ICD-10 check-in: Six months after implementation

For the past few years, healthcare professionals have focused on ICD-10 preparation. That prep work paid off—the transition has been largely successful. But facilities are experiencing a few bumps as their focus shifts from preparation to improvement of clinical documentation and coding. We spoke with a number of CDI experts, who identified five prominent post-implementation issues and gave their thoughts on how CDI specialists can work to tackle these challenges head-on.

Procedure mapping
Some inpatient procedure codes map to an incorrect DRG, says Anny Pang Yuen, RHIA, CCS, CCDS, CDIP, director of ambulatory CDI at Enjoin. For example, nonsurgical operating room procedures— such as arterial lines—map to surgical procedure DRGs, which results in higher reimbursement and opens facilities to potential auditor scrutiny.

“This is a conundrum in the coding world,” says Yuen. “Some facilities have decided not to pick up [and report the codes], while others follow the code book and are using its guidance for any denials appeals.”

This is perhaps the most apparent transition-related issue, and it likely will not be resolved without some direction from CMS, says Laurie Prescott, MSN, RN, CCDS, CDIP, CDI education director with HCPro in Danvers, Massachusetts. The placement of an arterial line or a paracentesis generally should not boost payment by thousands of dollars by providing movement to a surgical DRG, she says, but correct use of the code set and the mapping provided by CMS allows for this to occur.

“The decision to add these codes or not is something each organization should contemplate and ensure the decision is consistently applied throughout the organization,” says Prescott. (According to a February ACDIS poll, most facilities—62%— are coding them.) “CDI specialists should work to make sure the documentation clearly supports the related diagnoses and the procedures performed so that, if challenged, the organization can support their decision,” notes Prescott.

Organizations should also investigate how private payers will respond to these DRG mappings, she says. Unspecified diagnoses With the advent of ICD-10, there are many more unspecified diagnoses— which indicate the documentation of a condition does not contain the characteristics and precise information needed to accurately code a diagnosis.

There can be consequences if these unspecified diagnoses are overused. Specific diagnoses impact severity of illness, risk of mortality, risk adjustments, and other quality indicators.

In addition, secondary diagnoses support medical necessity, resource use, level of care, and admission status, says Judy Schade, RN, MSN, CCM, CCDS, clinical documentation specialist at Mayo Clinic Hospital in Arizona.

“Even if it’s not going to change the DRG, it’s important to have specific diagnoses,” she says. “In some cases, a link is needed between the condition and the cause in order to code the diagnosis accurately.”

There needs to be a balance between getting claims out the door and complete and accurate documentation and coding, Schade says.

The goal for CDI specialists is to be proactive, not reactive, and to address high-volume unspecified diagnoses that occur within the facility. When reviewing a record, specialists should try to identify missing information that could shift an unspecified diagnosis to a specific diagnosis.

By paying attention now, CDI can help avoid payment penalties or denials in the future, says Schade, because prior authorizations, services, and costly treatment plans need specific diagnoses. Yet, clarifying six or seven unspecified diagnoses for one case can be overwhelming, Schade says.

So use multiple educational venues, such as face-to-face interaction, documentation tips, online training, case review presentations, and feedback sessions, to raise physician awareness. Involve coding colleagues in the educational efforts and create documentation tip cards for unspecified diagnoses. Give providers the details, including the information required to code a diagnosis accurately, which can include acuity, laterality, location, relationship/ cause, and organism(s) if there is an infectious process.

Through education, explain the value of documenting a more specific diagnosis to achieve the complete clinical picture of the patient.

Excludes notes
There have been several questions regarding interpretation of Excludes1 notes in ICD-10-CM when the conditions are unrelated to one another. By way of background, in ICD-9, an excludes note had two possible meanings. ICD-10-CM was set to resolve this confusion by instituting two different excludes notes— Excludes1 and Excludes2—to differentiate the meanings:

• An Excludes1 note indicates that a coder should never use the excluded code with the code above the Excludes1 note. The two conditions cannot occur together.
• An Excludes2 note means a condition is not included in the code above the note. An Excludes2 note indicates that the excluded condition is not part of the condition the code represents, but a patient may have both conditions simultaneously. When an Excludes2 note appears under a code, coders may report both the code above the note and the excluded code together, when appropriate.

According to an October statement released by the Centers for Disease Control and Prevention (CDC), there are circumstances where both conditions in the scope of an Excludes1 note should be allowed to be coded together, thus making an Excludes2 note more appropriate. However, due to the partial code freeze, no changes to excludes notes or revisions to the Official Guidelines for Coding and Reporting can be made until October 1, 2016.

