ICD-10-PCS queries will vary by specialty

Ask a physician why he or she documents in the medical record and you'll get a variety of answers. Some physicians will say they document because the medical records people hound them for the information, or they do it so they get paid. They may also say they do it to complete the medical record.

 

Physicians generally don't think in-depth about their operative reports, says John C. Alexander Jr., MD, MBA, a cardiac and thoracic surgeon and member of the Huff DRG Review Services ICD-10 Physician Task Force. Before ICD-10-PCS, they didn't really need to think about who was going to read the operative report.

 

In fact, the majority of operative reports were not read, he says. "The referring physician wants to know that you put in an aortic valve and two bypass grafts and that's it," Alexander says.

 

Surgeons have developed their own way of generating operative notes that serve their purposes, he adds. Operative notes across a health system generally have some degree of consistency, but when operative notes are compared across systems, you find a large degree of variability, Alexander says.

 

The goal of ICD-10 PCS is to structure a code that will invariably define an operative procedure across health systems, which then becomes the center of quality and financial assessment. However, the source document from which it is constructed is anything but consistent, says James Fee, MD, CCS, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, vice president of Huff DRG Review Services. Fee is also a board member of the Association of Clinical Documentation Improvement Specialists.

 

Coders might think that one operative report is much like another, Alexander says. "When you start to read them, you realize they aren't."

 

"The PCS portion of ICD-10 is going to be problematic," Alexander says. The language that surgeons use in operative notes is "local" and coders might struggle to code what is meant unless both coders and surgeons understand what needs to be done to get it right.

 

Coders will need to talk directly with their surgeons about what is meant by their dictations, Alexander says. Surgeons are unlikely alter their clinical descriptions to make this uniform for coders.

 

"I am always surprised to read op notes that the surgeons are completely satisfied with, but that make no sense to the coding community because of local customary language in the dictation," Alexander says. "I do not think that admonitions to the surgeons to be concise and complete will accomplish much unless both coders and surgeons understand the objective and the rules of coding."

 

The only way coders are going to be able to make sense of an operative report is to develop a relationship with the surgeons, Alexander says. "The coding community is going to have to have a relationship with the surgeons where they can say, here's what we need in that operative note and develop a strategy at the local level to get that information."

 

The number and types of queries will depend largely on the specialty, as well as the individual surgeon's documentation.

 

For example, most orthopedic procedures are performed on an outpatient basis, says George W. Wood II, MD, professor of orthopedic surgery at the University of Tennessee Center for Health Sciences in Memphis and a member of the Huff DRG Review ICD-10 Physician Services team. Even total hip and knee replacements are now done on outpatients, although they remain primarily inpatient procedures.

 

Coders will continue to report those outpatient services with CPT^® codes. However, inpatient orthopedic surgeries could present a significant challenge because they are often very complex and involved, Wood says.

 

Orthopedic surgeons usually dictate a note so it can be checked later to determine the approach, implant, and any specific graft that was used because these implants may require revision or removal many years later. Unfortunately, this detail may or may not be enough for ICD-10-PCS coding, Wood says.

 

Devices may also present problems for inpatient orthopedic procedures. Surgeons often refer to a device by manufacturer name, Wood says. The coder may or may not know what type of device that is. For example, a surgeon performs a hip replacement. The ICD-10-PCS table provides the following choices for the device:

If the surgeon documents DePuy Elite Plus Ogee Cup, the coder may not know the surgeon used a cemented ultra-high molecular weight polyethylene implant.

 

"As a result, the coder may have to Google the device," Wood says. "Sometimes, that doesn't even help because a lot of the devices have multiple parts."

 

Coders will likely see a higher volume of cardiac procedures than orthopedic ones because many are performed on an inpatient basis. Many of these procedures, such as coronary artery bypass grafts (CABG) and Maze procedures will present coders with specific challenges, Alexander says.

 

Mitral valve repair procedures are going to be coded using root operation Supplement, which will not fit with the verbiage used by surgeons, he adds.

 

"I think each institution will have different issues once PCS coding begins because of local language habits," Alexander says.

 

The only way to make any sense of the procedures and documentation is for coders and physicians to develop a good working relationship with each other, Alexander says.

 

Too often the relationship is adversarial, Alexander says. "Interestingly I think this adversarial relationship is created because of the rules of the road for coders, i.e., no assumptions and if it is not expressly stated it cannot be coded."

 

Once the surgeons really understand the query process, they tolerate it much better, he adds. "When you are asked questions that you think are obvious, you lose trust in a coder, which breeds animosity."

