Encouraging Your Doctors to Come On Board the ICD-10 Train
Erica Remer, MD, FACEP Clinical Documentation Education Coordinator
of UH
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floccinaucinihilipilification the action or habit of estimating
something as worthless
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Biggest concern about ICD-10 in a poll done by ICD-10 Monitor
in January 2013
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Why is this so challenging? Doctors arent businessmen Doctors
really just want to take care of the patients They think the coding
is clerical They dont see the utility of ICD-10 Their time is
constantly being stretched They think modifying documentation is
fraud
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CMS position We do not believe there is anything inappropriate,
unethical, or otherwise wrong with hospitals taking full advantage
of coding opportunities to maximize Medicare payment that is
supported by documentation in the medical record. CMS 2008 IPPS
Final Rule
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Why is this so challenging? Schizophrenic coding and billing
Pro vs. technical side
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How to talk to the doctors What do they know? What
misconceptions do they have? What do they care about? How can you
get them to invest? What turns them off? How can you tailor your
discussion to the doctor?
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Reality Check ICD 9 has run out of space
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ICD 10 It is not just a revised and bigger version of ICD 9
(13,000 vs. 68,000 in CM) In many ways, it is much BETTER than ICD
9 (more detail, specificity)
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Reality Check LOTS OF PHYSICIAN INPUT
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Reality Check ICD-10 is coming! October 1, 2014
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Reality Check Documentation is not a waste of doctor time.
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Goal: Improved documentation Consequences: Support ICD-10
which, in turn: Better quality measures Capture revenue
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Better documentation trend quality and outcomes decrease errors
improve communication impact multidisciplinary care improve data
mining facilitate research public health surveillance global
comparability
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Whats in it for ME?! SOI/ROM, mortality index, CMI, LOS
Physician profiling and National Registries Consumer health sites
(Healthgrades) Quality reporting, QA committee reviews, Mortality
reviews Physician utilization profiles (efficiency metrics)
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Analogies for your arsenal Dictionary analogy Windows 98
Polaroid camera
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Why IS more specificity better? Respiratory distress Tachypnea
Nasal flaring, retractions Acute hypoxemic respiratory failure
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ICD 10 CM New sensible structure Characters 1-3 category 4-6
etiology, anatomic site, severity or other clinical detail 7
extension Need the full complement of characters H 4012 1 3
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ICD 10 CM example S52Forearm Fracture S52.5Fracture of lower
end of radius S52.52Torus fracture of lower end of radius
S52.521Torus fracture of lower end of right radius S52.521ATorus
fracture of lower end of right radius, initial encounter, closed
fracture (813.45Torus fracture of radius)
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More Codes 40% more codes in respiratory and digestive diseases
16 times more codes in musculoskeletal and connective tissue
disorders 26 times more codes to enumerate causes of injuries
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You already know it all! Not new medicine Not new procedures
Not new information Just need to document what you know!
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ICD 10 CM example T82Complication of cardiac and vasc
prosthetic devices, implants, and grafts T82.5Mechanical
complication of other cardiac and vascular devices and implants
T82.53Leakage of other cardiac and vascular devices and implants
T82.531Leakage of surgically created arteriovenous shunt
T82.531DLeakage of surgically created arteriovenous shunt,
subsequent encounter (996.1Mechanical complication of other
vascular device, implant, and graft) 1 code in ICD 9 to 156 codes
in ICD 10
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ICD-10-PCS Section Body System Root Operation Body Part
Approach DeviceQualifier 0 0 B 0 0 Z X Medical & Surgical CNS
Excision Brain Open No Device Diagnostic
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Benefits of specific documentation Eliminate wasted time
reading to figure out what the patient had or what procedures were
done G81.01 Flaccid hemiplegia affecting right dominant side
Eliminate risk of poor documentation: Medical necessity Compliance
Legal Revenue cycle Denials Audits Improve quality of care
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Example Crohns dxd 6 mo ago by colonoscopy. Flaring up with
cramping, diarrhea, abdominal pain, and melena. Repeat colonoscopy
shows abscess with bleeding. K50.80 = Crohns of both small and
large intestine without complications K50.814 = Crohns of both
small and large intestine with abscess
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Example Short order cook burns right forearm, and a week later
burns left forearm T22.211A = Second degree burn, right forearm,
initial encounter. T22.112A = First degree burn, left forearm,
