One of the biggest challenges for clinicians with the transition to ICD-10 will be coding for items that they would normally include in their notes. In the new world of ICD-10, everything has a code and insurance companies won’t reimburse for anything that’s not coded.
The external causes of injuries should be a focus for clinicians and may be the most difficult to remember. Payers want more intensive information about every aspect of a patient’s visit to their medical professional.Practitioners must code injuries, onset of symptoms, external causes and treatment plans.
It’s absolutely essential that professionals in any branch of the medical profession code to prove medical necessity. In some instances, it may be necessary to rely on records from the referring physician to provide acceptable documentation.
Clinicians should always strive to code at the highest level of specificity and detail that’s possible. Practitioners can no longer code for a probable or suspected diagnosis. Payers just want to know about the facts that can be proven by tests and the clinician’s observation.
The process will be smoother and less troublesome if clinicians identify the codes they most often use and convert them to ICD-10 before the implementation deadline. There are thousands of new codes, but clinicians in private practice will typically only use a small number of those, making it easier to begin converting and using them in dual coding.
Before ICD-10, a clinician’s notes were a tool that was used to create an ongoing record of a patient’s health history. They essentially created a database of knowledge that could be referenced about the client. With the implementation of ICD-10, that same information has been reduced to specific codes that determine what clinicians will receive for reimbursements.
The clinician’s expertise with ICD-10 coding will be a determining factor for practice revenues. The GEMs will assist in those efforts to be more specific, but practitioners will want to engage in some preemptive documentation. It will help medical professionals become familiar with the new coding and facilitate the changeover in patient records.
Professional organizations have predicted a 15 percent increase in documentation requirements. Those entities indicate that 65 percent of clinician notes aren’t specific enough for the new ICD-10 coding and will result in a significant increase in documentation times. The sooner that practitioners become adept at coding with ICD-10, the less time will be required as time progresses.
Payers have always sought reasons to deny claims and place the financial responsibility elsewhere. That’s their job. As comprehensive as the new code set is, medical professionals in all fields should be aware that they may encounter substantial difficulties. Many payers are under the impression that ICD-10 has a code for every possible instance, but that just isn’t true.
The current healthcare environment is one in which the focus is on saving money and ensuring that services are actually being received. Payers are no longer content to reimburse without practitioners without providing detailed to ensure the treatment is appropriate and is actually being carried out.
To accomplish that task, practitioners now have more specific coding, along with additional coding for documenting details about the causes and circumstances surrounding the patient complaint. Notes are no longer sufficient for that purpose and a practice’s revenue stream will directly depend upon the clinician’s ability to locate the appropriate codes to provide proofs in an alphanumeric fashion instead of words contained in notes.
Those who identify their most often used codes and begin rewriting their notes to conform to ICD-10 protocols have a better chance of mitigating denials once the new coding goes into exclusive use. The ICD-10 transition will be difficult enough. Taking the initiative in rewriting notes now will save time in the future.
The type of ICD-10 training needed by clinical staff will depend upon a variety of factors. An advanced level of ICD-10 training will be required for any clinical staff that works directly with patients to provide medical care.
The role of clinical staff has changed over the years. Nurses, therapists and nurse practitioners are now on the forefront of patient care. Many work directly with super bills that may be eliminated and new methods must be learned.
New provisions in HIPAA compliance affects the dissemination of protected patient information. Any clinical staff in a practice that is involved with providing patient care or access to client health information will need a thorough understanding of ICD-10 coding, including staff that provides in-home therapy or care.
Depending upon their level of education, the individual practice, and the laws within the state, clinical staff can conduct exams, make diagnoses, give injections and are authorized to prescribe medications. They can prescribe physical therapy services, make referrals and order testing. These staff members will need specialized training in ICD-10 coding.
Health care coverage is undergoing major changes due to the Affordable Health Care Act. Depending upon the individual practice, clinical staff may be responsible for scheduling referral appointments and obtaining pre-authorizations. Clinical assistants will be affected by changes in health insurance policies and advanced beneficiary notices (ABNs) that will need to updated and reformatted.
