Steven Andrews, for HealthLeaders Media , July 30, 2015
A variety of physician gripes over the coming diagnostic code implementation are deftly dismantled by coding experts from AHIMA and AAPC.
This is the second in a two-part series on physician concerns about ICD-10. Read Part I, which was initially published by Briefings on APC.
In a recent interview, Sue Bowman AHIMA senior director of coding policy and compliance and Rhonda Buckholtz, AAPC vice president of ICD-10 training and education answered questions about about ICD-10 concerns expressed by W. Jeff Terry, MD, an AMA delegate from Mobile, AL. Bowman and Terry testified at February’s ICD-10 hearing before the House Energy and Commerce Subcommittee on Health.
Bowman and Buckholtz responded to Terry’s claims and offered advice for how HIM managers and facilities can further prepare physicians for ICD-10-CM.
Q: How do you respond to physician concerns about having to document differently than they’re used to in order to accommodate ICD-10 language? What should they focus on in order to best prepare for implementation?
Bowman: Physicians may need to document more specifically to make the best use of the added detail in ICD-10-CM, but not necessarily “differently.” ICD-10-CM actually reflects updated terminology that is more in line with clinician terminology than ICD-9-CM.
For example, ICD-9-CM refers to “intrinsic” and “extrinsic” asthma, which is outdated terminology and thus not typically documented by most physicians. ICD-10-CM classifies asthma as intermittent and persistent, which is more in line with how clinicians currently document asthma.
ICD-10-CM does include greater specificity in some areas than ICD-9-CM, but this increased specificity has to do with aspects such as laterality, anatomic site, and disease severity. Fully 46% of the increased detail in ICD-10-CM is due to the addition of laterality (left or right side). Laterality does not seem like a new “ICD-10 language” and should be reflected in good clinical documentation.
Physicians should focus on providing complete and accurate clinical documentation—being as specific as possible regarding the disease type, site, severity, and laterality. The more complete and accurate the documentation is, the more complete and accurate the coding will be.
Buckholtz: Many of the concepts found in ICD-10-CM should already be captured in current documentation. They should already be familiar with common clinical indicators, such as type, anatomical location, temporal factors, and complications/manifestations.
Q: Some physicians feel too many ICD-10-CM codes exist to easily choose which diagnoses to report. What strategies should hospitals take in explaining why so many new codes exist and how to capture the most important information?
Bowman: The inclusion of expanded detail and specificity in ICD-10-CM was in response to demands for more detailed healthcare data, and the additional clinical detail was proposed by physician groups.
An increased number of codes doesn’t make it harder to assign a code. In fact, increased specificity makes it easier to assign a code because the most appropriate code is clearer than if the code titles are ambiguous.
The process of assigning a code is the same in both ICD-9-CM and ICD-10-CM. You don’t scroll down a list of codes hunting for the correct code, just as you don’t scroll through all of the pages of a phone book looking for the correct phone number, so the number of codes doesn’t affect the ease with which a code can be assigned. You still look up the clinical term in the Alphabetic Index and then verify the code in the Tabular.
Also, physicians and other providers will not use all the codes in ICD-10-CM. They will use a subset of codes based on their practice and patient population.
The clinician’s role is to provide complete and accurate documentation regarding the patient’s clinical conditions and the procedures the clinician has performed. The quality of the data depends on the quality of the clinical documentation.
Buckholtz: The amount of codes is simply not consequential. They will only use certain parts. Most won’t ever use the whole book. The best strategy is to show the physician codes most often seen in their clinical treatment.
Q: What is your opinion on the AMA or another physician group becoming a Cooperating Party? Does the current system include enough clinical input to appease physician concerns about the language or number of codes?
Bowman: There may be a misunderstanding by some physicians regarding the role of the Cooperating Parties. The Cooperating Parties are not responsible for creating the ICD-10 codes. The ICD-10-CM coding system was developed and is maintained by the National Center for Health Statistics and the ICD-10-PCS coding system was developed and is maintained by CMS. The process of developing and updating these coding systems is an open, public process that involves extensive input from the clinical community.
