Prepare for increased queries in ICD-10-PCS

ICD-10-CM will still allow coders to report unspecified codes. However, coders will not have that option in ICD-10-PCS. Every character has to have a value.

 

"You don't have the option of putting a Z wherever you want just because you don't know that value," says Cheryl Ericson, MS, RN, CCDS, CDIP, clinical documentation improvement (CDI) education director for HCPro, a division of BLR, in Danvers, Massachusetts.

 

The biggest growing pain is going to be figuring out what CDI specialists will need to query compared to coders, Ericson says. "We have to find that threshold of when are we nitpicking versus what's relevant." 

 

Coders and CDI specialists will not need additional information for every surgical case, of course, and some of the characters will be obvious.

 

For example, coders should be able to determine the section of the ICD-10-PCS Manual fairly easily. The majority of procedures fall into the Medical and Surgical section.

 

Other information, such as the body system, body part, root operation, and approach, may not be so simple to determine, says Lynn Salois, RHIT, CCS, CDIP, senior director of coding for MRA in Quincy, Massachusetts.

 

In ICD-9-CM Volume 3, it is appropriate for the physician to just indicate the large intestine when documenting a colon resection, Salois says. But in ICD-10-PCS, the surgeon needs to be much more specific about which portion of the intestine was removed. The table for colon resection (0DT) includes specific body part characters for:

 

The body part specificity may also affect root operation selection. Root operations excision and resection both involve cutting out or off, without replacement. The only difference is that an excision removes a portion of the body part, while a resection removes the entire body part.

 

If the physician documents a resection of the large intestine, coders don't know whether the physician removed the entire intestine (resection) or only part of the large intestine (excision). If the physician removed the entire right large intestine, coders are back to root operation resection.

 

"Excision and resection are going to be a definite problem area because you have to know how the body part is defined by ICD-10-PCS, which may or may not include parts of the whole organ," Ericson says.

 

The specificity of the body parts will create a problem for surgeons. Unlike pictures in textbooks, actual large intestines do not have indicators to show where the ascending colon ends and the transverse colon begins.

 

Amputations will be another troublesome procedure, Ericson says. For detachment procedures of the lower limb, physicians must document where the detachment occurred:

 

When the site isn't defined as the hindquarter, femoral, or knee region, then the detachment requires reporting a qualifier character of high, mid, or low to identify the level of the amputation. The physician documentation will need to be very clear so coders can select not only the correct body part, but also the correct qualifier, Ericson says.

 

In fact, just determining the root operation could be a challenge. "The root operations don't exactly fit into the lingo that we're accustomed to in ICD-9," Salois says.

 

Physicians don't need to understand the root operation types or document the root operation name.ICD-10-PCS guideline A11 states:

 

"We really need the physicians to describe the procedure that's being performed so that the coder can then accurately translate those clinical terms to the root operations," Salois says.

 

Coders may also struggle to determine the approach. ICD-10-PCS includes seven different approaches, but not all can be reported for every procedure. "The surgeons need to be very, very clear in their documentation," Salois says.

 

Devices are another potential problem area, Salois says. ICD-10-PCS defines devices in a very specific way. Only material that is integral to the procedure or remains in the patient after completion of the procedure in a fixed location (i.e., isn't absorbed or incorporated into the body) is classified as a device.

Six root operations always require a device character other than Z (no device). Those devices are very specific in nature.

 

For example, if the physician repositions a lower leg bone, coders have the following device choices:

 

Querying for procedures will be new for everyone involved, Ericson says. When it comes to clarification regarding ICD-9-CM Volume 3 procedures, CDI specialist queries are generally limited to details about debridement cases. CDI specialists aren't used to sending surgical queries, and surgeons aren't used to receiving them. However, CDI specialists are in the best position to query physicians, Salois says. "I really think these queries should be sent at the point of care."

 

Think about a surgical procedure, Salois says. The surgeon may operate within the first three days of the patient's stay. The patient remains in the hospital for another five days, but the surgeon is only involved in the immediate postoperative care.

