We hear a lot about the projected productivity declines after ICD-10 implementation. And coders will be less productive initially. That only makes sense because ICD-10 is new, coders will need to look for additional information, they (or their clinical documentation improvement specialist coworkers) may be sending more queries.
ICD-10 should actually speed up claims processing, according to Donna Smith, RHIA, project manager and senior consultant with 3M Health Information Systems in Salt Lake City.
For one thing, ICD-10-CM codes will better support medical necessity because they include more information, Donna points out. Right now, hospitals spend a lot of time copying records and shipping them off to payers because the ICD-9-CM codes are just so vague.
ICD-10 will also tell a better patient story. With the seventh character, you can actually follow a patient’s injury all the way through and see what kind of outcome the patient experienced.
A better, more complete picture of the patient’s severity of illness should also help reduce denials, Donna says. If Dr. Adams says her patients are really sicker than Dr. Smith’s, ICD-10 will allow her to show it. And if you don’t have to appeal denials, you get paid faster and you spend less time fighting with the payers.
Let’s not forget laterality. Joe comes in with a lacerated left index finger with injury to the nail. We have one code in ICD-9-CM (883.2). We’re reporting that same code for all 10 fingers.
In ICD-10-CM, we have separate codes for every finger, plus codes that specify whether the nail is involved and whether any foreign bodies remain in the wound. For our lacerated left index finger, we would choose between:
- S61.311-, laceration without foreign body of left index finger with damage to nail
- S61.321-, laceration with foreign body of left index finger with damage to nail
Both codes require a seventh character to denote the encounter.
The next day, Joe comes in with another finger laceration, this time of the left ring finger. In ICD-9-CM, we’re still reporting 883.2 and the insurance company may think we’re double billing or we did something wrong.
However, in ICD-10-CM, we will report one of these codes:
- S61.215-, laceration without foreign body of left ring finger without damage to nail
- S61.225-, laceration with foreign body of left ring finger without damage to nail
- S61.315-, laceration without foreign body of left ring finger with damage to nail
- S61.325-, laceration with foreign body of left ring finger with damage to nail
Again, we need a seventh character for encounter.
The payer can see that Joe injured a different finger, so we should be quickly reimbursed, which will save time (and aggravation).
What constitutes good documentation? The next physician treating the patient should be able to pick up the medical record and know exactly what happened in the previous encounter.
How often does this happen now? Sadly, not very. The fact is, most documentation doesn’t meet the current standards for ICD-9-CM coding, according to Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC, vice president of ICD-10 education and training for AAPC in Salt Lake City. Rhonda discussed documentation during an AAPC webinar August 15.
Think about how many times you assign an unspecified code because the physician hasn’t documented the information you need. In coding we are not allowed to assume or guess or suppose. If the physician didn’t document it, we can’t code it.
Good documentation isn’t about the code set. It’s about patient care. Physicians shouldn’t be documenting for payment. They should be telling the patient’s story.
What should you tell physicians about documentation improvement?
Start with the patient’s story. Would the physician know what went on with that patient based on his or her documentation alone? Physicians probably won’t remember specifics of a patient encounter three months down the road, so they need to document everything that happened in the encounter.
Check to make sure you can read the physician’s writing if you are still using paper charts. If you can’t read it, you can’t code it.
Eliminate the abbreviations. The physician might know what that shorthand note means, but coders and other clinicians might not. Ask the physician to clearly spell out the information.
Focus on what they aren’t doing. If the physician is already documenting laterality, don’t spend time discussing it in training. Give them a “Great job on documenting laterality. That’s one of the elements we need in ICD-10” and move on.
Remember that physicians can’t improve their documentation if they don’t know what we need. Show them the ICD-10-CM Manual. Then show them their documentation and point out what’s missing. Maybe the information isn’t missing, you just don’t know where to find it.
We don’t want physicians to write reams of additional information. They don’t have time to write an epic and we don’t have time to read one. In some cases, we only need a few extra words. One example Rhonda gave involves a superficial foreign body in a finger of the left hand. If the physician doesn’t say which finger, we need to use a default code. All we need is which finger and we can get to a more specific code. The physician only needs to add one word. Documentation improvement can be that simple.
