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©2014 The Advisory Board Company • advisory.com
What You Need to Know About ICD-10 Documentation in an ICD-10-CM/PCS World
A Physician Practice Perspective
Revenue Cycle Solutions Consulting & Management Services
©2014 The Advisory Board Company advisory.com 2
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©2014 The Advisory Board Company advisory.com 5
About Today’s Speaker
Shamim Noorani, MPH
• Project Lead for The Valley Hospital’s ICD-10 Implementation Initiative
• Has partnered with large health systems and community hospitals to improve
revenue cycle performance
• Works with multiple Advisory Board members on ensuring a successful
transition from ICD-9 to ICD-10
• Other areas of concentration include strategic planning, market analysis, and
revenue cycle optimization
Shamim Noorani, MPH
Associate Director
202.568.7147
For more information, contact:
©2014 The Advisory Board Company advisory.com
Our Firm in Brief
RESEARCH
AND INSIGHTS
• Dedicated to the most
pressing issues and concerns
in health care
• 300+ industry experts
on call
• 200+ customizable forecasting
and decision-support tools
Memberships Offering Strategic
Guidance and Actionable Insights
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TECHNOLOGIES
National Peer Collaboratives Powered
by Web-Based Analytic Platforms
• Leading provider: Over 50% of
inpatient admissions in the United
States flow through our technology
platforms
• Over 1.5 million user sessions
annually
• Key challenges addressed:
physician performance, population
health, revenue cycle, referral
growth, surgical profitability, and
supply/ service cost
CONSULTING
AND MANAGEMENT
Seasoned, Hands-On Support and
Practice Management Services
• 2,500+ years of “operator”
experience in hospital and
physician practices
• Principal terrains: hospital-
physician alignment/practice
management, transition to value-
based care, revenue cycle
optimization, hospital margin
improvement
• Range of engagements from
strategy/diagnostic to best
practice installation to interim
management to fully managed
services
TALENT
DEVELOPMENT
Partnering to Drive Workforce
Impact and Engagement
• Impacted the achievement of
76,000+ executives, physicians,
clinical leaders, and managers
• 17,000+ outcomes-driven
workshops tailored to partners’
specific needs
Survey Solutions
• Customized strategies for
improving employee and
physician engagement
• National health care-specific
benchmarking database of
480,000 respondents
165,000+ health care leaders
served globally
$500+ million in realized
value per year
1,300+ engagements
completed
6,200+ employee-led
improvement projects
3,600+ 2,200+ 1,500+ Hospitals and health care
organizations in our membership
Health care
professionals employed
Hospitals using our
performance technologies
6
©2014 The Advisory Board Company advisory.com 7
The Valley Hospital’s ICD-10 Physician Education Approach
A Three Phased Approach
1
Better indication of
Severity of Illness
(SOI) and Risk of
Mortality (ROM)
January-March 2014
• Distribute high-level physician awareness
• Begin ICD-10-related messaging in Med Staff
Bulletin
• Launch Physician Champion Intensive
• Schedule specialty specific education sessions
April – September 2014
• Initiate specialty specific physician education
• Provide tip sheets to physicians by specialty
• Host on-site sessions and offsite webinars for select focus areas
• ICD-10 case study examples and focused messages
October- December 2014
• Ongoing education and support
• Reinforcement of ICD-10 concepts
• Sustainability plan
What is in it for ME?
2
3
4
Better information to
support and drive
quality of care
Greater specificity
provides insight for
patients and other
providers
Greater opportunities
for advanced medical
research
5
Completion of the
ICD-10 specialty
specific training
curriculum will
provide CME credits
Phase 2 Phase 3 Phase 1
Protect your bottom
line
6
©2014 The Advisory Board Company advisory.com
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Road Map for Discussion
8
Impact on Physician Practices
Documentation Best Practices
Resources and Q&A
ICD-10-CM/PCS: What Changes?
©2014 The Advisory Board Company advisory.com 9
ICD-10-CM/PCS: What Changes?