 

If CDI specialists are reviewing records concurrently, they can identify missing documentation and reach out to the surgeon.

 

However, if no one reviews the documentation concurrently, a coder may be the one who finds information missing after the patient is discharged. Depending on the turnaround time at the coder's facility, that discovery could come as many as 10 days after the surgeon performed the procedure.

 

"We've created a situation where you have to query retrospectively and the physician may not be approachable or available," Salois says. 

 

In some cases, coders will be able to obtain the information they need without querying a physician. For example, when a physician inserts a peripherally inserted central catheter (PICC), coders need to know the end point in order to code the procedure. The surgeon may not clearly identify that end point. But instead of querying the physician, coders can use the radiologist's report to find the PICC line's end, Salois says. Coders and CDI specialists may need to work with the radiologists to make sure providers understand what they need to document.

 

"There will be times when we can use other documentation in the record to assist us and thus avoid needing to go back and query the physician," Salois says.

 

Coders and CDI specialists may disagree about when to query, Ericson says. Coders are instructed to code to the highest level of specificity possible, so they may expect the CDI specialist to query for very precise details that the CDI specialist and surgeon may consider irrelevant.

 

"CDI [specialists] are good with guesstimates, so we're going to have to find commonality on how much specificity is necessary versus how much specificity will be nice to have," Ericson says.

 

Coders and CDI specialists can do some additional work on their end to prepare for ICD-10-PCS. Consider inviting physicians to explain procedures to coders and CDI specialists. This can help train coders and CDI specialists, reduce the number of queries, and build relationships between surgeons and coding staff.

 

Remind physicians that they don't need to change the way they document, Salois says. Instead, ask them to provide some specificity to enhance the record.

 

Coders can use the remaining time before implementation to strengthen their skills in ICD-10-PCS, Salois says. Most coders will be fine on the diagnosis side, but failing to understand the root operation definitions will cause problems, she notes. This lack of knowledge will slow down productivity and result in incorrect queries or missed query opportunities. 

 

Surgeons receive very few queries right now and many involve excisional debridement.

In addition, CDI specialists rarely query surgeons for diagnoses, Ericson adds. They usually query hospitalists about diagnoses because hospitalists are involved in treating the patient. However, only the surgeon can answer questions about the procedure.

 

Getting a query in front of a surgeon could also be a problem, Ericson says, especially with electronic medical records (EMR). Surgeons are paid on a global rate, so they don't need to evaluate the patient on a daily basis. They do still stop by and check on the patient, but "you don't get a lot of information because they are not being paid to do that daily assessment," Ericson says.

 

Use a physician champion to find out the best way to get the query in front of the surgeon, Salois says. Try to make the query process as unobtrusive as possible. "It's really important that we understand and respect the workflow of the surgeons," Ericson adds—that might mean working different hours. "We have to adjust our workflow to accommodate them."

 

Be creative in getting surgeons on board with answering queries, Ericson says. For example, many surgeons use boilerplate language for their operative notes. Find out if the surgeons will allow modifications to the boilerplate to capture information about specific anatomic locations or device types, she says.

 

Also consider adding prompts to the EMR or modifying those templates, Salois says. Compare the information currently captured in the EMR to the information needed to assign an ICD-10-PCS code. See where the gaps are and begin to develop queries from there, she adds. 

 

Most physicians should already be aware of the upcoming switch to ICD-10-PCS and should have some idea of what information they will need to document from earlier training sessions. Now is a good time to revisit that education, Salois says. Be careful not to panic physicians. Remind them that they don't need to change the language in their documentation; they just need to add some specificity.

 

Through the dual coding process, coders should focus on high-volume operative procedures, Salois says. Coders and CDI specialists can then identify common documentation shortcomings for those procedures and proactively begin the query process.

 

Surgeons don't need to know the root operations, devices, or qualifiers, so don't focus on those topics, Ericson says. Instead, work with physicians to make sure they are documenting the information the coder needs to assign the character.