Preemptive ICD-10 Documentation – Rewriting Your Notes, Onset and Contributory Factors

Preemptive ICD-10 Documentation – Rewriting Your Notes, Onset and Contributory Factors

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 10 Step Preparation Blueprint for ICD-10

The 10 Step Preparation Blueprint for ICD-10

The transition to ICD-10 encompasses much more than simply acquiring the codes and using them. It’s an involved process that requires careful planning, organization, funding and training. With the Oct. 14, 2014 implementation date just a few months away, it’s imperative that clinicians have an action plan in place to meet the deadline. Failure to be ready will result in practices being out of compliance and the denial of reimbursements.

Make A Plan

Planning is key for ICD-10 implementation. The plan must include a timeframe for all the changes and training to be completed, along with a review of the regulations and requirements for transition. ICD-10 can’t be put in place piecemeal. Solicit volunteers or appoint a single individual or team that will be in charge of ensuring each planning step is accomplished.

Break It Down

The transition will include several phases, from the installation of software and hardware to staff training and equipment testing. Break the implementation process into smaller bites to make it more manageable.

Discover if there are any steps or measures that must be completed by a certain time. Clinicians should select a single person or a team to oversee each additional phase of the transition. These individuals will be responsible for ensuring training, IT, software, funding and other associated steps are addressed and completed correctly.

High-Level Assessments

No action plan can be launched without knowing what the impact of ICD-10 will be on the practice. Practices are not the same, even within the same field or specialty. ICD-10 will affect documentation, billing and coding, and the practice’s technology, along with staff education, procedures and funding. An in-depth assessment of the practice and staff will identify areas of concern.

Two of the most critical departments are billing/coding and documentation. Constant and continued communication with vendors, payers and clearinghouses must be maintained to determine compatibility during testing phases. This is also a good time to discover any changes in reimbursements that may be coming in the future. Documentation practices will need evaluation to ascertain if they’ll meet ICD-10 coding requirements.

Secure Funding

Implementation is going to be expensive. Funding will need to be secured for a multitude of expenses, many of which may change along the way. There will be costs associated with software upgrades. Practices that opt to maintain their own on-site server will require equipment purchases and advanced security protection.

Until all patient data has been transitioned to the ICD-10 system, clinicians will be utilizing dual coding. The most recent version will be needed in software and printed form. There will be hardware systems to upgrade and software to install. Technical modifications may be required to meet HIPAA standards or meet high-speed data transmission.

Personnel Training

Training staff in the use of ICD-10 and new privacy guidelines is necessary, and clinicians should be prepared for a loss of productivity. A wide array of professional organizations and companies offer training in multiple formats. All staff members won’t require the same amount of education and not all people learn the same way.

Training services offer sessions that incorporate eLearning, interactive exercises, and mobile and smartphone applications, along with classroom education, discussion forums, practice tools and simulations. Some customize the training to the individual. Clinicians should ensure that the training entity maintains an appropriate means of ensuring that each staff member is proficient.

Clinicians should be aware that the ICD-10 transition requires new knowledge, skill sets and procedures. Not every staff member may be able to make the transition successfully. New staff may need to be hired to replace those unable to cope with the changes. Training should begin with coders, clinicians, clinical staff and other staff, in that order. Everyone should be aware of the training schedule.

Internal Testing

Practices should begin internal testing of their new hardware and software systems to address the inevitable problems that come with such a major undertaking. IT professionals will be a common sight in practices as they perform upgrades, test systems and address problems, all of which can result in productivity losses. Be prepared.

External Testing

When internal testing is complete, practices should begin testing their systems with clearinghouses, insurance companies, payers and vendors as soon as possible. Staff should know when testing is scheduled and be prepared for interruptions. Conduct simulations and test runs to ensure communication with critical entities and develop a contingency plan for any potential problems.

HIPAA compliance standards must be met for the secure transmission of data. Clinicians work with a host of pharmacies, labs, hospitals and other physicians and they’ll also need to communicate securely and seamlessly with those entities. This is also the time when clinicians should determine which ICD-9 codes they use most often and map them to the ICD-10 version.