ICD-9 Deconstructed
Understanding where we are…
History of ICD-9
• World Health Organization (WHO) endorsed ICD-9
codes for use worldwide
• U.S. developed clinical modification (ICD-9-CM) in
1979
• Expanded number of diagnosis codes; developed
inpatient procedure coding system
ICD-9 Uses Today
• Calculate Payment: Medicare Severity-Diagnosis
Related Groups (MS-DRGs)
• Adjudicate Coverage: diagnosis codes for all settings
• Compile statistics
• Assess quality
Current ICD-9 Users
• ICD-9-CM Diagnoses: used by all types of providers
• ICD-9-CM Procedures: used only by inpatient
hospitals
• Current Procedural Terminology (CPT): used for all
ambulatory and physician procedure reporting
Why a New System?
• ICD-9 cannot accurately describe the diagnoses and
inpatient procedures of care delivered in the 21st
century
©2014 The Advisory Board Company advisory.com 10
ICD-10-CM/PCS: What Changes?
ICD-10-CM/PCS Quick Facts
…to understand where we’re going…
Source: Nichols, J.C. (2011). ICD-10 – A primer. Advisory Board
Applications and Technologies Collaborative.
ICD-10 Regulatory Requirements
• All HIPAA transactions will require the use of ICD-10-CM/PCS codes
• The compliance deadline is October 1, 2014
• Institutional, outpatient and professional services claims submitted with a date of service or
discharge on or after the compliance deadline must contain ICD-10-CM (diagnosis) codes
• ICD-10-PCS (procedure) codes will also be required for inpatient institutional services only
• CPT codes remain unchanged as a means to define procedures conducted in the clinic and
physician practice settings
Significant Changes on the Horizon
This migration from the current ICD-9 standard to the ICD-10 standard will represent one
of the greatest changes in health care information in many years.
Joseph C. Nichols, MD
”
©2014 The Advisory Board Company advisory.com 11
ICD-10-CM/PCS: What Changes?
October 1, 2014 Transition from ICD-9-CM/PCS to ICD-10-CM/PCS
Add Source: 2011, The Clinical documentation Improvement
Specialist's Guide to ICD-10 p.9 Glenn Krauss, BBA, RHIA, CCS,
CCS-P, CPR, C-CDI, CCDS and Sylvia Hoffman, RN, C-CDI, CCDS.
Benefits and Goals of ICD-10-CM/PCS
• Provides better detail and a more accurate depiction of patient
severity
• Improves care management of patients
• Obtains reliable and robust clinical data that can be used to make
intelligent, data-driven decisions related to all aspects of health care
• Allows for more accurate payment for new procedures
• Improves disease management through capture of morbidity and
mortality data
• Offers a better understanding of the value of new medical procedures
• Provides more specific data to address global disease emergencies
• Reduces the number of miscoded, rejected and improper claims for
reimbursement
• Provides comprehensive data for improved fraud and abuse
monitoring
©2014 The Advisory Board Company advisory.com 12
ICD-10-CM/PCS: What Changes?
ICD-10 Substantially Increases Code Volumes
~14K
~68K
~4K
~87K
ICD-9 ICD-10
Diagnosis Codes Procedure Codes
ICD-10 Code Set Characteristics
Increase in Codes from ICD-9 to ICD-10
Percentage of ICD-10
codes related to
musculoskeletal conditions
Percentage of ICD-10
codes related to fractures
Percentage of ICD-10-CM
codes that are different
due to distinguishing
between “right” vs “left”
>50%
~25%
36%
©2014 The Advisory Board Company advisory.com 13
ICD-10-CM/PCS: What Changes?
