The AHIMA ICD-10 and CAC Summit ended without a new ICD-10 implementation date, but according to Denise Buenning, MsM, acting deputy director for CMS’ Office of E-Health Standards and Services, we should not have long to wait.
CMS was as surprised as everyone else that Congress acted to delay ICD-10 implementation. After the delay, CMS administrators “sliced and diced” the legislation and engaged in robust discussions, Buenning said.
CMS officials consulted with the Office of General Counsel and the Office of Legislation while crafting the policy with the new implementation date. CMS and HHS will work to get the word out as quickly as possible on the new date, according to Buenning.
The most recent delay is not a killer for ICD-10, she added. It provides an additional year to perform end-to-end testing. CMS is currently scheduled to perform limited end-to-end testing in July, but that date may change. Buenning said the delay should also give CMS a more robust group of providers to test with because more providers will be ready to test.
If anything, the latest delay “eliminates the excuses to not transition to ICD-10,” Buenning said.
Rose Dunn, MBA, RHIA, CPA, CHPS, FACHE, FAHIMA, chief operating officer of First Class Solutions, started the second day of the AHIMA ICD-10 and CAC Summit with a rundown of ways HIM professionals can use the current ICD-10 delay to their advantage.
Complete your ICD-10 upgrade: Many vendors coupled ICD-10 and Meaningful Use stage 2 upgrades together. Perform internal testing to make sure that upgrade is working.
Follow up with your payers: Find out if they want to continue testing. If so, take advantage of that additional testing time to make sure claim submission runs smoothly.
Revisit your managed care contracts: If you have contracts that specify October 1, 2014 as the date you will begin submitting ICD-10 codes, check to see whether the contract includes a force majeure clause—meaning parts of the contract don’t apply if the government steps in and changes the ICD-10 implementation date.
Complete your EHR implementation: Reassess which screens require mandatory information. Customize them to include information you will need in ICD-10 but aren’t currently getting. Fix your drop down menus and pick lists. Ask you vendor if it can move the unspecified option to the bottom of the list. Some can, some can’t, but you won’t know if you don’t ask.
Most importantly: Stay the course. You can move forward on some areas of implementation at a slower pace, but don’t stop completely.
Here are some briefs highlights from the conference so far:
- The ICD-10 journey is a little like training for a marathon. You train and train and then in the race, when you get to mile 20, they tell you they are adding five more miles. Welcome to mile 27. – Stacie J. Watson, MBA, Aetna
- HIM professionals need to be mindful of the folks in the finance department, especially the CFO. We weren’t planning on doing a lot of things in 2015, such as ICD-10 refresher training, that we are now going to need to do. Unfortunately, that means money may be hard to come by.—Connie S. Tohara, RHIT, director of health information at the University of Utah Hospitals and Clinics.
- ICD-10 will bring better data and we need better data—Angela Kennedy, EdD, MBA, RHIA, 2014 AHIMA president
- We as an industry can do a better job of telling the consumer why better data is important.—also from Angela
- CMS is still working on a new implementation date. – Donna Pickett, MPH, RHIA, medical classification administrator for the CDC.
- If coders don’t understand concepts and terminology in ICD-9, they are going to have a lot of trouble in ICD-10. –Deborah Neville, RHIA, CCS-P, from Elsevier
- You have to understand where you are today if you want to make predictions about what is ahead – also from Deborah
That’s only a sampling of the great information at the conference. Can’t wait for tomorrow’s sessions.
Don’t blame the AMA for the most recent ICD-10 delay, says Steven Stack, MD, immediate past chair of the AMA Board of Trustees. Stack gave the keynote address at the AHIMA ICD-10 and CAC Summit in Washington today.
The AMA wants to kill ICD-10, Stack says, but also did not want Congress to pass another patch to the Sustainable Growth Rate. So the AMA actually pushed for Congress to kill the bill.
In some ways, ICD-10 was in the wrong place at the wrong time. Physicians—and the rest of the healthcare industry—have been dealing with so many other mandates that either don’t work as intended or don’t work at all. Stack called EHRs “not ready for prime time” and says Meaningful Use has been overbuilt and is irrational in many ways.
“We’re all using tools that aren’t quite as good as they should be,” Stack says. Physicians are frustrated by all of the mandates that they’ve been faced with in recent years.
Stack, a practicing ED physician, acknowledges the increased specificity in ICD-10 could provide value, but doesn’t really matter much to the physician at the time he or she is seeing the patient. He used the example of an elderly patient seen in the ED for a hip fracture. ICD-10-CM includes multiple codes that include specific details about the fracture.
“I know there’s value to that information, but at that point, I don’t really care,” Stack says. “I know the bone is broken, I know it needs surgical treatment, and the patient can’t go home. That’s all I need to know.”