One of the responsibilities for non-coding clinical staff will be to educate patients about all of these changes and how they will be affected. Clinical staff may also include technicians for practices that maintain on-site lab and testing facilities. In smaller practices, a single individual may wear many hats and ICD-10 training options must take that into account.
Large, comprehensive practices may encompass case workers, patient advocates and staff that oversee sales of medical products and devices. Clinical personnel in these capacities may need ICD-10 training, but not the intensive level of those who must enter ICD-10 coding. For many non-clinical personnel, the biggest shift with which they may have to adapt is procedural changes.
A byproduct of the Affordable Health Care Act is that patients will have increased access to their health information through patient portals, but it may result in an increased work load for clinical staff. A patient portal allows clients to access test results and other information, but it could result in an influx of calls to which clinical staff must respond.
The patient understanding of what medical personnel told them and subsequent coding may not be an exact terminology match, leading clients to contact the practice for clarification. Any terminology with which patients are unfamiliar or they disagree may result in calls and an additional workload.
Conversely, the greater specificity that coding clinical staff can utilize may be appreciated by older patients. ICD-10 allows clinicians to more accurately describe their level of pain or disability. The in-depth information may result in increased services for chronic conditions and pain management programs.
The bottom line for practitioners is that every member in the practice will need some type of familiarization with ICD-10 coding and/or the procedural changes the transition will engender. A careful analysis must be conducted to identify the level of training and ability each person has to provide effective training for everyone from the front desk and clinical staff to management.
ICD-10 implementation means changes at all levels. One of the first responsibilities for managers will be to analyze the practice environment and personnel to determine specific needs to bring the practice into compliance and readiness for implementation. The entire process will require many managers to assume duties with which they’re unfamiliar or require them to step out of their comfort zone.
Managers will take on the role of overseeing and coordinating the implementation of ICD-10 and that will include contacting vendors, payers, clearinghouses and billing professionals. Contracts will all need to be evaluated, revised, updated and receive final approval before the official implementation date. New policies for employees will need to be revised, distributed and a signed copy returned.
Budgetary concerns will occupy a large part in managers’ responsibilities. Operating funds must be set aside to account for the inevitable reimbursement delays to come. There will be numerous software and hardware updates, purchases and IT considerations. Testing is a crucial part of preparation to ensure that the practice can communicate appropriately with others in the system. It’s a process that will take time and will rely on the readiness of other entities.
The transition to ICD-10 will require training and education for all staff members and sufficient money will need to be appropriated. Implementation will affect staff members in different ways. Managers will be responsible for determining the level of education each individual requires, ensure staff participation and that they’re fluent upon completion. Managers will want to explore various instruction methods, from online options to on-site instruction. Not all staff will need the same level of training.
The workflow in practices and the billing department will experience delays. These should be expected. Staff training and system testing will require a significant amount of time, resulting in a loss of productivity prior to implementation. It may be necessary to hire extra staff in various departments to alleviate back-up and loss of productivity. Additional personnel may be required for up to six months following implementation.
Significant risk accompanies ICD-10 implementation. HIPAA compliance for securely transmitting medical information is critical. Sufficient safeguards must be in place. Part of the implementation process involves how information will be stored and manipulated by those within the practice and entities with which the practice works.
The additional documentation and coding required by ICD-10 places much more patient information at risk and security measures must be addressed.Risk management also extends to potential loss in revenues after the conversion. The best laid plans may encounter snags and delays. A contingency plan to handle any problems will be essential.
The implementation of the new coding system is a major undertaking at all levels of the practice. It will require new methods, practices and policies. Medical practice managers will be extremely busy ensuring that staff receives training, the revenue flow experiences minimal disruptions, and the practice is in compliance for the ICD-10 conversion. During the transition, managers should take care not forget to obtain the ICD-10 training they need.
The rules of coding for ICD-10 have been established in cooperation by the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). It’s a standard to which all clinicians must adhere.
Reviewing The Basics
ICD-10 encompasses 21 chapters and expanded code options that have been reorganized and expanded. Injuries are described by site first and then by type. They include laterality, greater specificity and combination codes.
