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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.”

ICD-10-CM: What goes on the baby’s chart?

If you code for pregnant patients and newborns, you may occasionally wonder which record to code a condition on. Is it something you code for the mother or for her child?

crying baby

Don’t let ICD-10 pregnancy coding bring you to tears.

ICD-10-CM divides the codes into two different chapters:

  • Chapter 15, Pregnancy, Childbirth and the Puerperium (O00-O9A). These codes are only used on the mother’s record.
  • Chapter 16, Certain Conditions Originating in the Perinatal Period (P00-P96). These codes are only reported for the newborn. These codes include conditions that have their origin in the fetal or perinatal period (before birth through the first 28 days after birth) even if morbidity occurs later.

Make sure you code all clinically significant conditions noted on a routine newborn examination. A condition is clinically significant if it requires any of the following:

  • Clinical evaluation
  • Therapeutic treatment
  • Diagnostic procedures
  • Extended length of hospital stay
  • Increased nursing care and/or monitoring
  • Has implications for future health care needs

What types of problems can newborns have? Well, the baby may arrive too early. We would use codes from category P07.3- to report 28 completed weeks or more but less than 37 completed weeks (196 completed days but less than 259 completed days) of gestation.

We have nine different choices to specify exactly how early our bundle of joy arrived, plus an unspecified code. If the newborn arrives at 31 weeks, four days, we would report P07.34.

Maybe our baby is underweight for gestational age. ICD-10-CM includes codes for:

  • P07.0-, extremely low birth weight newborn
  • P07.1-, other low birth weight newborn

The codes in these categories specify weight ranges. So if the newborn weighs 850 grams at birth, we would report P07.03 (extremely low birth weight newborn, 750-999 grams).

So we have a preemie with a low birth weight. Which condition do we sequence as the principal diagnosis for the birth encounter? It’s a trick question because the answer is neither. When coding the birth episode in a newborn record, we will always assign a code from category Z38.- (liveborn infant) as the principal diagnosis. Birth takes precedence.

Z38.- still gives us plenty of options and we need some specific details to choose the correct code. First, how many babies? Where did the baby arrive? How was the baby delivered? You could conceivably have a different place and method if mom is delivering more than one baby.

For example, if mom gives birth to twins in the hospital, she could deliver one vaginally (Z38.30) and one by cesarean (Z38.31).

Alternately, she could have one on the way to the hospital (Z38.4, twin liveborn infant, born outside hospital) and one vaginally in the hospital. Don’t assume it will be the same for each infant in a multiple birth.

Chapter 16 codes may be used throughout the life of the patient if the condition is still present.

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

What to do about the ICD-10 delay: Stay the course, target physician documentation

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Dear ACDIS Member,

As you doubt have heard this week the Senate and House of Representatives approved–and the President signed–H.R. 4302 (“Protecting Access to Medicare”).

So, it’s now official: ICD-10 will be delayed at least another year.

The actual language in the bill does not include a new enforcement date, but says “no earlier” than October 1, 2015.

H.R. 4302 primarily addresses Medicare payments to physicians and the Sustainable Growth Rate. But buried in it is section 212, a seven line section that calls for a delay in implementation of the ICD-10 code set until October 1, 2015. The actual language reads as follows:

The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal Regulations.

Some see a silver lining in the delay, as it means another year to prepare physicians, coding staff, and CDI for ICD-10.

But the delay also creates considerable turmoil. Staff will need to be retrained or take refresher courses. Implementation and staffing plans will be put on hold. CMS estimates that a one year delay could cost between $1 billion to $6.6 billion, according a statement from AHIMA officials. In addition, credibility with physicians will be strained.

The best advice we at ACDIS can offer is to stay the course, and do your job to the best of your ability. Since you are clarifying diagnoses and procedures to their highest level of specificity, and ensuring that all diagnoses/procedures are supported by clinical indicators, the codes will take care of themselves, regardless of whether they are ICD-9 or ICD-10. Continue educating providers on the importance of complete and specific documentation in the health record.

In short, try not to be discouraged, and know your job as CDI specialists remains as important as ever.

We at ACDIS are committed to providing you with the best and only dedicated support network for CDI, regardless of what the future holds. And we will continue to provide you with the latest news and guidance on ICD-10, both on the ACDIS website and at our annual conference in May.

