User documentation, education and governance remain the top three issues threatening ICD-10 readiness. But another, equally disturbing practice is emerging. Many hospitals and practices have opted to let coding staff select ICD-10 codes based upon physician documentation, placing key decisions in the hands of the coders instead of clinicians.
In a recent Healthcare Informatics article, Dr. John Elion noted that certain ICD-10 PCS (procedure coding system) codes require a great degree of detail and granularity. The physician must explicitly detail a procedure and the circumstances associated with the event so that there is no ambiguity as to the correct code.
The real concern is not missing information, it is that the physician’s description is not formatted to meet the requirements of ICD-10. When this happens, then it is up to the coder, or clinical documentation improvement (CDI) specialist, to either refer the chart back to the physician for clarification, or decide themselves which code would best be applicable.
The same situation applies to clinical modification (CM) codes. For example, an ankle sprain, to be thoroughly coded to ICD-10 standards (i.e., S93.4_ _ _), requires both laterality (right-01, left-02 or unspecified-09) and the encounter (initial-A, subsequent-D, or sequellae-S) to construct the 7-digit code.
Unless all this information is present at the time of coding, then the organization must either query the physician for more detail or choose a lower value, unspecified code. Unfortunately, neither of these two options works in the organization’s favor:
Option A – If you opt to refer the case back to the physician, the chance of getting any additional information is small at best, expending valuable time with no positive result.
Option B – If your coders choose an unspecified code, then you would be able to drop a bill. However, your organization runs the risk of being graded at a lower risk and severity code, lowering reimbursement rates accordingly.
Fortunately, many electronic health records (EHRs), including all Allscripts products, provide tools to help clinicians select the right code and prompts complete documentation while charting. For those organizations that rely on paper charting, then the only real options are to develop a set of “reminder” sheets by service or specialty or rely on coders and/or CDI staff to identify these omissions and query the physician.
Whether you employ an EHR- or paper-based documentation system, now is the moment to make certain you have identified the core ICD-10 diagnoses for every specialty within your organization. Providers should be familiar with each, know what they need to document and how it should appear in the chart, and understand that every digit within the ICD-10 code has a specific meaning and purpose. It is up to the organization to make certain that providers are adhering to this process so that the financial and operational integrity remains intact.
If you’d like to learn more about how to assess, analyze, develop and implement ICD-10 readiness, contact us. Allscripts can help.
Editor’s note: If you’re looking for additional ICD-10 resources, check out Dr. Goldstein’s features in a recent IPI (International Pharmaceutical Industry) article and NRHA (National Rural Health Association) webinar.