ICD-10: Gaps Revealed in Physician Documentation
Training healthcare professionals in ICD-10 implementation and usage during the past two years has unveiled some gaps in the way physicians document compared to the way an ICD-10 manual is written for selection of the most precise diagnosis codes.
In order to ensure a successful transition to ICD-10, it is imperative that coders possess a much deeper understanding of physician documentation and disease processes. Providers will be in need of education on the expectations of ICD-10 and how to align documentation with coding guidelines.
With ICD-10 implementation only two years away, there are many things that must be considered as part of an effort to be prepared for the upcoming changes. First things first: the migration to the electronic version of 5010 is just two months away!
There are many improvements that 5010 will bring regarding the electronic submission of claims. For example, 5010 will allow a hospital to report whether or not a diagnosis was present on admission (POA), and it will provide clarity in the front matter sent to the payer. It is also a necessary change to allow ICD-10 codes to be reported in an electronic format. While the deadline for 5010 compliance is Jan. 1, 2012, we will not be able to use ICD-10 codes until Oct. 1, 2013.
Once a successful migration of 5010 has been completed, many will be left wondering what they can do to prepare for ICD-10 implementation. It is important to remember that individuals must receive the right training at the right time, and this training should cover anticipated areas of change related to ICD-10. Solutions and tools should be offered in order to begin the process of organizing the implementation effort. The training should have an interactive approach so as to provide a comfortable learning environment for all while also encouraging networking with peers to build professional relationships with others in the healthcare community.
Other training should include an overview of ICD-10 code and guideline changes, with additional guidance offering the ability to work through coding cases to get a hands-on understanding of how ICD-10-CM differs from ICD-9-CM.
What we are hearing from the field is that one of the most common areas of concern involves how organizations will be able to educate physicians and providers about how to document so that ICD-10-CM codes can be assigned to the highest levels of specificity. There are many challenges coders face today regarding insufficient documentation, and with the available code choices increasing from approximately 14,000 to approximately 69,000, there undoubtedly will be new challenges faced by all.
The most effective way to ensure that documentation will meet the requirements of ICD-10 is to begin performing documentation readiness assessments now. Providers will need to understand what the expectations are so they can document accordingly. It is important to perform these assessments early and offer appropriate education to staff promptly so that when Oct. 1, 2013 arrives, they already will be documenting to ICD-10 standards, making the transition seamless.
Once these assessments are performed it also is important that providers are educated on the findings so they can begin to understand and incorporate the changes in their documentation that will be required in 2013.
Another concern is how codes will be cross walked for use in electronic health records (EHR or EMR). This is an area that should be scrutinized heavily by every practice or institution. Some practices will rely primarily on their vendors for this, so it is extremely important to understand what questions to ask of the vendors as well as to determine the projected costs of any software or hardware that may be required. It is imperative that practices develop a solid understanding of how their vendors will develop the ICD-10-CM codes for their use.
An in-depth understanding of anatomy and pathophysiology also will be very important in being able to assign appropriate ICD-10-CM codes to the highest level of specificity. It is recommended that coders and billers take a refresher course on A&P to ensure a solid understanding of disease processes and the clinical language used by providers. There always have been discrepancies in the languages spoken by providers and coders. But it is the coder’s responsibility to assist providers in understanding how each patient’s condition must be reported to payers to ensure prompt and appropriate reimbursement for services.
Change is coming. The question remains, can coders facilitate the change? With proper training and education, the resounding answer is “yes.” But time is running out.
About the Author
Kimberly Reid, CPC, CPMA, CEMC, CPC-I, is the Director, ICD-10 Development and Training for AAPC.
Kim brings more than 22 years of progressive coding experience in healthcare to her role as director of ICD-10 development and training for AAPC. She has a vast range of knowledge developed from working in a variety of professional medical settings, including a large academic medical group in Vermont with 500+ physicians. Her most recent role as a senior coding educator proved her success in leading physicians and students to achieve comprehensive levels of understanding on complex coding and documentation guidelines. She is a national speaker who presents regularly on various coding topics across the country.
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Source: Written by Kim Reid, CPC, CPMA, CEMC, CPC-I