Join me and a host of fellow healthcare industry leaders including Rhonda Buckholtz from the AAPC, Margarita Valdez from AHIMA, Robert Tennant from the MGMA, Jim Daley of WEDI among others as we discuss the implications on next week’s Talk Ten Tuesday April 8.

Take care,

Brian Murphy, CPC
Director, ACDIS

ACDIS: Keep on clarifying despite ICD-10 implementation delay

Keep on going!

Keep on going!

At roughly 6:30 p.m. last night, Monday, March 31, the U.S. Senate voted to approve a bill to temporarily “fix” the Sustainable Growth Rate (SGR). However, tucked into the bill was one sentence that could cost the healthcare industry upwards of $6 billion and shake a number of healthcare improvement initiatives to their core:

The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets  as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal Regulations.

What this means is that, barring a Presidential veto of the bill, ICD-10 will be delayed until at least Oct. 1, 2015

The delay of ICD-10 impacts much more than just coded medical bills, but also quality, population health, and other programs that expected to start using ICD-10 codes in October. The extent of the logistical challenges and costs associated with “dialing back” to ICD-9-CM are not yet fully understood but are expected to be extensive, according to a statement from AHIMA officials in the Journal of AHIMA.

Although many pointed to the AMA—a longtime opponent of ICD-10 implementation—as leading the charge to include the delay language, AMA President Ardis Dee Hoven, MD, said in a statement that the Association is “deeply disappointed by the Senate’s decision to enact a 17th patch to fix the flawed Sustainable Growth Rate (SGR) formula. Congress has spent more taxpayer money on temporary patches than it would cost to solve the problem for good.”

The SGR is the CMS’ way to control costs for physician services. It attempts to cap the yearly increase in expense per beneficiary to less than the growth of the GDP, but nearly every year Congress votes to negate the measure in bills typically dubbed the “doc fix.”

This year, physicians were expecting a 24% reduction in Medicare payments at the turn of the year, but lawmakers extended the previous fix until March 31, according to Kaiser Health News.

The ICD-10 language was not included in an earlier version of the bill, according to the ICD-10 Trainer Blog.

During the vote in the House of Representatives the ICD-10 measure was not referenced but some members of Congress opposed passage of the bill as being rushed through. Later in the Senate a new bill without the ICD-10 measure was introduced but opposed.

The ACDIS advisory board recommends CDI professionals stay the course, clarify diagnoses and procedures to their highest level of specificity, and ensure that all diagnoses/procedures are supported by clinical indicators. When we do this, the codes should take care of themselves, regardless of whether they are ICD-9 or ICD-10.

Journal Excerpt: Bonus structures help programs retain staff through ICD-10

Check out the latest tools donated to the ACDIS community.

Staff bonus may help retention for CDI programs through ICD-10 implementation.

Editor’s Note: This excerpt was adapted from the January 2013 edition of the CDI Journal

There is no doubt about it—CDI specialists will be taking on more work and a greater complexity related to that work in 2014 due to the implementation of  ICD-10. The question for many CDI managers around the country is: How do I keep my staff intact, given that they’re facing a greater workload, competing pressures, and increased career opportunities from other facilities and consulting firms looking to hire?

“I know my staff is juggling responsibilities and doing so much more than simple chart reviews,” says Samantha Joy, one Illinois-based CDI director whose name has been changed at the request of her facility. Joy took over the program two years ago and grew its staff by 50%. She now has 12 full-time CDI  specialists. One has been working at Joy’s facility for eight years; the newest staff member started a few months ago. There are no plans to hire additional staff members due to the ICD-10-CM/PCS implementation.

Although Joy hasn’t had any trouble with staffing turnover in the past, and salaries are in line with the ranges reported in her area (read the 2013 Salary Survey results in the October edition of the CDI Journal), she understands how valuable CDI expertise will be in 2014 and wants to be ahead of the curve. So when her facility’s ICD-10-CM/PCS steering committee began discussing retention bonuses for coding staff, Joy began researching similar trends in the  industry for her staff as well.