Of course, not all documentation improvement involves adding a single word. But knowing the ICD-10-CM codes and the guidelines won’t help you if the information you need is not in the record.
It’s a texting world, and more and more we use shorthand in our everyday lives. What about shorthand in a medical record? Can you code from it?
First, let’s look at what kind of shorthand you might see. Physicians may use a +, ↑, or ↓. Those symbols could mean positive (like a pregnancy test), increased level, or decreased level, respectively. The problem is, they aren’t very clear or specific.
Na↑ could mean hypernatremia (elevated sodium) or it could just mean the sodium level has increased. Maybe the patient has a low sodium level and the physician is simply indicating that treatment to raise the level is working. It could mean the sodium level is a little high or significantly elevated. Maybe the physician just documented a slight elevation so he or she remembers to have it rechecked during the patient’s next encounter.
Bottom line: you just don’t know, so you can’t code from it.
So that means it’s time to query the physician, right? Well, it depends. First, make sure you review the entire record and see if the physician documented the information anywhere else more specifically. Maybe BP↑ was just a note on a summary sheet and in the history of present illness, the physician stated, “Patient’s blood pressure elevated.” No query needed. We have the information.
Maybe the physician didn’t document it more completely elsewhere. Is the condition clinically significant?
Hypernatremia is a CC, so it could affect MS-DRG assignment and the patient’s care. You should probably query.
↓BP could also be clinically significant because a low blood pressure could cause other health problems, such as dizziness, weakness, and fainting. Again, probably worth a query.
↓low chloride is probably not worth querying, because it isn’t associated with any adverse health effects.
If you have providers who routinely seem to document using symbols, work with them to eliminate the symbols and document in clear words. (because we can’t code from symbols in any coding system). The better the physician documents, the better the story of the patient becomes.
Take it from today’s victims, er, patients, at the Fix ‘Em Up Clinic: not every idea is a good idea.
Jeff was so determined to claim the s’mores title that he ate a few marshmallows that were a little too hot. As in, they were on fire. And while fire eating is fine for professionals, for a kid at camp, it’s not such a great idea.
Dr. Sunni Daze examines Jeff and documents burns to the mouth, pharynx, tongue, and lips.
The burns of the mouth, pharynx, and tongue are easy. One code covers all three and it does not specify degree of the burn. Since this is Jeff’s initial visit, we would report T28.5XXA.
The lip burns require a little more information. We need to know what degree of burns Jeff suffered on his lips. Fortunately for him, Dr. Daze notes the burns are first degree, so we would report T20.12XA (burn of first degree of lip[s]).
ICD-10-CM does not include separate codes for the upper and lower lip, so T20.12XA covers one lip or both.
We also find the following note under pretty much all of the burn codes:
- Use additional external cause code to identify the source, place and intent of the burn (X00-X19, X75-X77,X96-X98, Y92)
We definitely need an X00-X19 code, which in Jeff’s case is X10.1XXA (contact with hot food, initial encounter).
The X75-X77 codes are for intentional self-harm. Overeating burning marshmallows doesn’t quite qualify as planning to hurt yourself. Jeff just got caught up in the moment.
The X96-X98 are codes for assault. Again, not applicable in Jeff’s case.
For our place of occurrence, we’ll use Y92.833 (campsite as the place of occurrence of the external cause). Notice we do not need a seventh character for this code.
Our second patient Grace tried to change the direction of the fan by grabbing the cage that houses the blades. Turns out that wasn’t the best plan. That “squeeze” caused the blades to hit the cage and Grace’s fingers.
Fortunately, the fan wasn’t going fast enough to sever any of Grace’s fingers, but she does have some wicked-looking lacerations.
ICD-10-CM finger laceration codes are very specific, as in you need to know which hand and which finger is involved. You also need to know whether the nail is damaged and whether any foreign body remains in the laceration.
Let’s see what Dr. Daze documented:
14-year-old female with lacerations to the palm side of the right index, middle, ring fingers, no nail involvement. No foreign bodies remain in wounds. Flexor digitorum profundus tendon of index finger severed.
The first injury we’ll code is the severed tendon, because it is the most severe injury. If you look under laceration (because the tendon was lacerated, right?), the entry for tendon directs you to see Injury, muscle, by site, laceration.