In fact, the vast majority of proposals regarding code language and new codes has come, and continues to come, from physician organizations. So the increased detail was requested by the clinical community as it was thought to be valuable in order to completely and accurately reflect patients’ clinical conditions and procedures performed.
Buckholtz: AAPC has lobbied for this. We believe there needs to be a group representing the physicians on the Cooperating Parties. Currently no one has the experience. AAPC and AMA can both bring a lot to the table. Physicians use the codes differently than hospitals or academic institutions.
Q: Some physicians do not believe ICD-10-CM will have any impact on patient care. What are the advantages to moving to ICD-10-CM for patients that HIM or coding managers can share with physicians?
Bowman: Improvements in patient care depend on good data, and ICD-10-CM providers much better data than ICD-9-CM. Better data for analysis and research will lead to improvements in patient outcomes and patient safety. More detail about patients’ clinical conditions means an improved ability to manage chronic diseases by better capturing patient populations as well as an improved ability to identify high-risk patients who require more intensive resources, assess effectiveness and safety of new medical technology, and manage population health.
AMA Pushes for More Delay, But ICD-10 is Necessary
Access to better data will lead to increased patient engagement (due to better data to guide consumers’ choices regarding their care). Better data will also provide better justification of the medical necessity of services provided, thereby leading to fewer denials and appeals based on medical necessity.
Buckholtz: ICD-10-CM should not have an impact on patient care. It should enhance the ability to offer services and procedures through accurate submission and documentation.
Q: How do you respond to physicians who think that waiting for ICD-11 is the best course of action?
Bowman: ICD-11 will not be released before 2017. For the U.S., that date is the beginning, not the end, of the process toward adoption of ICD-11. The process of evaluating ICD-11 for use in the U.S., developing a national modification to meet U.S. information needs, and developing a procedure coding system would take at least a decade, followed by the rulemaking process to adopt ICD-11 as a HIPAA code set standard.
Replacement of ICD-9-CM is already long overdue. Waiting until ICD-11 is ready for implementation in the U.S. is not a viable option, as waiting that long to replace the ICD-9-CM code set would seriously jeopardize the country’s ability to evaluate quality and control healthcare costs. U.S. healthcare data is being allowed to deteriorate while the demand increases for high-quality data that can support new healthcare initiatives.
Also, implementing ICD-10-CM/PCS is an important step on the pathway to ICD-11.
Buckholtz: ICD-11 is still in beta format and has not been finalized. We only have speculation. In addition, it is highly dependent on technology, which many physicians still do not have.
Q: Do you have any other advice for coding or HIM managers to share with physicians in order to help ease the transition?
Bowman: Although ICD-10-CM contains more codes than ICD-9-CM, the process of finding the right code has not changed.
No physician will use all of the ICD-10-CM codes. He or she will use the subset of codes based on clinical practice and patient population.
Focus on providing complete and accurate clinical documentation. High-quality medical record documentation is increasingly being demanded even without the transition to ICD-10. And don’t assume that details included in ICD-10-CM codes that are not included in ICD-9-CM codes will automatically require a change in documentation practices. Many new details included in the ICD-10-CM codes may already be in the documentation, such as laterality.
Consider using electronic tools, such as computer-assisted coding technology and electronic health record templates and prompts, to facilitate the coding and documentation processes. These tools can ease the physicians’ documentation burden, improve clinical documentation at the point of care, reduce physician queries, increase productivity and accuracy, and reduce costs.
Unspecified codes are still available for use when sufficient clinical information is not known or available to report a more specific code.
Buckholtz: There are many concepts that can be put into templates, helping physicians capture the extra information needed yet will not require extra work on their part. Streamlining this strategy will help.
Steven Andrews is editor of Briefings on APCs and outpatient editor of JustCoding.com.