She found only a few facilities who had developed retention bonuses for CDI staff, but that was enough to convince her it was a good idea. So she drafted a  proposal, and received approval in December. According to the proposal, CDI specialists will receive an incentive payment for remaining on as staff,  staggered and delivered in the following increments:

  • 25% of the incentive payment once they start their ICD-10-CM/PCS training
  • 25% of the payment once they complete their training, based on an 85% or higher proved competency rate
  • 50% of the payment one year post-ICD-10 implementation

If these staff members leave the facility for any reason they will have to pay back the money they’ve received; and, of course, they must remain in good  standing while on staff, completing their regular workload and performing their duties as appropriate, says Joy. Training is expected to begin early in 2014 and take about four or five months to complete. CDI specialists will also review the components of physician training so they understand what physicians have learned and have the ability to fill in the gaps if necessary.

“The question is how to reward my staff for taking on all this additional information, and how can I retain them once I’ve trained them,” says Joy. “There are  not a lot of facilities doing this yet—either that or they haven’t thought through to this level of planning so far. So I feel like I am just one more step ahead.”

Editor’s Note: Download a free ICD-10-CM/PCS CDI survey results and analysis. Also, don’t forget to register for the free webinar Six Months until ICD-10 Hits: Last Minute Tips for Coding and Improving Physician Documentation, which takes place Tuesday, April 1 at 1-1:45 p.m., with Coding Boot Camp Instructor Jillian Harrington, MHA, CPC, CPC-I, CPC-P, CCS, CCS-P, MHP, and CDI Boot Camp instructor Laurie Prescott, MSN, RN, CCDS, CDIP.

The wait is on: Will ICD-10-CM/PCS be delayed?

Ask your CDI question in the comment section.

Will an ICD-10 delay actually pass the Senate on Monday?

The fate of the October 1, 2014 ICD-10 implementation date will remain in limbo until Monday.

The House of Representatives passed HR 4302 Thursday as a one-year fix to the Sustainable Growth Rate (SGR). Tucked into the bill was one sentence that could significantly impact the healthcare industry:

The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets  as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal Regulations.

The Senate is now expected to vote on the same bill Monday around 2 p.m. (Eastern).

No one seems quite sure who introduced the delay language into the bill, which is a compromise bill worked out by House and Senate leadership.

Although some have suggested the idea may have come from the AMA, (since it was vocal in its opposition to ICD-10 previously) but the association sent a letter asking Congress NOT to pass this bill. The AMA wants a permanent fix to the SGR.

I actually feel kind of bad for CMS (never thought I would say that). The agency’s representatives have repeatedly and forcefully stated CMS was not changing the implementation date. Now, it might not have a choice. Congress could force CMS to change the date and at that point, who will take a new implementation date seriously?

And speaking of a new implementation date, notice that the language in the bill says CMS may not require ICD-10 “prior to October 1, 2015.” That doesn’t mean October 1, 2015, would be the new implementation date. So the date could get pushed back to 2016 or 2017. It will also reignite the debate about whether we should just wait for ICD-11.

AHIMA quoted a CMS estimate that a one-year delay could cost the industry between $1 billion and $6.6 billion. Healthcare providers are already feeling the pinch of budget constraints now and have spent literally billions on preparations so far. We would also be looking at a longer code freeze. The last regular update for ICD-9-CM happened back in 2011. If ICD-10 is delayed again, we’re looking at no new codes until at least October 2016.

During the House debate, no one talked about ICD-10, at all. I fear the same will happen in the Senate. Congress doesn’t want to face the specter of a 24% cut in physician payments scheduled to hit April 1, the Senate will probably pass the SGR one-year fix. Which means they will probably also mandate the ICD-10 delay.

Hopefully, CMS, AHIMA, ACDIS and the host of other like-minded organizations who have already expressed their disbelief and dissatisfaction in the recent turn of events can do some intensive out reach to Senators over the weekend to get the ICD-10 delay language removed. Sadly, I’m not optimistic.

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

Free ICD-10 for CDI survey released

Download this free ICD-10 survey

Download this free ICD-10 survey

The results of a December ACDIS survey show the CDI profession toddling toward the ICD-10-CM/PCS transition, says founding ACDIS advisory board member Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, AHIMA-approved ICD-10-CM/PCS trainer and HIM professional in Fremont, Calif.