 

The best way to get everyone on the same page is to ask the surgeons to explain the procedures to the coders. That way, coders can learn not only what the procedure itself is, but also how their surgeons perform it, Alexander says.

 

At the same time, coders and CDI specialists need to communicate to the surgeons why this is important. In the past, surgeons regarded coding as something that is done in the basement of the hospital by people they didn't know, and they didn't want to be bothered by coders, Alexander says.

 

"Unfortunately, I think that attitude is pervasive," Alexander says. "That's really got to change because coding is going to be very important. I don't know if any of the surgeons are going to take it seriously until they get hit in the face with denials and revenue shortfalls at the facility level."

 

Coders need to remember that surgeons want to do a good job, Alexander says. But they need to know the rules of the road. They also don't want to be viewed as being difficult, so coders needs to help them understand what they need to do differently.

 

ICD-10-PCS does not require coders to use the Alphabetic Index. Once you know the root operation, you can go straight to the table. However, you do need to consider the evolution of the disease process, Fee says.

 

Sometimes coders have to use the index because the original procedure is coded based on the original condition and not the evolution of the condition. That becomes a significant complexity.

 

Consider a subdural hematoma. The ICD-10-PCS Alphabetic Index instructs coders to report root operation Extirpation because the initial physiological process of a hematoma means it has particle matter in it, Fee says. The physician is removing both liquid and clot material.

 

If the physician doesn't drain the subdural hematoma until later in the process when it becomes chronic, the hematoma is more liquid. That raises the question of whether coders should use root operation Drainage, Fee says.

 

The ICD-10-PCS Official Guidelines for Coding and Reporting state that the coder must choose the root operation based on the intent of the procedure. Physicians are not required to specify the root operation in their documentation. The physician can document evacuation of a hematoma.

 

Organizations should already have identified the most common operations performed, Wood says. Make sure coders can code those operations well. Resolve any coding errors or lack of documentation in those procedures first.

 

"After that, you'll be left with a smaller number of less common operations," Wood says. For those procedures, coders can spend a little more time looking at the operative report and determining the code and any documentation shortcomings.

 

Coders and CDI specialists will likely send quite a few queries in the initial months after ICD-10-PCS implementation, Wood says. However, they can reduce the number of queries and improve the actual queries by doing some work now.

 

Look at standard descriptions of operations and try to pre-code them, Wood suggests. Then determine whether the coding accurately represents the procedure. "I really think when you look back at standardization, you should look back at the textbooks, which will explain some of these operations," he says.

 

One of the things coders won't find in standard operative reports is the implant. Hopefully physicians will realize that other physicians don't use the same implants they do, Wood says. If the patient goes elsewhere, the patient and new treating physician need to know what implant was inserted and may need to be removed.

 

Coders and CDI specialists can help surgeons prepare now, Wood says. Consider creating simple cards that list the information the surgeon needs to document. For a joint replacement, coders need to know exactly what part(s) the surgeon removed, what parts the surgeon repaired, and what parts were

put in.

 

Recruit your facility's physician advisor to help, Fee says. The physician advisor is typically a medical specialist, but he or she can branch out to talk to surgeons in various specialties. The physician advisor can work with the surgeons to compile a list of common devices and approaches used.

 

"Often it's going to be a case of clinical understanding," Fee says. "The more physicians are involved, the better, and the more specialty physicians involved, the better."

 

Larger facilities may also develop specialty-specific coders, Fee says. Those coders would be able to build relationships with the physicians and would develop a good understanding of what procedures are performed, how the surgeon performs it, and what, if any, devices are commonly used.

 

Consider adding templates to your electronic medical record to prompt surgeons to document specific information. Make sure the template allows surgeons to include individual information, Wood says.

 

Many coders and CDI specialists may be worried about how to get queries in front of surgeons. After all, surgeons aren't used to seeing queries for most procedures and often aren't providing daily care during the recovery period.

 

No single approach will work well for every surgeon, Wood cautions. Some physicians carry a cell phone everywhere, so sending a message to their phones might be the best way to query them. Other physicians would rather get a query by email.

 

Talk to the individual surgeons and learn their preferences. They'll be more likely to respond to a query communicated through their preferred method, Fee says. "Don't try to force a general approach. Find ways to customize how you send queries."

 

Editor’s note: This article was originally published in the August issue of Briefings on Coding Compliance Strategies. Email your questions to editor Steven Andrews at sandrews@hcpro.com.