In the interim, the agency detailed temporary guidance, approved by the four Cooperating Parties, which says that if the two conditions are not related to one another, it is permissible to report both codes despite the presence of an Excludes1 note.

For example, the Excludes1 note at code range R40–R46 states that symptoms and signs constituting part of a pattern of mental disorder cannot be assigned with the R40– R46 codes. However, if dizziness is not a component of the mental health condition—such as dizziness unrelated to bipolar disorder—then separate codes may be assigned for both the dizziness and the mental health condition. In another example, code range I60–I69, cerebrovascular diseases, has an Excludes1 note for traumatic intracranial hemorrhage. Codes in this range should not be used for a diagnosis of traumatic intracranial hemorrhage.

However, if the patient has both a current traumatic intracranial hemorrhage and a sequela from a previous stroke, then it would be appropriate to code for both conditions, according to the CDC’s October release. CDI specialists need to ensure that the documentation clearly establishes the relationship between the two conditions, Yuen says.

If the conditions are unrelated, the documentation must reflect this, and a query should be placed if the relationship is not clear. “It should not be a guessing game,” she says.

Electronic health records
Electronic health records frustrate physicians because they focus on coding versus clinical needs, said Robert S. Gold, MD, CEO of DCBA, Inc., during a January 19, 2016, Talk Ten Tuesday broadcast. There are two major issues.

First, the digital field on which physicians are expected to play is designed by coders using coding rules. Instead of focusing on patient care, physicians are now mandated to focus on codes.

“If you don’t get the right code,” said Gold, “you don’t get paid.”

Second, many physicians feel the support they once received from CDI specialists and ancillary staff is being replaced with computer-assisted coding or clinical documentation software.

“We’re back to ICD-10 coding language and DRGs being the prime driving force, and docs are left out of the equation altogether,” said Gold. “What physicians need is support by humans who are clinically driven, and not digital programs that are coder driven.”

Capitalize on this CDI opportunity by helping physicians get acquainted with their electronic health records and processes, said Gold. Whether it’s done by a physician advisor or a clinically astute CDI specialist, take the opportunity to educate physicians and ensure they know what coding and clinical documentation support is available to them. Include physicians when developing query templates and policies, says Yuen. They should be allowed some say when it comes to the electronic systems that they must use. CDI specialists can gather feedback and find out what works and doesn’t.

“ICD-10 and the meaningful use deadlines hit at the same time,” Yuen says. “Providers are greatly affected and upset that their EHR is taking time away from patient care. CDI staff members’ contribution to this conversation can be highly beneficial to resolve these issues.”

Finally, just because ICD-10 has been implemented does not mean coding- and documentation-related education should end. Physicians are looking for continued support, as well as education that is clinically based, not financially focused.

Work to develop ongoing educational resources for physicians and present such education in a way that makes sense to physicians: in pure medical terms, said Gold. Productivity There’s been a slight decrease in productivity with the arrival of ICD- 10, with the plurality (40%) of respondents to an ACDIS poll conducted prior to implementation reporting a 16%–20% reduction in productivity or less. At that time, 25% of respondents said they were not sure how ICD-10 would affect CDI productivity, and 34% reported a greater than 20% reduction in productivity.

The effect of ICD-10 implementation on CDI productivity has generally been less drastic than some facilities feared, Yuen says, with most finding a 20%–30% decrease. Most facilities took the opportunity afforded to them by the ICD-10-CM/ PCS implementation delays to continue their documentation education efforts. Those facilities that did not may be relying on outside contractors.

If a facility is using an outside resource that may not be operating at the appropriate skill level, it should conduct consistent audits from an internal perspective to ensure quality, Yuen says. In fact, she notes, facilities in general should evaluate their productivity and success with ICD-10.

“If you can’t report accurate data from your facility, then public data is going to be skewed,” Yuen says. “Be proactive and understand the case-mix index, specifically within an institution. That’s where CDI comes into play and can make an impact in terms of getting the correct documentation that’s going to be reported and available to the public.”

CDI specialists need to stay on top of education and not drop the ball now that ICD-10 has been here for a few months, she adds. Communication with coding is essential for success.

“Open communication will offer education opportunities among two teams and reduce duplication of efforts,” says Yuen. “Facilities can create strategies and deliver the same messages from coding and CDI to providers, who will appreciate a consistent message.”