initial encounter
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Research Heaven W 58 Contact with animate mechanical forces
W58.01 = Bitten by alligator W58.02 = Struck by alligator W58.03 =
Crushed by alligator W58.11 = Bitten by crocodile W58.12 = Struck
by crocodile W58.13 = Crushed by crocodile
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Specificity is good W00.1XXA = Fall from stairs and steps due
to ice and snow, initial encounter Contribution of tobacco,
alcohol, and drugs Medication underdosing
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Nonspecific codes will still exist Scheduling and registration
delays Delays in coding Increase in queries Increase overall
billing cycle time Increase A/R days Increase in medical necessity
questions and denials Increase in rejected claims Decrease in
reimbursement Increased scrutiny by CMS and OIG
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GEMs will not be the answer GEM = General Equivalence
Mapping
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Costs DRG shifts Coder productivity will go down 20-50% MD
productivity will go down 10-20% Patient dissatisfaction with
delays and resubmissions
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Hospital Providers
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Solutions Peer to peer ICD 10 education, workshops, and staff
meetings Online, self paced learning Webinars Website repository of
information Smart phone apps and mobile resources Simulation
training EHR prompts, drop down lists, templates
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Solutions Peer to peer ICD 10 education, workshops, and staff
meetings Online, self paced learning Webinars Website repository of
information Smart phone apps and mobile resources Simulation
training EHR prompts, drop down lists, templates
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Solutions CDISs Queries Printed resources, cheat sheets
Demonstrations, modeling E-mails One on one meetings Data
crunching
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Physician Champions Love a challenge Have knowledge, skills,
and talents Like to break down barriers Can recognize and reach out
to colleagues who might not think this important, dont handle
change well, or who think ICD 10 is a coder problem Can articulate
in doctor-speak
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Tailor Education for Service Line Cardiology Dermatology
Emergency Medicine Endocrinology Infectious Disease Neurology
Obstetrics Psychiatry Surgeons
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. Copyright 2014 University Hospitals ICD-10 Specialty Specific
Conditions Ophthalmology
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ICD 10 CM Timing Exact date or number of days or weeks as
opposed to recent, current, prior, previous MI, OB Frequency:
single episode, recurrent, paroxysmal, intermittent, persistent,
status, transient Asthma, atrial fibrillation, migraine Initial,
subsequent, sequela, late effect CVA, injury
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Acuity Acute, chronic, acute on chronic, exacerbation of,
decompensation CHF, pancreatitis, DVT, pericarditis, sinusitis
Severity Mild, moderate, severe Depression, asthma, glaucoma,
malnutrition ICD 10 CM
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Type Type 1 vs 2; systolic vs diastolic; native vs bypass
(autologous, biological); idiopathic vs primary, secondary, drug
induced; STEMI vs NSTEMI vs Type 2 DM, CHF, CAD, gout,
thrombocytopenia, MI, fractures Staging Mild, moderate, severe;
Numbered stages Decubiti, CKD, glaucoma, ROP, syphilis ICD 10
CM
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Laterality Right, left, bilateral Musculoskeletal, paired
organs, heart, colon Location/Anatomic Detail Need specificity
Diverticulitis or osis, Crohns: large +/or small intestine Adhesion
lysis: cant say intraabdominal or abdominal EGD: location, not by
measurement Vessel: which one? ICD 10 CM
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Associations or linkages Etiology-caused by, due to, secondary
to Association-with or without Manifestation-causing, with May be
able to be described in several different ways to get to the same
linkage ICD 10 CM
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Etiology Infection Organism, mechanism (aspiration, due to
Foley) Traumatic Cerebral bleed, chronic pain Pathologic fracture
From metastasis, osteoporosis Arthropathy Rheumatoid or
osteoarthritis, DM (Charcots), gout, syphilis Induced Drug,
chemical, alcohol, lead Complication of procedure ICD 10 CM
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Miscellaneous adjectives Dominant vs nondominant Neuro
conditions, like monoplegia, affecting dominant side Intractable vs
not intractable, refractory Migraine, epilepsy, headache Displaced
vs not displaced Fractures Congenital vs acquired Controlled vs
poorly controlled ICD 10 CM
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If injury, think episodes of care: Actual injuries, like burns,
sprains/strains, fractures/dislocations/subluxations, traumatic
brain injury, spinal cord injury External causes, like accidents,
falls, exposure to smoke, fire, or heat, assault Complications of
implants, prostheses, devices, like infection, displacement,
dislodgement, etc. Poisonings, allergic reactions Episodes of
Care
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Use, abuse, dependence, in remission, poisoning External causes
Location where did the injury happen? Circumstances how did the
injury happen? V95.41XA Spacecraft crash injuring occupant, initial
encounter ICD 10 CM
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