ICD-10 codes are now identified with an alpha-numerical system that can include up to seven characters and the first will always be a letter. The letters I and O are not used, as they can easily be confused with the numbers 1 and 0. Letters aren’t case sensitive.
The first three identifiers represent the category, the next three describe the anatomical location and severity, and the last is an extension that identifies if it as the first or subsequent encounter, or the result of a previous injury or disease. X is used as a placeholder in some codes.
Injuries are grouped by body part rather than injuries. Clinicians will focus on documenting the current complaint of the client. Never assume that “standard” treatment has been provided or code on a suspected diagnosis. Payers just want the facts of what’s readily observable.
Practitioners will need to document variables that were not required under ICD-10. Clinicians will need to include data on all external causes that led up to the actual injury, the exact location of the injury, and the patient’s actions at the time of the injury.
Documentation will also require information about the environment in which the injury took place, and any measures the patient has taken to alleviate the problem. Additional data must be included on any complications, the results of tests and exams, and very detailed data on the treatment plan.
The conventions for ICD-10 have an alphabetic index of terms and codes that may apply. It’s broken down into four parts: Index of Diseases and Injury, Index of External Causes of Injury, Table of Neoplasms, and Table of Drugs and Chemicals. ICD-10 also has a tabular list that divides codes into different chapters that’s based on condition or body system.
ICD-10 coding conventions dictate that clinicians record the underlying or casual condition first. This should be followed by the condition displayed. Up to 12 diagnosis codes can be included for accurate representation of all conditions related to the patient’s visit.
A new coding convention for ICD-10 provides laterality in reporting. Clinicians now have designations for right, left, bilateral and unspecified. Coding can then be specified for the type of injury, disease or condition, along with an even more finely detailed description of the affected area.
Medication conventions have also been expanded. An example of this is drug under-dosing, a concept that doesn’t exist in ICD-9 but can be coded for under ICD-10. Many of the new codes reflect changes in terminology and technology. Some codes have been updated, while other terms have been eliminated or disassociated from specific conditions.
Even punctuation is addressed in the conventions. Specific guidelines have been established for the use of parentheses to designate supplementary words and terms that should be documented, but won’t change the diagnosis. Clinicians can differentiate between signs, symptoms and unspecified codes.
While ICD-10 codes are extensive and comprehensive, the good news for practitioners is that they generally won’t have to contend with the entire complement of code options, only those that affect their specialties. For instance, physical therapists and dermatologists won’t be coding for the same types of disease or injuries.
Clinicians preparing and training for implementation of the ICD-10 code set have encountered some unusual results. In an effort to be more specific, eliminate waste, reduce fraud and save money, the ICD-10 codes are very specific, sometimes to the point of being humorous.
Practitioners can now provide coding that may leave insurance companies wondering about their clients and the activities in which they’ve been engaging. Every clinician remembers a strange or unique situation for which they’ve billed – and the difficulty they had explaining it to the patient’s insurance company. The following are some examples of the unusual and sometimes humorous coding available with ICD-10.
Members of the animal kingdom can be unpredictable, but ICD-10 coding points out just how unanticipated some situations can really be, from fast moving turtles to equine collisions. In the animal category, practitioners will find some interesting injuries to be noted and places where the event took place.
W59.22XA – Struck by a turtle
W611.2XS – Struck by a macaw, initial encounter
S30.867A – Anal insect bite, non-poisonous
V80.730A – Animal-rider injured in collision with a trolley
Y92.72 – Injury obtained in a chicken coop
All families have problems, but it seems that some clichéd situations are eternal. When families have problems, there’s a code for that.
Z63.1 – Problem with in-laws
Z62.891 – Sibling rivalry
W21.31XS – Struck with footwear
Z62.1 – Parental overprotection
Z73.4 – Inadequate social skills, not elsewhere classified
R46.1 – Bizarre personal appearance
G44.82 – Headache associated with sexual activity
R45.2 – Unhappiness
The arts can be dangerous and that’s amply demonstrated by ICD-10 codes that identify the supposedly safe venues in which to enjoy entertainment, but may not be as protected as individuals might think.