Okay, so off to Injury, muscle, finger we go. And find all sorts of code options. The codes are divided into the forearm and hand level. We don’t have a code for finger level, so we’ll go with hand level.
However, we can code to the specific finger. In Grace’s case, that’s the right index finger and code S66.120A (laceration of flexor muscle, fascia, and tendon of right index finger at wrist and hand level, initial encounter).
The other codes for Grace’s misadventure would be laceration codes for the middle and ring fingers:
- S61.212A, laceration without foreign body of right middle finger without damage to nail, initial encounter
- S61.214A, laceration without foreign body of right ring finger without damage to nail, initial encounter
Dr. Daze is done for the day and so are we. Remember to make sure your food isn’t on fire before you eat it.
ICD-10-CM includes 68,000 codes and ICD-10-PCS features 71,924 code choices. Scary numbers, right?
All of those codes will actually make it easier to find the code that best represents either the patient’s diagnosis or the procedure the physician performed.
Some ICD-9-CM codes are vague. By now, you’ve probably seen the comparisons for fracture codes. ICD-9-CM may include only two code choices for a particular fracture (open or closed), while ICD-10-CM can offer more than 100 (sometimes more than 200) codes, which include laterality, specific site of the fracture, type of fracture, and encounter.
Sue likes to compare the code book to a phone book. If you look at the New York City phone book, you’ll find lots and lots of names. More than 8 million people call the Big Apple home. By contrast, Schenectady, New York, is home to slightly more than 66,000 people and requires a much smaller phone book.
You’ll still look up a name the same way. You just have more names to sort through in New York City.
Same holds true for ICD-10-CM. (ICD-10-PCS is very different than ICD-9-CM Vol. 3).
You still look in the Alphabetic Index, you still go to the Tabular List to double check the code. The only difference is you have more code choices.
Increase specificity makes it easier to assign a code because it takes some of the guess work out of the process, Sue says.
That’s especially true in ICD-10-PCS. The ICD-9-CM Vol. 3 codes are so vague that one code could represent more than 100 procedures. That about ambiguity!
With all of the code choices in ICD-10-PCS, you’re more likely to find a code that represents what the physician actually did. And that should save time in the long. It will certainly give us more accurate data about the patient and allow us to tell a better story about the patient’s health.
“It’s never too early to start learning,” says Jillian Harrington, MHA, CPC, CPC-I, CPC-P, CCS, CCS-P, MHP. “By keeping the ball rolling, staff can continue to drive home those documentation improvement aspects to providers.”
Another advantage to starting now: “We as coders and CDI specialists can become experts in ICD-10-CM coding ourselves,” Jillian says. By becoming experts, we’ll know what is needed from a documentation standpoint and we’ll also know the coding guidelines before ICD-10-CM implementation.
Diabetes coding won’t really be harder in ICD-10-CM, Jillian says, but it will be different. The codes will look different, the documentation requirements will change, and you can’t use 250.00 after October 1, 2015. (Don’t worry, though, ICD-10-CM does have an equivalent code.)
Jillian will gives coders, CDI specialists, and clinicians the inside scoop on how to code for diabetes in ICD-10-CM during the live 60-minute webinar, ICD-10-CM Diabetes: Combine Coding and Documentation for Greater Specificity.
She will reveal how the new codes better represent a patient’s clinical picture and what information coders and CDI specialists need to see in the documentation to assign the most specific code. She’ll also review what the ICD-10-CM guidelines and Coding Clinic have to say about ICD-10-CM diabetes coding and offer some tips on getting physicians to improve their documentation.
Be sure to join us at 1 p.m. Thursday, August 14, for the live webinar. Come ready with questions for Jillian! She’ll answer live questions after her presentation.
And if everyone at your organization can’t make it to the live show, don’t worry, you get a free on-demand version of the webinar!
Ötzi the Iceman suffered from atherosclerosis. A pair of hikers discovered Ötzi’s well-preserved mummy in the Ötztal Alps, near the border between Austria and Italy, in 1991. Since then, scientists have performed numerous tests on Ötzi and discovered a wealth of medical information.