“People seem to be getting there, but they’re taking baby steps. That’s good, but now we really need to be getting ready to jog and run,” she says.

Twelve percent of survey respondents indicated they received no information to raise their awareness of ICD-10-CM/PCS documentation improvement needs. Only 68% said they received training on the code set, and 32% indicated their CDI staff assists with ICD-10-related education for physicians.

Click here to register and download the complete survey results.

Also, don’t forget to register for the free webinar Six Months until ICD-10 Hits: Last Minute Tips for Coding and Improving Physician Documentation, which takes place Tuesday, April 1 at 1-1:45 p.m., with Coding Boot Camp Instructor Jillian Harrington, MHA, CPC, CPC-I, CPC-P, CCS, CCS-P, MHP, and CDI Boot Camp instructor Laurie Prescott, MSN, RN, CCDS, CDIP.

News: Congress sneaks ICD-10 delay language into SGR bill

Dear ACDIS members and CDI professionals,

A new bill introduced in the House and Senate includes a small, rather buried section that would delay implementation of ICD-10 for another year, to Oct. 1, 2015. The main focus of the bill is a fix to the Sustainable Growth Rate (SGR), which is necessary. This small provision of the bill is not.

The bill is expected to go to the House floor tomorrow, March 27, for a vote. In accordance with the American Health Information Management Association (AHIMA), we urge our members to contact your local congressman and request removal of the ICD-10 delay provision. See the AHIMA release here, which includes a lookup tool to find the number of your local representative of Congress: http://www.capwiz.com/ahima/callalert/index.tt?alertid=63161891.

ICD-10 is necessary, and it’s coming. Further delay only hinders our ability to better capture the necessary specificity of the conditions our physicians and facilities are treating today. It also hurts the work many of our members have already done to prepare for the Oct. 2014 deadline, and undermines our credibility as CDI specialists. And there is the cost to consider: CMS estimates a one-year delay could result in additional costs of $1 billion to $6.6 billion.

Please contact your representative in Congress today and ask them to take the ICD-10 provision out of this bill. Help us spread the word and tell Congress, tell your colleagues, tell your friends why ICD-10-CM/PCS implementation is so important to the work you do every day. #NoDelay!

Thanks,

Brian Murphy

Director, ACDIS

Free Webinar April 1: Six months until ICD-10 hits

Which countdown to ICD-10 calendar will you use?

Time’s running out. Is your CDI department prepared for ICD-10?

Join Coding Boot Camp Instructor Jillian Harrington, MHA, CPC, CPC-I, CPC-P, CCS, CCS-P, MHP, and CDI Boot Camp instructor Laurie Prescott, MSN, RN, CCDS, CDIP, for a free, April Fool’s Day webinar, Six Months until ICD-10 Hits: Last Minute Tips for Coding and Improving Physician Documentation, on Tuesday, April 1 at 1-1:45 p.m. Yes, it’s April Fool’s Day, but this is no laughing matter. With just six months left to prepare, HCPro’s ICD-10 instructors have two important questions for you:

  • Are you up to date on the latest ICD-10-CM/PCS guidance?
  • Do you have a process for identifying physician education topics?

If you answered, “no,” “maybe,” “I don’t know,” or “huh?” to either questions, listen in to our free webinar. During this presentation, Jillian Harrington will take you through the latest ICD-10 guidance from the AHA Coding Clinics to make sure you have all of the newest ICD-10 information. The webinar will wrap up with Laurie Prescott addressing one of the ICD-10 transition’s million-dollar questions: How can we train physicians on ICD-10? She will walk you through how to leverage existing data and processes to focus physician teaching efforts.

Learning objectives include:

  • Summarize the changes to ICD-10-CM recently released
  • Identify resources in the ICD-10-PCS coding manual
  • Discuss strategies for assessing physician documentation
  • Review methodologies and opportunities for physician education on ICD-10

The most recent ACDIS ICD-10-CM/PCS preparation survey published in the January edition of the CDI Journal illustrates that few organizations have comprehensive CDI-related efforts in place. If you have started a program, let us know what efforts you’re doing and how you’ve managed to get the ball rolling in the comments section below. We’ll send free ICD-10 documentation handbooks to the first 10 responses.