Inc., in Danvers, MA. “Providers are expected to comply with meaningful use, transition their practices to the 5010, and implement EHRs in their office. When you consider that providers are also facing a decrease in their reimbursement rates it is no wonder that they feel that their backs are against the wall.”
That said, providers have had plenty of advance notice, Spryszak noted. CMS announced the conversion to ICD-10 in January of 2009, giving them nearly five years to plan.
Until further information becomes available on the exact nature of the delay, providers should continue to push forward with their implementation efforts, according to industry experts.
“Even if they do delay ICD-10, especially for physician practices, this should not deter the infrastructure redevelopment to accommodate ICD-10’s likely implementation in whatever time frame they do implement it, be it six, 12, 18, or 24 months from their previously announced date of October 1, 2013,” said James S. Kennedy, MD, CCS, managing director of FTI Consulting in Brentwood, TN.
The rest of the world is already using ICD-10, Kennedy explained, and will likely transition to ICD-11 soon, while the United States is still using ICD-9. “Change is necessary if we are to develop a robust database of our patients’ illnesses and treatments as to better measure outcomes and efficiency. While ICD-10 is not perfect—nothing is—we should not let the need for perfection be the enemy of the common good. Procrastination is not the solution,” Kennedy said.
Clarification regarding Coding Clinic publication
The AHA will begin to collect and respond to limited questions regarding the ICD-10 code set.
The American Hospital Association (AHA) has not made any formal decisions regarding when it will begin publishing a separate Coding Clinic for ICD-10, contrary to what was reported in December 1 edition of CDI Strategies, according to Nelly Leon-Chisen, RHIA, director of coding and classification for the AHA.
Those with questions pertaining to ICD-10 can submit them to the AHA now. Those who submit inquiries must have working knowledge of the new code set and questions must pertain to the application of the codes and the interpretation of the medical record.
The AHA is beginning to collect questions regarding the new code set and will include some of those questions starting with its 4th Quarter 2012 edition of Coding Clinic for ICD-9-CM, Leon-Chisen told ACDIS.
“This service is for coding advice only not for advice about ICD-10 implementation,” Leon-Chisen said during CMS’ “ICD-10 Implementation Strategies and Planning National Provider Call” on November 17.
The AHA has no plans to translate guidance from previous volumes of Coding Clinic for ICD-9-CM, as the increased specificity of the new code set is expected to make much of the guidance obsolete. However, it has not made a decision just yet about when it will stop publishing Coding Clinic for ICD-9-CM, or when it might begin publishing a specific Coding Clinic for the new code set.