In addition to his atherosclerosis, Ötzi also suffered from:
- Lyme disease
- Whipworm infestation
- Tooth decay
He probably suffered a head injury, according to proteins in his brain, before being shot in the shoulder by an arrow and bleeding to death. And because of his advanced (for the time) age of 45, he also suffered from worn joints, which probably caused pain.
How would we code Ötzi’s various maladies in ICD-10-CM?
For his atherosclerosis, we need to know whether it is a native vessel or a bypass. Since they didn’t do bypass surgery in Ötzi’s day, we’ll go with native vessel. That leaves us with these choices:
- I25.10, atherosclerotic heart disease of native coronary artery without angina pectoris
- I25.110, atherosclerotic heart disease of native coronary artery with unstable angina pectoris
- I25.111, atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm
- I25.118, atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
- I25.119, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
We also see a note to use an additional code, if applicable, to identify:
- coronary atherosclerosis due to calcified coronary lesion (I25.84)
- coronary atherosclerosis due to lipid rich plaque (I25.83)
The team that uncovered Ötzi’s atherosclerosis noted a buildup of calcium in his arteries, so we’ll need to add I25.84 as a secondary code.
On to Ötzi’s Lyme disease. That’s a pretty easy one because we only have one choice: A69.20.
If Ötzi suffered complications due to his Lyme disease, we would use one of these codes instead:
- A69.21, meningitis due to Lyme disease
- A69.22, other neurologic disorders in Lyme disease
- A69.23, arthritis due to Lyme disease
- A69.29, other conditions associated with Lyme disease
The whipworm infestation is also easy to code. When you look up whipworm in the ICD-10-CM Alphabetic Index, you find an entry for: whipworm (disease)(infection)(infestation) B79.
Because we know not to code only from the Alphabetic Index, we look up B79 in the Tabular List, where we find:
Next up is tooth decay. When we look up decay in the ICD-10-CM Alphabetic Index, we are directed to see Caries, dental. You may have already known that, but if not, the index directs you to the correct entry.
These codes require more information than just dental caries. For example, we need to know what kind of caries Ötzi had:
- K02.3, arrested dental caries
- K02.5-, dental caries on pit and fissure surface
- K02.6-, dental caries on smooth surface
- K02.7, dental root caries
- K02.9, dental caries, unspecified
For caries on pit and fissure surfaces and those on smooth surfaces, we also need to know how far the caries penetrated:
- Limited to enamel (fifth character 1)
- Penetrating into dentin (fifth character 2)
- Penetrating into pulp (fifth character 3)
ICD-10-CM does not require you to specify which teeth are involved.
What about Ötzi’s fatal injuries—the blow to the head and the arrow wound?
Scientists documented that he suffered a craniocerebral trauma with major bleeding in the back of the brain, along with a skull fracture. Unfortunately, they didn’t say exactly what type of fracture.
As for the bleeding, Ötzi likely suffered a brain hemorrhage caused by an artery in the brain bursting and causing localized bleeding in the surrounding tissues. You’ll find the codes for traumatic cerebral hemorrhages divided by side of the brain:
- S06.34-, traumatic hemorrhage of right cerebrum
- S06.35-, traumatic hemorrhage of left cerebrum
- S06.36-, traumatic hemorrhage of cerebrum, unspecified
The codes also specify different times for loss of consciousness:
- without loss of consciousness
- with loss of consciousness of 30 minutes or less
- with loss of consciousness of 31 minutes to 59 minutes
- with loss of consciousness of 1 hours to 5hours 59 minutes
- with loss of consciousness of 6 hours to 24 hours
- with loss of consciousness greater than 24 hours with return to pre-existing conscious level
- with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving
- with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness
- with loss of consciousness of any duration with death due to other cause prior to regaining consciousness
- with loss of consciousness of unspecified duration
Because we don’t know if Ötzi lost consciousness or specifically where the hemorrhage occurred, we can’t assign a code. We would need to query Ötzi’s physician.
We’ve now come to Ötzi’s final injury: the arrow in the shoulder. The arrowhead entered the left shoulder blade and came to rest near Ötzi’s lung. Although it did not damage any internal organs, the arrowhead severed an artery and Ötzi bled to death.