Based on Stack’s comments, it seems many of the physician frustrations with ICD-10 center on EHRs. “We’re clicking and checking through stuff and not really telling the story we want to tell,” Stack says.
During the question and answer portion of Stack’s presentation, an audience member pointed out that documentation drives coding. She asked how the AMA plans to do great things with diabetes treatment and diagnosis if physicians don’t document the patient’s condition well.
Stack never quite answered the question. “Physicians have an obligation to completely and accurately document,” Stack says. “That doesn’t mean we don’t fail to achieve that obligation.”
He added that physicians don’t always document details because they don’t affect clinical judgment.
The AHIMA ICD-10 and CAC Summit continues through April 23.
Coding for pressure ulcers in ICD-10-CM requires precise documentation of the ulcer’s location, which really shouldn’t surprise anyone. ICD-10-CM includes increased specificity for almost every condition.
For pressure ulcers, coders need to know laterality for the limbs (e.g., right lower leg, left elbow). For ulcers on the back, the physician should document where on the back the ulcer is (i.e., upper, middle, lower, or presacral).
The physician should also document the stage of the ulcer:
- Stage I: Intact skin with non-blanchable redness of a localized area, usually over a bony prominence.
- Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
- Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.
- Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.
- Unstageable: Full thickness tissue loss, in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
If the ulcer can be staged after treatment, the physician should revise the staging.
When you look up ulcer, pressure, in the ICD-10-CM Alphabetic Index, you’ll find the codes listed two different ways:
- By site
- By stage
If you look under ulcer, pressure, stage 1, you see a list of all of the possible anatomic sites for a stage 1 pressure ulcer. ICD-10-CM also helpfully includes the description of the stage.
Another helpful thing in ICD-10-CM: the guidelines tell us we can use documentation from other clinicians to stage the ulcer. So the nurse can document the ulcer is stage 2 and we can code from that documentation. We can also code the ulcer as stage 2 if the nurse documents “ulcer with partial thickness skin loss involving the dermis.” We can use either a stage number or the description of the ulcer.
If a clinician cannot stage an ulcer at a given time because the bottom cannot be visualized, we can report it as unstageable. For example, if the patient has a pressure ulcer of the left elbow and our provider documents he or she can’t determine the stage, we would report L89.020 (pressure ulcer of left elbow, unstageable).
However, our awesome wound care nurse debrides the ulcer and determines it is a stage 3 pressure ulcer. Going forward we would report L89.023 (pressure ulcer of left elbow, stage 3).
Unstageable and unspecified are not the same, however. If the clinician simply fails to document a stage, we would report L89.029 (pressure ulcer of left elbow, unspecified stage).
Here comes Peter Cottontail, hopping down the bunny trail—and right into a gopher hole. Stupid rodents.
After a thorough exam and some x-rays, Dr. Long diagnoses Peter with a broken right foot. That’s a big foot on that bunny, Dr. Long. Can you be a little more specific?
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.
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 6-8 weeks.
Now it’s time for us to hop on out of the clinic to enjoy a long weekend!
A patient undergoes a hysterectomy and experiences post-procedural bleeding. The surgeon cauterizes the bleed and evacuates a blood clot.
Control (stopping, or attempting to stop, postprocedural bleeding) in ICD-10-PCS represents a very limited set of procedures. You will use root operation Control when the only objective of the procedure is to stop hemorrhaging after a procedure.
Procedures that fall under Control include:
- Irrigating or evacuating a hematoma at the operative site
- Ligation of arterial bleeders
- Cautery with blood clot evacuation
- Drainage at previous operative site to stop bleeding
The site of the bleeding is coded as an anatomical region and not to a specific body part. For our patient with the post-hysterectomy bleed, we would report 0W3R8ZZ (hysteroscopy with cautery of post-hysterectomy oozing and evacuation of clot).
Other Control procedures include:
- 0X3F0ZZ, open exploration and ligation of post-op arterial bleeder, left forearm
- 0W3H0ZZ, control of post-operative retroperitoneal bleeding via laparotomy
- 0W3C0ZZ, reopening of thoracotomy site with drainage and control of post-op hemopericardium
- 0Y3F4ZZ, arthroscopy with drainage of hemarthrosis at previous operative site, right knee
What happens when the physician needs to perform a more involved procedure to stop the bleeding? For example, a physician needs to resect the spleen in order to control post-procedural bleeding. Do you report a Control procedure, a Resection procedure, or both?
According to ICD-10-PCS guideline B3.7:
If an attempt to stop post-procedural bleeding is initially unsuccessful, and to stop the bleeding requires performing any of the definitive root operations Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection, then that root operation is coded instead of Control.