ICD-10-CM Captures More Information
New codes are more descriptive
Characteristic ICD-9-CM Diagnosis Codes (Vol. 1 & 2) ICD-10-CM Diagnosis Codes
Field Length 3-5 characters (except for the 1st character for
“E” and “V” codes) 3-7 characters
Acuity Capture Limited inclusion of co-morbidities,
complications, severity, manifestation, and, risk
Includes many of these parameters within
codes
Laterality Does not distinguish laterality (left vs. right vs.
bilateral)
Usually includes laterality where
appropriate
Encounter Does not define initial vs. subsequent
encounters Includes these concepts
Available Space for New Codes Expansion ability is limited
Alphanumeric support and place holder
characters provide significant ability to
expand the codes sets
Consistency of Terms Consistency of terms and definition has been a
challenge
Consistency for terms and concepts has
been improved
Code Combination Combination codes are limited
Combination codes are frequent, with
multiple distinct medical concepts per
code
©2014 The Advisory Board Company advisory.com 14
Introduction to ICD-10-CM Diagnosis Coding Structure
ICD-10-CM codes will contain 3-7 alphanumeric characters with the following structure
α # α/#
α/# α/# α/#
Category Sub-categories (Etiology, Anatomic Site, Severity, Laterality,
Complication)
Extension
(3-16 options
depending on
category)
α/#
Key ICD-10-CM Documentation Concepts
Specific anatomical location
Degree (mild, moderate, severe, or
unspecified; total/complete vs
partial/incomplete)
Type (primary, secondary, unspecified) Episode of Care (Initial, Subsequent,
Sequelae)
Acuity (acute, subacute, chronic, acute on
chronic, or unspecified ) Laterality (Right, Left, bilateral, or unspecified)
Trimester (1,2,3,unspecified) Number of fetus (1-5, other)
©2014 The Advisory Board Company advisory.com 15
ICD-10-CM/PCS: What Changes?
More Specific Codes Requires More Specific Documentation
Physician documentation drives successful ICD-10-CM coding
A provider sees a patient in a [subsequent encounter] for a [non-union] of an [open] [fracture] of the [right] [distal] [radius]
with [intra-articular extension] and a [minimal opening] with [minimal tissue damage]
ICD-10 Code Description
S52571M Other intra-articular fracture of lower end of right radius, subsequent encounter for open fracture
type I or II with nonunion
ICD-9 Code Description
813.52 Other Open Fracture of Distal End of Radius (Alone)
For all codes related to fractures of the radius:
• Volume of ICD-9-CM codes = 33
• Volume of ICD-10-CM codes = 1,818
©2014 The Advisory Board Company advisory.com 16
ICD-10-CM/PCS: What Changes?
All Codes Change
No Familiar Favorites to Choose From
ICD-9-CM ICD-10-CM
250.02
Diabetes mellitus without
mention of complication, type II
or unspecified type, uncontrolled
E11.65
Type 2 diabetes mellitus with
hyperglycemia
250.43
Diabetes with renal
manifestations, type I [juvenile
type], uncontrolled
E10.21
Type I diabetes mellitus with
diabetic nephropathy
AND
E10.65
Type I diabetes mellitus with
hyperglycemia
Well… Not Exactly…
Required ICD-10 Concepts: Type, Clinical details of disease manifestation or complications
”
Not much will change. I use 250.0x for diabetes in my office now. In the future, I will still use 250.0x. I will just need to add more information in the record to support it.
VPMA
300+ bed facility
©2014 The Advisory Board Company advisory.com
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Road Map for Discussion
17
Impact on Physician Practices
Documentation Best Practices
Resources and Q&A
ICD-10-CM/PCS: What Changes?
©2014 The Advisory Board Company advisory.com 18
Impact on Physician Practices
Impact Spans Acute and Ambulatory Settings
Addressing documentation and query impacts
Documentation
• Additional clinical details must be noted.
Queries
• Additional requests from coders attempting to enter procedures and diagnoses
into information systems.
• Additional requests from documentation improvement staff.
Hospital:
Coding Challenges
Potential physician workflow disruptions
derive from new documentation
requirements and increased query
volumes that may exist to facilitate code
assignment.