If we look up laceration, blood vessel in the Alphabetic Index, we are directed to see injury, blood vessel. We find lots of codes for blood vessel injuries. These codes, not surprisingly, identify the location of the blood vessel and, in some cases, the actual blood vessel itself. For example, we can code an injury to the common carotid artery.
When we look at blood vessel, shoulder, we’re directed to see:
- Specified, NEC – see injury, blood vessel, arm, specified site, NEC
- Superficial vein – see injury, blood vessel, arm, superficial vein
We know we are not dealing with a superficial vein because the physician documented that the arrowhead ended up near the lung. Our most likely code is S45.812A (laceration of other specified blood vessels at shoulder and upper arm level, left arm, initial encounter).
And with that, we are at the end of the Iceman’s medical record.
Well, we once again have an official ICD-10 implementation date. HHS released a display copy of Administrative Simplification: Change to the Compliance Date for the International Classification of Diseases, 10th Revision (ICD–10–CM and ICD-10-PCS) Medical Data Code Sets July 31. It is scheduled to hit the Federal Register August 4.
The rule, which makes October 1, 2015, the new implementation date, doesn’t really contain any surprises. We’ve known since HHS released the IPPS proposed rule April 30 that the ICD-10 delay would be one year. The final rule makes it (theoretically) final.
Can we trust the new date? That’s the $64,000 question right now. We were sure (and so was CMS) that October 1, 2014, would be the date. And by and large the industry and HHS seemed okay with that date.
Then Congress got involved. I’ve heard a lot of rumors about why Congress acted, but since no one has claimed credit (or taken the blame depending on your point of view) for pushing out the date, we don’t really know the reason for it. That also means we don’t know how to keep Congress from acting again.
Will ICD-10 go live October 1, 2015? I hope so. I’d like to say I am 100% confident in the date, but once bitten, twice shy.
The problem comes down to credibility. Not just HHS’ credibility in saying October 1, 2015, is THE date and it’s not changing. We’ve heard that before and it changed.
We also have a credibility problem within the industry and within our organizations. Some people have been lobbying hard for ICD-10 and promoted it within their organizations. They created training plans, begged for budget money, harangued colleagues to complete training. They were going to make sure their organization was ready. And quite a few were on track for October 1, 2014. Then the latest delay happened.
Are we going to be able to get people within our organizations to buy into 2015? Will they listen when we say, you need to be trained, you need to prepare, you need to sign the check for the training? Or will they look at us like we’re Chicken Little screaming that the sky is falling?
ICD-10 is coming eventually. We know that. I think even the physicians know it at this point. If we as an industry are ready—not just the big hospitals, but the small physician practices and everyone in between—there won’t be a reason to delay again. The hard part is making sure everyone is ready.
We were expecting October 1, 2015, to be the new ICD-10 compliance date and CMS made it official with the release of a final rule, Administrative Simplification: Change to the Compliance Date for the International Classification of Diseases, 10th Revision (ICD–10–CM and ICD-10-PCS) Medical Data Code Sets . The final rule will be published in the Federal Register August 4.
Congress forced the one-year delay when it passed H.R. 4302, “Protecting Access to Medicare Act of 2014″ in March. President Obama signed the bill April 1. The bill also forced HHS to delay implementation of ICD-10 until at least October 1, 2015.
HHS referenced the new 2015 compliance date as part of the 2015 IPPS proposed rule, released April 30. HHS then issued a statement advising the industry that it would release an interim final rule making October 1, 2015, the new implementation date. HHS made the date official with today’s release of the rule.
Ah, the joys of camping. The fresh air, the beautiful scenery, the friendly forest creatures. Sounds like a great way to escape from the urban jungle and the daily grind.
Larry headed off to the state park to spend some quality time with nature. He packed all the essentials—tent, stove, cell phone, skillet, sleeping bag, water, and of course, raw meat. Nothing like a good meal when you are out of doors.
Sadly for Larry, he forgot to pack matches, fuel for his stove, and enough ice for his cooler.
He also forgot to practice setting up his tent before setting off for the great outdoors. And Larry apparently is not very coordinated.
