The new documentation requirements for ICD-10 have a focus on the specifics. Payers want as many in-depth details as possible for each claim so they can decide if they’ll make the reimbursement or if the financial responsibility can be shifted elsewhere. Clinical documentation is a critical element for clinician reimbursement.
The American Academy of Professional Coders (AAPC) estimates that only 37 percent of current clinician documentation provides enough detail to meet the stringent reporting requirements of ICD-10. Documentation will require more detailed information on topics that include the what, when, where and why of injuries, diseases and conditions.
Typical information about the client’s height, weight and vital signs will remain, but the details of an injury and surrounding circumstances are much more specific. In the previous example of the woman who suffered shoulder pain and headaches after an accident on a cruise ship, the following information will be required under ICD-10 coding.
All external causes that led up to or contributed to the injury;
The exact location of the injury on the patient’s body;
The patient’s actions and activities at the time of the injury and after;
Injury codes require a character extender to identify the type of encounter and if the patient sought medical attention;
Data will be required to identify where the client sought medical treatment, any tests that were conducted and referrals that were made;
The patient’s location when the injury took place or when the symptoms appeared is essential and ICD-10 provides data that narrows the location to a specific room, environment or mode of public transportation, including cruise ships;
Applied specificity is required for any number of accidents and injuries to document the immediate symptoms experienced by the patient at the time of the incident, as well as ongoing symptoms, severity and frequency;
Clinicians must indicate any methods the patient has used for pain relief or to alleviate the problem, from over the counter medications to hot and cold therapies;
Documentation must identify if the pain or symptoms from the injury are chronic or acute;
Any related complications encountered;
The result of hands-on examination and any tests ordered;
A detailed account of the treatment plan, including the symptoms that will be addressed and how.
Complete and detailed documentation is essential for reimbursements and Medicare requires clinicians to maintain records on all of a patient’s health and medical history both past and present. A number of variables must be documented that were not required under ICD-9 code sets.
Clinicians will need to exercise caution to ensure each item is thoroughly documented with the corresponding code. The new documentation requirements have a focus on the immediate complaint and no suspected diagnosis must enter the equation, only what can be clearly determined from the available information.
More codes, greater specificity and increased reporting regulations, combined with coding rules and categorization changes, are all leading to significant increases in documentation time when ICD-10 is fully implemented. It’s estimated that clinicians will experience a 15 percent increase in their documentation time and that’s a conservative number.
Many ICD-10 codes are very similar except for one or two differences, while other codes are only differentiated by which side of the body the problem affects. Searching with a GEM may turn up no results or thousands. Even practitioners who have acquired ICD-10 training and use a computer assisted search tool will face challenges when locating the exact code that’s needed.
Productivity is expected to drop by up to 10 percent due to physician queries from billers/coders. The potential for denials and the need for additional management of claims will affect revenue flows. Very real problems will arise with clinician queries using keywords. The following example outlines a potential patient complaint and the results of a keyword search.
Subjective:
Mrs. Johnson was on vacation aboard a cruise ship and was walking in the gift shop when a vase fell on her right shoulder. She has had pain in the right shoulder since then. At the time that this injury occurred, she did not consult with a healthcare provider; she thought it would just go away on its own. After a few days, the pain seemed to get worse, and she started noticing more trouble reaching up and to the side. Also, ever since the incident, she has been suffering from chronic headaches. The patient complains of severe pain across the insertion of the supraspinatus. Traditional over the counter medications do not relieve the headache or the shoulder pain. Past medical history is unremarkable. She followed up with her primary care physician, who referred her to physical therapy. Patient indicates that no diagnostic tests (i.e – X-rays, MRI) were done so far.
Objective:
The patient weighs 220 lbs. and is 5 feet 4 inches tall. Her blood pressure is 128/86, pulse rate is 72 and respiratory rate is 16. She has full strength in all muscle groups in the upper extremity with the exception of the right middle deltoids, which are 3+ and right supraspinatus, which is 2+. All deep tendon reflexes in the upper extremity are normal. Range of motion is normal in the upper extremity with the exception of right shoulder external rotation (to 25 deg), abduction (to 130 deg) and flexion (to 135 deg). All of these ranges exhibited pain at end range.
Special tests: Right shoulder (+) Neers, (+) Hawkins-Kennedy, (+) IR lag sign with pain.