©2014 The Advisory Board Company advisory.com 19
Impact on Physician Practices
Challenges in the Physician Practice Area
Coding challenges yield operational and financial impacts
Drivers of Coding Challenges
• Insufficient physician documentation
• Code structure, number, detail,
rules, sequencing, definitions, and
relationships
• Paper encounter form
Physician documents
patient and
procedure details
Coder tries to
crosswalk codes
Increase in denied
claims from payer
Coding Challenges Operational Challenges Financial Challenges
What it Affects
• Practice management system
• Encounter form
• Staff training
©2014 The Advisory Board Company advisory.com 20
Impact on Physician Practices
Impact on Day-to-Day Operations
ICD-10-CM creates structural challenges in the physician office
Source: Nichols, J.C. (2011). ICD-10 – Physician impacts. Advisory
Board Applications and Technologies Collaborative.
Drivers of Operational Challenges
• Workflow disruptions
• Training time
• Coding productivity
• Updates to electronic health record
systems
• Redesign of the encounter form
Create and Implement Strategies Early
to Prevent Workflow Crisis
Traditional Paper Encounter May be an
Ineffective Coding Tool
What it Affects
• Patient flow in the office
• Coding efficiency
• Public health reporting
• Clinical and quality reporting
• Encounter forms
• Practice management system
• EMR
Coding Challenges Operational Challenges Financial Challenges
©2014 The Advisory Board Company advisory.com 21
Impact on Physician Practices
How Practice Finances are Impacted
ICD-10 will impact physician practice revenue
Source: Nichols, J.C. (2011). ICD-10 – Physician impacts. Advisory
Board Applications and Technologies Collaborative.
Drivers of Financial Impact
• 10-20% estimated increase in denials
• Processing rules
• Remediation of medical policies
• Crosswalk complications
• Differences in authorization and
referral triggers
• Increased scrutiny of documentation
to prevent fraud and abuse
What it Affects
• Conversations with vendors
• Conversations with payers
• Budget for new or updated technology
• Revenue from lost productivity and increase
in denials
Physicians Discuss ICD-10 with Vendors
Coding Challenges Operational Challenges Financial Challenges
©2014 The Advisory Board Company advisory.com
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Road Map for Discussion
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Impact on Physician Practices
Documentation Best Practices
Resources and Q&A
ICD-10-CM/PCS: What Changes?
©2014 The Advisory Board Company advisory.com 23
Documentation Best Practices
Understand Coding the Medical Record
Coders rely primarily on physician documentation
Unable to code from: Able to Code/Capture:
ED Physician Notes
History and Physical
Progress Notes
Consultation
MD Orders
Discharge Summary
Operative / Procedure Note
× Nursing Notes
× Pathology Report
× Lab
× X-rays (exception: can be utilized for laterality
and specific type or site. Example: # of rib
fractures and site specificity)
× Ancillary documentation (exception:
stage of pressure ulcers and BMI can be
captured from ancillary documentation if there is
a corresponding diagnosis by the physician)
Attending Physicians
Surgeons
Anesthesiologists
Consulting Physicians
Only the documentation of a credentialed, treating provider can be used
for hospital coding. Examples include:
Interventional Radiologists
Residents
Nurse Practitioners
Physician Assistants
A “provider” is defined as any physician or health care practitioner who is legally accountable for
establishing the patient’s diagnosis. (Official Coding Guidelines October 2012).
©2014 The Advisory Board Company advisory.com 24
Documentation Best Practices
Specific Items for Consideration
What does more robust documentation look like?
Coders Unable to Assume Documentation Intention
Robust H&P, D/C
summary, past
vs. current
conditions
Secondary
diagnoses,
comorbid
conditions
Clinical
indicators
Modifiers matter!
(POA, resolving,
suspected,
severity,
relationships, etc.)