When he tried to set up his tent, he realized he also forgot to pack a hammer to drive the tent stakes into the ground. Not to be deterred, Larry found a really big rock to use instead. Apparently, Larry’s aim was off and instead of driving in the stake, he smashed his thumb.
If Larry sought treatment for his thumb injury, we would need to know:
- Which thumb (Larry is right-handed, so he smashed his left thumb)
- Whether the nail is injured (it’s not, Larry didn’t hit it that hard)
- Episode of care (first visit)
For Larry’s thumb contusion, we would report S60.012A (contusion of left thumb without damage to nail, initial encounter).
Since he knows some basic first aid, Larry opens his cooler (with the raw meat inside), takes out some ice, wraps it in a spare shirt, and applies the ice-filled shirt to his throbbing thumb.
While he’s waiting for the pain to subside (he also forgot to pack some aspirin), Larry wanders over to sit on a boulder and enjoy the view. Alas, he forgot to close the lid on the cooler and the smell of Larry’s uncooked meat draws the interest of a mountain lion.
The mountain lion arrives to raid the cooler and Larry decided to defend his dinner. He snatches up a tree branch and attempts to ward off the mountain lion, who is unimpressed by Larry’s makeshift club. The mountain lion knocks the branch out of Larry’s hand with a nice loud growl, sending Larry fleeing for the safety of the nearest tree.
On the way to the tree, Larry trips over a log and does a face plant into the dirt on the other side. In the course of this trip, Larry cuts his forehead and twists his ankle.
If Larry seeks medical attention for these injuries, we need to know a lot more information.
For example, does any of the forest floor remain in Larry’s laceration? We have two code bases to choose from in ICD-10-CM:
- S01.81-, laceration without foreign body of other part of head
- S01.82-, laceration with foreign body of other part of head
Both codes will require a seventh character, and to make sure it’s in the seventh position we need to add an X placeholder. You’ll also note that the forehead does not have its own ICD-10-CM code. It’s simple “other part of the head.” Not to be confused with unspecified part of the head.
On to Larry’s sprained ankle. Again we need laterality, and this time we also need to know which specific ligament. If you aren’t familiar with the ankle ligaments, ICD-10-CM includes choices for:
- Calcaneofibular ligament (S93.41-)
- Deltoid ligament (S93.42-)
- Tibiofibular ligament (S93.43-)
- Other ligament, specifically the internal collateral and talofibular ligaments (S93.49-)
We also have a code for unspecified ligament (S93.40-), but we’re trying to avoid using unspecified codes.
Each of these codes requires two additional characters. The sixth character provides the laterality—right, left, or unspecified—and the seventh is the encounter.
If you find yourself about to report a code starting S93.409-, STOP. That code is an unspecified ligament of an unspecified ankle. That’s not going to cut it. At the very least, the physician should be documenting laterality. If he or she isn’t, you need to have a polite conversation about the importance of complete, accurate documentation.
It is highly possible that the physician doesn’t know which ligament, especially if he or she doesn’t deal with ankles much. So you could legitimately report an unspecified ligament. If the physician never provides that information, you might want to ask a CDI specialist to chat with the physician to find out why.
Now back to poor Larry. He has picked himself off the ground while the mountain lion is picking the steak out of the cooler. Deciding that discretion is the better part of valor, Larry continues for the safety of the tree. Unfortunately he forgot about his damaged thumb in his quest to climb the tree and all he succeeds in doing is annoying the tree’s resident squirrels.
The squirrels, who weren’t too sure about this visitor in the first place, are now very unhappy and vent their displeasure by pelting Larry with acorns. For furry little rodents, their aim is pretty good and they succeed in hitting Larry in the eye, and also in knocking out one of his teeth.
What type of eye injury did Larry sustain? Corneal abrasion (S05.0-)? Laceration of the eyeball (S05.3-)? Maybe it’s just a lacerated eyelid (S01.11-).
We’ll need laterality and the encounter to round out any of these codes.
For the tooth injury, we need to know whether the tooth is just cracked, in which case we would report K03.81. If it’s actually fractured, we need S02.5- with two placeholders and a seventh character.
Either way, we don’t need to know which tooth. ICD-10-CM isn’t that specific, yet.
Having by now had his fill of the great outdoors, Larry throws his gear back in his car and heads for the nearest hotel.