By Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS
The transition to ICD-10-CM/PCS requires a well-orchestrated road map and game plan. The sheer number of ICD-10-CM/PCS codes will undoubtedly require detailed clinical documentation in the record regardless of the patient setting. Unfortunately, most facilities simply aren’t prepared for the October 1, 2014 implementation.
To date, coder and clinical documentation improvement (CDI) specialist ICD-10-CM/PCS education has been general, primarily consisting of coursework in anatomy and physiology and, in some cases, a medical terminology refresher. Although this training may be well-intentioned, it merely serves as a starting point for ICD-10-CM/PCS readiness and preparation.
Some facilities have hired consultants who provide online training courses focused on the structural components of ICD-10-CM/PCS. However, one major limitation of this type and format of training is that the primary emphasis is on promoting a theoretical approach to ICD-10-CM/PCS.
Organizations must engage coders and CDI specialists in a more practical application of ICD-10-CM/PCS. First-year medical students receive on-the-job training through resident rotation and ongoing attending physician and senior physician resident mentoring. Coders and CDI specialists also require this hands-on approach to learning.
A practical approach to ICD-10-CM/PCS
Most facilities have active CDI programs. These programs are primarily geared toward enhancing clinical documentation specificity that can, in turn, increase case mix and reimbursement.
Coders and CDI specialists often review inpatient medical records to identify opportunities for increased specificity in principal and secondary diagnoses—particularly CCs and MCCs. They draft non-leading queries when clinically appropriate.
CDI initiatives generally aim to capture and appropriately report patient clinical acuity. This information then correlates with hospital resource consumption and accompanied reimbursement from third-party payers.
However, today’s CDI programs are woefully inadequate with regard to ICD-10-CM/PCS preparation.
Some forward-thinking facilities have invested the necessary time and resources. The majority of facilities have yet to recognize the magnitude of CDI efforts that will be required to meet the specificity challenges presented with the new ICD-10-CM/PCS coding classification system.
A fresh perspective
The ideal approach to ICD-10-CM/PCS preparation is to capitalize on the synergistic partnership between CDI and coding professionals.
CDI specialists work with clinicians as an integral part of their jobs. Coders work with the current ICD-9-CM coding classification system and are cognizant of current documentation limitations that may affect code assignment in ICD-10-CM/PCS. Coders can identify opportunities for documentation improvement, many of which can be implemented today—with the help of CDI specialists—even despite the lack of specificity in ICD-9-CM.
For example, ICD-10-CM classifies pressure ulcers of the lower leg as follows:
- L97.921, non-pressure chronic ulcer of unspecified part of left lower leg limited to breakdown of skin
- L97.922, non-pressure chronic ulcer of unspecified part of left lower leg with fat layer exposed
- L97.923, non-pressure chronic ulcer of unspecified part of left lower leg with necrosis of muscle
- L97.924, non-pressure chronic ulcer of unspecified part of left lower leg with necrosis of bone
- L97.929, non-pressure chronic ulcer of unspecified part of left lower leg with unspecified severity
Coders and CDI specialists can help obtain this clinically-directed documentation now. This clinical specificity regarding laterality, manifestations, cause-and-effect relationships, syndromes, and late effects can ultimately be reported and used for clinical research, outcomes studies, clinical best practices, measures of efficiency, and more.
Ccoders and CDI specialists can help obtain clinically-directed documentation now for osteomyelitis.
In ICD-9-CM, osteomyelitis is classified into:
- Acute/sub-acute
- Chronic
- Due to or associated with diabetes
In ICD-10-CM, the code sets for osteomyelitis are classified into:
- Acute hematogenous
- Other acute
- Subacute
- Chronic multifocal
- Chronic with draining sinus
- Other chronic hematogenous
- Other chronic
- Other osteomyelitis (Brodie’s abscess)
Consider osteomyelitis of the femur:
- M86.051, Acute hematogenous osteomyelitis right femur
- M86.052, Acute hematogenous osteomyelitis left femur
- M86.059, Acute hematogenous osteomyelitis, unspecified femur
- M86.151, Other acute osteomyelitis right femur
- M86.152, Other acute osteomyelitis left femur
- M86.159, Other acute osteomyelitis, unspecified femur
- M86.251, Subacute osteomyelitis, right femur
- M86.252, Subacute osteomyelitis, left femur
- M86.259, Subacute osteomyelitis, unspecified femur
- M86.351, Chronic multifocal osteomyelitis, right femur
- M86.352, Chronic multifocal osteomyelitis, left femur
- M86.359, Chronic multifocal osteomyelitis, unspecified femur
- M86.451, Chronic osteomyelitis with draining sinus, right femur
- M86.452, Chronic osteomyelitis with draining sinus, left femur
- M86.459, Chronic osteomyelitis with draining sinus, unspecified femur
- M86.551, Other chronic hematogenous osteomyelitis, right femur
- M86.552, Other chronic hematogenous osteomyelitis, left femurM86.559, Other chronic hematogenous osteomyelitis, unspecified femur
- M86.68, Other chronic osteomyelitis, other site
- M86.8X8, Other osteomyelitis, other site
Developing an action plan
Developing an action plan to practically prepare for the increased clinical specificity necessitated by ICD-10-CM/PCS is not difficult.
Begin by recognizing that it’s not feasible to incorporate all clinical code expansions into physician clinical documentation education. Instead, take on a structured approach to practical ICD-10-CM/PCS clinical documentation readiness.
When taking this approach, coders can perform the following tasks:
- Generate reports to identify commonly-coded CCs, MCCs, principal diagnoses, and secondary diagnoses. Generate reports to identify the top 20-30 most common MS-DRGs.
- Use the General Equivalence Mappings as well as the draft ICD-10-CM/PCS MS-DRG Definitions Manual to translate these diagnoses and MS-DRGs to ICD-10.
- Work in strong collaboration with CDI specialists to develop training material for physicians that promotes the specificity required in ICD-10-CM/PCS. Coders can achieve this collaboration with CDI specialists by focusing on the synergies between the two roles. An effective collaborative approach to physician education occurs when coders educate CDI specialists about specific nuances of ICD-10-CM/PCS. CDI specialists can then tailor that information to various clinical specialties, focusing on common disease processes by physician specialty. CDI specialists can use this best practice to can educate and prepare clinicians for the future of ICD-10-CM/PCS.
The million-dollar question
What are you waiting for? Overcome any objections or reluctance and begin this process. Coders’ success in ICD-10-CM/PCS ultimately depends on their own drive. Hospitals can only provide so much training and preparation. Coders, themselves, must have a vested interest in ensuring they meet their educational needs for ICD-10-CM/PCS, thereby controlling their own professional destiny.
Editor’s note: Krauss is senior manager with Accretive Health in Chicago. Reach him atglennkrauss@earthlink.net.