©2014 The Advisory Board Company advisory.com 25
Documentation Best Practices
Defining Detailed Documentation
Will Rehydrate Dehydration
Unable to Void Urinary Retention
Shortness of Breath Acute Respiratory Failure
Pulmonary infiltrate Suspected Pneumonia (type)
The above represent descriptors, lab
values or other test results
The above represent clearer
diagnostic statements
The following diagnoses are detailed
documentation with no changes required:
Elevated Creatinine Acute Kidney Injury or Acute Renal Failure
The following phrases elude data assignment
and additional information is required:
©2014 The Advisory Board Company advisory.com 26
Diagnoses in the Outpatient and Clinic Setting
Unspecific Diagnoses Examples
• Diabetes: not clearly noted to be controlled or uncontrolled, type 1 or 2 or whether there were complications
related to DM (i.e., neuropathy).
• Carcinoma: often described as “history of carcinoma” while the patient is actually still under treatment for
carcinoma; diagnosis frequently lacks specificity around malignant vs. benign, type, and/or site
• Fracture: often unclear whether the patient is suffering from an acute fracture or aftercare for a fracture that
has occurred previously vs. nonunion vs. malunion
• Acute/Chronic/or Further Described: many diagnoses (i.e., bronchitis, sinusitis, conjunctivitis, hepatitis, otitis
media) lack this specificity
The most common and problematic documentation issue in the Outpatient and Clinic
Settings is the lack of specificity of diagnoses documented.
!
©2014 The Advisory Board Company advisory.com 27
Documentation Best Practices
ICD-10-CM Documentation Concepts
Important to capture dysfunction
Source: Advisory Board Research
A routine patient evaluation reveals presence of congestive heart failure [systolic] or [diastolic].
Bottom Line: Specific physician documentation will be necessary to capture
the specificity between the two most commonly encountered types of heart
failure, given two different treatment options.
ICD-10 Code Description
150.21 Acute combined systolic (congestive) and diastolic
ICD-9 Code Description
428.21 Congestive heart failure, unspecified
©2014 The Advisory Board Company advisory.com 28
Documentation Best Practices
ICD-10 Documentation Concepts
Important to capture history and type
Source: Health Data Consulting
A provider sees a patient in an outpatient setting for a [past] dependency of [tobacco] use.
ICD-10 Code Description
F17.211
F17.213
Nicotine dependence, cigarettes, in remission
Nicotine dependence, cigarettes, with withdrawal
ICD-9 Code Description
305.1 Tobacco use disorder
Bottom Line: Additional, specific physician documentation will be necessary to capture the history
of tobacco dependence and type (cigarette, chewing tobacco, etc.) In ICD-10.
©2014 The Advisory Board Company advisory.com 29
Documentation Best Practices
ICD-10 Documentation Concepts
Important to capture disease origin
Source: Health Data Consulting
A routine patient evaluation reveals presence of a respiratory infection.
ICD-10 Code Description
J20.2 Acute bronchitis due to streptococcus
ICD-9 Code Description
466.0 Acute bronchitis
Bottom Line: Additional, specific physician documentation will be necessary to capture the cause of
the bronchitis.
©2014 The Advisory Board Company advisory.com 30
Documentation Best Practices
ICD-10 Documentation Concepts
Important to capture cause of disease
Source: Health Data Consulting
A routine patient evaluation reveals reason for a patient’s obesity.
ICD-10 Code Description
E66.09 Other obesity due to excess calories
ICD-9 Code Description
278.00 Obesity, Unspecified
Bottom Line: Additional, specific physician documentation will be necessary to capture the origin of
obesity.
©2014 The Advisory Board Company advisory.com 31
Documentation Best Practices
ICD-10-CM Documentation Tips
Details Matter
• Specify acuity: acute, chronic, or acute on chronic
• Specify level of severity: mild, moderate, severe or profound
• Link causal agents to specific diagnosis(es): i.e., constipation due to dehydration; otitis
media due to strep pneumonia
©2014 The Advisory Board Company advisory.com 32
Ten Ways to Improve Documentation Now
Below are the elements most commonly missed in clinical documentation. Often times the intent of the physician to
capture these elements can be construed, but the clarity and specificity needed by the coding professionals is not
present. The list below is not in any ranked order.