Cervical range is restricted to 50% for flexion, extension and side-bend. Tenderness and hypertonicity noted at suboccipital area (right>left).
Assessment:
Exam findings are consistent with rotator cuff strain in the right shoulder. Pain, range of motion restrictions, and weakness in right shoulder, with chronic headaches.
Plan:
Physical therapy 3 times a week for 4 weeks for treatment of right shoulder pain, with range restrictions and weakness, with symptoms consistent with rotator cuff involvement. Treatment to also address chronic headaches and neck range restrictions, with therapeutic exercises, therapeutic activities, postural exercises, patient education, joint mobilizations/soft tissue mobilizations, home exercise, and modalities as indicted.
A clinician that searches for the keywords cruise ship will find 233 results in two classification sets and a further search for falling object and right shoulder pain each has 500 references in three classification sets. A more specific search for rotator cuff returns 109 results in four classifications. Results increase with a key word search for physical therapy returning more than 500 results across seven classification sets.
Searching by specific codes will display results for multiple categories ranging from nuclear medicine and obstetrics to mental health, substance abuse and poisoning. The typical practice won’t experience many of the situations described in the new ICD-10 coding, but they must still wade through a morass of potential codes to arrive at the desired data.
Navigating the ICD-10 code set will affect every individual within the practice and clinics can’t rely on GEMs and crosswalks indefinitely. Implementation requires that all staff members receive education and clinicians obtain coding training in their specialty. It will help reduce documentation times and the instances of claim denials under the new codes and documentation rules.
A General Equivalency Mapping (GEM) system is available to assist clinicians determine the correct coding options in the ICD-10 system. It’s a necessary and useful tool, but one that has distinct limitations. It provides no substitute for real training. A GEM is a general purpose tool and wasn’t originally developed for coding. It was a means of analyzing data and conducting research and studies.
GEM is a tool that can be used by clinicians to conduct searches and reverse searches to identify the correct ICD-10 codes in their practice. Translations and conversions can be done between either coding system to the other. Translating ICD-9 to ICD-10 is known as forward mapping, while ICD-10 to ICD-9 is called backward mapping. Searches will turn up approximate matches, possible combinations, and potential scenarios from which to choose and search for more data.
There are multiple versions available that have been created by vendors and professional organizations. Versions are available from the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), along with many vendors of EMR software systems. The ease of use will be determined by multiple variables that include the developer, logic and programming used.
The results that the GEM returns are dependent upon the creating entity. Clinicians will receive entirely different coding options depending upon which GEM they’re using. The sheer volume of codes in ICD-10, combined with those that didn’t exist in the old system, means that a given GEM won’t always return the best matches or choices.
The chance of a one-to-one match is very slim, and in certain circumstances the GEM may offer none at all. All search features aren’t created equal and clinicians may find they have to try multiple search terms before the GEM returns any results at all.
It’s imperative that practitioners remember that GEMs aren’t designed to be an exact converter within a clinical setting and even an “exact match” may only be an approximation. Other coding difficulties may arise when differentiating between an initial encounter and a subsequent encounter. Some ICD-10 codes may not offer lateral solutions, which means practitioners will have to create the data themselves.
The imperfections of GEMs can have a significant impact on revenues for practices, making it imperative that clinicians bill and code at the highest possible level whenever practical and prudent. GEM results may not provide an accurate reflection of the clinician’s intent or care episodes.
Any unmapped codes that are encountered will present additional challenges for overworked practitioners struggling to adapt to a new code set and maintain revenues. Examples that reflect no translation between codes are surgical instruments, cardiovascular devices and autopsy. While the latter two are unlikely to arise in the average practice, it still points out the limitations of a typical GEM.
A GEM is a tool that provides a starting point for clinicians and is no substitute for ICD-10 training and education. The GEM can’t think or factor in the many aspects that practitioners must consider when diagnosing and treating a patient. For that, clinicians must rely on their training and unique experience.
Crosswalks and mapping are terms that clinicians will be hearing a lot about when trying to ascertain the correct translation of an ICD-9 code into the new ICD-10 code system. Mapping and crosswalk tools are included with the ICD-10 codes to help clinicians covert the old codes with which they’re familiar to the new code set. The crosswalks will be maintained for three years past the official ICD-10 implementation date of Oct. 1, 2014.