So for our patient who lost her spleen, we would report 07TP0ZZ (resection of spleen, open approach) or 07TP4ZZ (resection of spleen, percutaneous endoscopic approach).
Don’t look now, but mumps are making a comeback. How do we code mumps in ICD-10-CM?
In ICD-10-CM, we can assign one of the following codes for a patient with mumps:
- B26.1, mumps orchitis
- B26.1, mumps meningitis
- B26.2, mumps encephalitis
- B26.3, mumps pancreatitis
- B26.8, mumps with other complications
- B26.9, mumps without complication
One difference you’ll find is an increase in the named complications of mumps. In ICD-9-CM, we have codes for mumps hepatitis, mumps polyneuropathy, and other.
ICD-10-CM specifies these complications:
- B26.81, mumps hepatitis
- B26.82, mumps myocarditis
- B26.83, mumps nephritis
- B26.84, mumps polyneuropathy
- B26.85, mumps arthritis
- B26.89, other mumps complications
Well, that’s not so bad.
What about whooping cough (also known as pertussis), another reappearing disease?
In ICD-9-CM and ICD-10-CM, we see separate codes for whooping cough due to Bordetella, but ICD-10-CM specifies the type of Bordetella:
- A37.0, whooping cough due to Bordetella pertussis
- A37.1, whooping cough due to Bordetella parapertussis
- A37.8, whooping cough due to other Bordetella species
- A37.9, whooping cough, unspecified species
Each of those categories includes two subcategory codes to identify whether the patient has pneumonia as well. In ICD-9-CM, we needed a second code to identify the pneumonia.
Don’t worry about getting confused on this change. An Excludes1 note (not coded here) under ICD-10-CM category J17 (pneumonia in diseases classified elsewhere) tells us not to use a code from A37 and one from J17 together.
Sometimes a physician just needs to take a look around a body part and see what’s what. If the physician’s sole objective is to examine a body part, either visually or manually, report the procedure using root operation Inspection (third character J).
If the physician discontinues a procedure before performing any other root operation, you would also report the procedure using root operation Inspection.
Examples of Inspection include:
- 0WJ90ZZ, thoracotomy with exploration of right pleural cavity
- 0CJS8ZZ, diagnostic laryngoscopy:
- 0SJD0ZZ, exploratory arthrotomy of left knee:
- 0UJD8ZZ, colposcopy with diagnostic hysteroscopy:
- 0DJD7ZZ, digital rectal exam
One other thing to keep in mind: if the physician begins a procedure laparoscopically and must convert it to an open procedure, report the laparoscopic procedure is reported as an inspection.
For example, the surgeon begins a cholecystectomy using a laparoscopic approach, but must complete it using an open approach. Report an open cholecystectomy (0FT40ZZ) and a percutaneous endoscopic inspection of the gall bladder (0FJ44ZZ).
If the physician inspects the body part(s) to achieve the objective of a procedure, do not code the inspection separately.
If the physician inspects multiple non-tubular body parts in a region, report the body part that specifies the entire area inspected.
We know we’re facing at least a one-year delay in ICD-10 implementation. What you with that time? will directly affect how prepared you are for the eventual ICD-10 implementation.
Coder training: How far along are you? Are all of your coders trained? Are they in the process of being trained? How are you going to keep their skills sharp until they actually start coding in ICD-10? If you are currently dual coding, will you continue to do so? You can use this extra time to add to coders’ clinical knowledge and comfort level with ICD-10.
Documentation: Here’s where you can really use the delay to your advantage. Start updating your EHR and query forms now. You have more time to make changes and get physicians used to the changes. Not sure where your physician documentation is falling short? You have more time to pinpoint the biggest problem areas, but you need to take advantage of the extra time.
Leadership buy-in (and, of course, money): Did you have trouble getting your CFO on board with spending lots of money to revamp everything for ICD-10? He or she is probably not very happy right now. Don’t let the leadership slack off on ICD-10 implementation plans.
Physician engagement: This is probably one of the biggest hurdles to ICD-10 implementation. A lot of organizations struggled to get physicians engaged in learning documentation requirements for ICD-10 before this latest delay. I think the problem is only going to get worse. Physicians will drag their heels and say, “why should I learn this? It’s never going to be implemented.” Before you talk with your physicians, make sure you have answers ready. Explain why ICD-10 is better (more specificity, better clinical picture of the patient, use of physician terminology—think asthma descriptions). Tell them how it will help their ratings and improve patient care. Stress that we don’t want them to code, we just want them to completely and accurately document their patients’ conditions and the procedures they performed.
We have two choices when it comes to this delay: put our ICD-10 preparations on hold (not really a good plan) or find ways to use the extra time to our advantage.