Top 10 Considerations for Improvement
1. Document the reason for admission 6. Prevent conflicting documentation between
different caregivers (i.e.: attending vs. consulting)
2. Clearly document whether diagnosis was
Present on Admission (POA)
7. Document the clinical significance (diagnosis)
for each abnormal lab value and all diagnostic
test results
3. Link symptoms to diagnosis 8. Avoid symbols and non-approved
abbreviations as shorthand
4. If patient is empirically treated prior to
confirming a diagnosis, describe such a
diagnoses as “probable,” “likely,” “presumed,”
“can’t rule out,” etc. in progress notes and
discharge summary. Clearly document any
diagnoses that have been resolved or ruled out
9. Link associated diagnoses with
manifestations, indwelling devices, and/or
medications
5. Capture all specificity
10. Include all clinically significant diagnoses,
findings, procedures, and treatment provided in
the discharge summary
©2014 The Advisory Board Company advisory.com
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Road Map for Discussion
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Impact on Physician Practices
Documentation Best Practices
Resources and Q&A
ICD-10-CM/PCS: What Changes?
©2014 The Advisory Board Company advisory.com 34
ICD-10 Apps
• There are numerous mobile apps dedicated to providing tips and strategies for proper
documentation in ICD-10
• Apps allow the user to enter a disease or condition of interest and view any relevant ICD-10
information
• Most apps are free and available on iPhone, Android and other mobile devices
©2014 The Advisory Board Company advisory.com 35
ICD-10 Apps
• Diseases Codes ICD-10 - Trofo Systems
• ICD 10 Lite 2012 - iPremiumApps
• Find-A-Code ICD10/ICD9 +GEMs - Find A
Code, LLC
• ICD-10 Search - Queo Sistemas
• Medisoft ICD-10 Medical -
www.MedicalBilllingSoftware.com
• ICD 10 Codes 2012 Free - JTO Dev Team
• ICD 10 - appgroup lab
• ICD 10 Professional - AppHouse Software
• ICD 10 HD 2012 - iPremiumApps
• ICD-10-CM - Webpatient.net
• ICD-10 Doc Guide - Precyse
And many more!
Android Apps: iPhone Apps:
• ICD 10 On the Go Medical Codes - VLR
Software
• HCPCS Pro - 2011 Codes – SvmSoft
• ICD10 Codes - Black Knight Lab
• ICD-10 Virtual Code Book – Precyse University
• STAT ICD-10 Coder - Austin Physician
Productivity, LLC
• AHIMA’s ICD-10 PCS Flash Cards – AHIMA
• ICD 10 HD 2013 – Eslam Farhat
• ICD 10 Reference – Grupo CRM
• ICD-10 Search – The Coding Institute
• ICD 10 – Nirmala T V
• ICD 10 Mobile – SvmSoft
And many more!
©2014 The Advisory Board Company advisory.com
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ICD-10 Resources
• Develop custom action plans to help prepare for ICD-10 implementation
• Library of references for all ICD-10: From clinical documentation to vendors
• Template library to augment your action plan
• http://www.roadto10.org/
©2014 The Advisory Board Company advisory.com
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ICD-10 Resources
• Implementation roadmaps available for different providers
• Readiness assessments including prioritization tools and vendor questionnaires
• http://www.ahima.org/topics/icd10
©2014 The Advisory Board Company advisory.com 39
The Valley Hospital’s Physician Portal
More information on how you can access
this information will come from the Office
Manager Advisory Board.
!
©2014 The Advisory Board Company advisory.com 40
The Engagement Team
Paul Gallo
Senior Project Consultant
202-266-5511
Ben Beadle-Ryby
Associate Director
202-266-5323
Nick Tanner
Project Consultant
202-568-7065
James Green, MBA
Senior Partner
202-266-5443
Samantha Hauger
Partner
202-266-6679
Shamim Noorani
Associate Director
202-568-7147
Emeric Palmer, MD
Medical Consultant
202-266-5600