Y92.253 – Injured in an opera house
Y9250 – Injured at an art gallery
Y92.26 – Movie house or cinema
Y92.251 – Museum
Work-related accidents and injuries are a common complaint for medical professionals and the new codes reflect such injuries. It would appear that some individuals are at high risk of being injured is some unique ways, and some return for an encore performance.
V97.33XD – sucked into a jet engine, subsequent encounter
X52 – Prolonged stay in weightless environment
V95.41XA – Spacecraft crash injuring occupant
Z89.419 – Acquired absence of unspecified great toe
Leisure time activities account for a large portion of injuries. Sports-related injuries top the list, but there are some lesser known activities that can be just as dangerous. When it comes to leisure time activities, clients are presented with multiple opportunities for injuries.
V91.07XA – Burn due to water skis on fire
Y93.D1 – Stabbed while knitting or crocheting.
Y92.146 – Hurt at prison swimming pool
T63 – Unspecified event, undetermined intent (to be specific)
Some of the ICD-10 codes bring to mind weird and wacky laws that have outlived their usefulness, but have never been removed from the books. It bears remembering that while some codes were developed to address potential problems and injuries of the future as technology advances, many of the codes currently exist because a particular situation actually happened to someone, somewhere, sometime…
Coding with ICD-10 will offer some interesting experiences for clinicians. Practitioners must keep in mind that they need to bill at the highest level whenever possible. That means taking extra time if necessary to track down the correct codes for optimal billing. Getting the codes right will mean the difference between getting reimbursed and delayed payments.
The following is an example of the type of coding required to provide premium treatment for the patient and optimal reimbursement for the clinician.
Mrs. Smith was riding her horse through an orchard road adjoining her property. Her two siblings were riding their horse with her. As she neared an irrigation pond on the property, a Canadian goose flew up and startled one of the other horses. The second horse whirled to put his rump toward the “threat” and lashed out with both back hooves. One hoof struck Mrs. Smith on the tailbone causing immediate pain. The injury happened two weeks prior and she still experiences pain, along with numbness at the tailbone, radiating 3-4 inches in all directions from the site of the injury. Over the counter medications offer no relief. Past medical history is unremarkable. She followed up with her primary care physician who referred her to physical therapy. Patient indicates no x-rays or other diagnostic tests have been done.
Patient is 5 feet tall and weighs 120 lbs. Blood pressure is 120/70, pulse rate 72 and respiratory rate is 16. She has full strength and function in all muscle groups, but now walks slowly and hunched over. Has pain upon walking, sitting and reclining. Range of movement is normal but patient complains of pain upon movement and examination. Special tests: X-ray.
Exam/x-ray shows bruising, swelling and fracture of the coccyx. Treatment is to rest and to address pain. Postural exercises and home exercise for continued mobility.
Y93.52 – Horseback riding, describes the activity at the time of the injury
W55.12XA – Struck by horse, describes what caused the injury
532.2XXA – Fracture of coccyx, initial encounter for closed fracture, describes the anatomical area where the injury is located and indicates this is a first time injury
R26.2 – Describes the symptom of the injury (constant pain and difficulty walking, sitting and reclining)
Clinicians know that ICD-10 codes are much more specific, but part of the learning curve will be wading through massive numbers of potential codes to arrive at the options that best suit the injury or need. The new codes include activities ranging from gardening and pollen reactions to knitting and running into a lamp post, complete with initial and subsequent encounters. It’s unlikely that therapists will require the codes for those potential incidents, but it points out the increased specificity of the new codes.
One of the challenges that practitioners will face is the sheer volume of data contained in the new code sets. GEMs provide a partial solution, but in an effort to stamp out fraud and save money, clinicians are now being inundated with too much information. GEMs, EMRs and other software can sort through data quickly and provide potential solutions, but they can’t make decisions about what to display for a given situation.
The final decision on which codes to utilize will ultimately fall upon the practitioner. GEMs and other computerized solutions can present the possibilities, but it will be the clinician’s practical experience and understanding of ICD-10 to code accurately and profitably.