The mapping ability is a valuable tool, but practitioners shouldn’t be tempted to use it as a substitute for the appropriate training. There will be many look up entries that return multiple results and practitioners must rely on their training, experience and common sense to identify the correct ICD-10 code to use. The crosswalks are searchable and will return multiple choices. Mapping will lead to an alphabetic list, then to tabular listings for further data.
Approximate Matches
Due to the greater specificity in ICD-10 codes, there will be extremely few exact matches between the two coding systems when they perform a search, but practitioners will find a wealth of approximate matches. The mapping tools included in the new codes provides medical professionals with a dictionary for translation and a starting point from which to work.
Searches
When no match is located, clinicians can perform searches that will lead to a multitude of potential coding options. A single translation can lead to any number of matches with additional possibilities to explore to create an accurate description of the condition. ICD-10 codes come with expanded possibilities for each condition. Consequently, there will be few exact matches and a single crosswalk for every situation just isn’t possible.
Combinations There will be multiple translation choices and clinicians must go further into the system to determine which code best reflects the immediate situation. The increased specificity of the coding set will often return multiple options. Depending upon the situation, clinicians can utilize up to 12 codes if needed to accurately describe a patient’s illness, disease or injury.
Reverse Matches
It’s possible to obtain the appropriate ICD-10 codes through reverse matching, but it’s important to remember that even when only one match is located, it won’t be a complete equivalent to the previous ICD-9 code. Clinicians will need to delve deeper to establish an exact match. Converting codes from ICD-10 to ICD-9 is backward mapping and one way to ascertain the correct code conversion.
Scenarios
There will be times when no match can be found and the mapping tool will provide a clinician with multiple scenarios, each with its own set of variations and parameters. Choice lists provide professionals with additional determination tools.
Exact Matches
Clinicians will find very few exact matches when converting ICD-9 to ICD-10 codes. If a search turns up only one alternative, it’s considered a one-to-one match. However, practitioners should exercise caution, as the return of a single match doesn’t automatically mean the two codes are identical.
A much more common occurrence will be a return of no matches due to the new concepts expressed in the ICD-10 codes. The new codes may express multiple results for a single ICD-9 code and vice versa. The crosswalk search tool isn’t perfect or infallible. In some instances, clinicians will need to try different search terms to navigate the system and find the desired information.
Crosswalks and mapping tools provide clinicians with a bi-directional dictionary of coding options, but much like a foreign language, there will be times when a particular concept, illness, disease or injury won’t have an exact translation. Alternately, a search may return multiple possibilities. In these instances, the experience, expertise and training of the clinician will be the determining factors.
ICD-10 codes represent the biggest change to medical billing and coding since the late 70’s. Nitin Chhoda explains why transitioning and implementing this new coding standard will determine the survival of your practice.
Understanding the ICD-9 and ICD-10 codes is important to getting the most from your medical billing.
Without the right medical billing and coding practices, health insurance companies will deny claim after claim.
But there is more to ICD-10 codes than meets the eye. This new coding standard is more than just a hassle you’ve got to go through to get paid.
International Classification of Diseases
The ICD in ICD-10 codes stands for International Classification of Diseases.
From the widest perspective, this codification of health management terms and practices can serve as a way to analyze the health of a population. Epidemics, mortality rates, and all kinds of statistics can be gathered if a common codification system exists.
The World Health Organization (WHO) and The International Health Terminology Standards Development Organization (IHTSDO) take decades to update the ICD, in an effort to better understand the health of populations around the world.
Because the ICD and ICD-10 codes system is what the world is using to identify diagnoses, the United States government also uses it to classify and communicate about medical diagnosis.
For example, medical diagnosis and inpatient procedure coding for Medicare and Medicaid services uses the ICD-9 and ICD-10 codes system for all claims. Any medical billing relating to those services must use the ICD-10 codes.
Transition Time
Right now is an exciting time for medical coding and billing. On October 1st, 2014, the United States will finally adopt the ICD-10 codes. The ICD-9 codes were adopted in 1977, and since then we have not updated our coding procedures.
And the ICD-10 codes were finalized and endorsed in May of 1990 by the Forty-third World Health Assembly. ICD-10 codes came into use starting from 1994 by many member states.
That has been some push-back, however, because this isn’t going to be the only change the United States undertakes this decade. The ICD-11 codes are being classified already with an estimated finalization scheduled for 2015.
While it may be a few more years before ICD-11 codes are available for adoption, if the U.S. wants to be up to date, two switches will likely occur in the next ten years.
On the other hand, the switch to the ICD-10 codes may present enough of a modernization for now.
After all, the U.S. waited ten years to adopt the ICD-10 codes. And this change is going to be significant enough. The ICD-9 codes number around 13,600. The ICD-10 codes number over 144,000.
Medical Coding Evolves
While not everyone is excited about the change to the ICD-10 codes, there are medical coding professionals who look forward to a more precise system.
There are also plenty of medical professionals who rely on ICD data for research.
By updating to the ICD-10 PDF codes, the United States is joining much of the developed world in building a better resource for health studies within the country as well as worldwide. The complexity that is being introduced will be a challenge to adapt to at first. But overall, everyone will benefit from a more modern system of medical coding.
ICD-10 is coming soon and will replace the current ICD-9 terminology. Nitin Chhoda clarifies the changes that are coming in the world of medical coding and how to deal with the upcoming transition to ICD-10.
As with any significant change in procedure, there is a portion of the medical billing and medical coding community that is in panic.
There are also many people who unaware of the extent of impact that the ICD-10 codes will have on them.
To clarify some of the commonly misunderstood aspects of this change, below are the facts about medical coding changes due to ICD-10 implementation codes.
Compliance and Flexibility
The compliance date for switching to ICD-10 codes is October 1, 2014. There have been rumors circulating that that date is somewhat flexible or that extensions will be granted either to individual practices or to everyone.
The compliance date is set and will not be changed. All health care providers must use ICD-10 codes by Oct 1, 2014.
Additionally, many people believe that compliance with ICD-10 codes requirements is only necessary if you are using electronic medical records and an EMR system. This is also an incorrect assumption. No matter whether you use electronic medical records or you are still doing all of your filing on paper, the ICD-10 codes will be required for all medical practices.
Too Many Numbers
Changing from a code system of about 13,600 codes in the ICD-9 to the ICD-10 codes which number over 144,000 sounds daunting. The exponential rise sounds overwhelming, and it should come as no surprise that medical coding professionals are worried that it will be too complex to be practical. There are also serious (and legitimate) concerns about the increase in documentation time, claiming this level of detail is unnecessary.
ICD-10 codes are structured to be more logical to use and the codes are more clinically accurate than the ICD-9 codes. Medical coding should be easier, not harder.
The structure itself is improved so that you will be searching through categories which contain more specific codes than the previous version. Of course, every change requires some learning and adjusting. But once medical coders settle into the new system, they may find they like it better than the previous system.
Introduction of Unnecessary Tests
One concern voiced by clinicians is that with a more complex and detailed set of ICD-10 codes, medically unnecessary tests will need to be taken with patients so that a diagnosis can be made and the correct code can be assigned.
Fortunately, this is not the case. Nothing about the ICD-10 codes should dictate what medical tests and procedures are prescribed for your patients. The ICD-10 codes are intended for documentation of what is found by the clinician.
If a diagnosis hasn’t been made, the code used will be dictated by the symptoms. The ICD-10 codes are more flexible in this way than the ICD-9 codes, and they still contain the non-specific codes that can be used when you cannot make a diagnosis.
Many medical professionals are nervous about the change to ICD-10 codes. Before you worry about what this change will mean for you and your practice, remember that the ICD-10 codes were designed by and for clinicians like yourself.
The new documentation requirements for ICD-10 have a focus on the specifics. Payers want as many in-depth details as possible for each claim so they can decide if they’ll make the reimbursement or if the financial responsibility can be shifted elsewhere. Clinical documentation is a critical element for clinician reimbursement.
More codes, greater specificity and increased reporting regulations, combined with coding rules and categorization changes, are all leading to significant increases in documentation time when ICD-10 is fully implemented. It’s estimated that clinicians will experience a 15 percent increase in their documentation time and that’s a conservative number.
GEM is a tool that can be used by clinicians to conduct searches and reverse searches to identify the correct ICD-10 codes in their practice. Translations and conversions can be done between either coding system to the other. Translating ICD-9 to ICD-10 is known as forward mapping, while ICD-10 to ICD-9 is called backward mapping. Searches will turn up approximate matches, possible combinations, and potential scenarios from which to choose and search for more data.
Crosswalks and mapping are terms that clinicians will be hearing a lot about when trying to ascertain the correct translation of an ICD-9 code into the new 
Searches