Going Live

Once all system software is working in concert with critical entities, begin dual coding as needed. Create an ongoing plan for determining the source of any errors or problems. Identify any staff members that may need additional training. Additional staff may need to be hired to address back-logs and loss of productivity in the first few months of ICD-10 implementation.

Getting Paid

Coding and billing activities deserve special monitoring to ensure continued productivity. In-house billing/coding departments could require additional personnel to maintain a steady workload. The alpha-numeric composition of ICD-10 coding requires billers/coders to switch between their keyboard and numeric pad. It will take extra time to complete the billing process. Any denied claims will need careful tracking to determine where documentation or coding errors may be occurring.

Auditing The Process

There are sure to be glitches along the way, even after several months of ICD-10 use. Processes and procedures throughout the practice have changed. The new codes should be audited to ensure the latest versions are being employed and communication with essential entities monitored for any undetected problems that may have crept in. Most importantly, monitor reimbursements to ensure that pre-ICD-10 implementation amounts have remained the same.

The ICD-10 changeover will be many things – exciting, expensive and frustrating. Creating an action plan will alleviate many of the potential problems. Appropriate training and education is essential and ongoing monitoring of revenues, procedures and processes will ensure a successful transition.

The Impact of ICD-10 on Management

The Impact of ICD-10 on 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 New Challenges with the ICD-10 Rules

The New Challenges with the ICD-10 Rules

(What’s Going to be Toughest to Learn – External Causes)

Remembering some of the changes that will take place as a result of the transition to ICD-10 will come quickly, but documentation requirements are a major issue for clinicians. The greater specificity of the ICD-10 codes allows for greater accuracy, but it increases clinician documentation requirements by 15 percent.

Some of the differences include codes that include place holders on documentation forms for future needs. In the current healthcare climate, payers will want to know if another entity may be responsible for paying the costs. They’re going to examine each claim closer, making it essential that clinicians are as specific as possible. It’s estimated that 65 percent of a practitioner’s notes won’t be specific enough.

One of the most difficult facets of the new codes is the way documentation is divided. There are four parts and external injury will cause the most frustration and be the hardest to remember. The external causes portion of the documentation should be a primary focus for practitioners. New documentation requirements want very exact information about the external causes of where and how an injury took place.

General Equivalency Mapping (GEM) was created by the National Center for Health Statistics to make the documentation task easier, but the system isn’t perfect. GEM is linked to all the various code alternatives for a given instance, and a single search can return as many as 2,500 responses. Other times, a compound word search will turn up nothing, while a single word will result in what the clinician wants.

GEM displays approximate matches and combinations through an alphabetic list first and then to a tabular listing from there. Practitioners will always want to wind up at the tabular section. There is always the “Not Elsewhere Classifiable” or “Not Otherwise Specified” category, but many clinicians anticipate problems with payers if either designation is used, considering the push for greater specificity.

Many payers are under the assumption that the implementation of ICD-10 codes automatically means that there’s a specific and corresponding code for every patient issue. This isn’t the case and there will be times when those two designations will be the only available options to use.

Disease classifications and categories have received some restructuring and classification of some conditions is different from what clinicians have become accustomed. Injury groups are now classified by specific locations on the body. Practitioners will find that some diseases that were lumped together now have their own separate chapters.

Clinicians should always endeavor to code at the highest level of specificity and detail, but avoid coding for a probable or suspected diagnosis. Coding should only be completed for all the symptoms that can be documented. Acute conditions should be listed before chronic issues if both exist. In some instances, a bilateral code doesn’t exist in which case clinicians will be required to do this separately.

Coding requirements with ICD-10 are more stringent and will require considerably more effort on the part of clinicians during the documentation process. The learning curve will lead to an inevitable loss of productivity at first. Practitioners should be prepared for this and book patient appointments accordingly. Productivity and efficiency will return to normal levels as all concerned become more familiar with the new ICD-10 coding requirements.

HIPAA Electronic Transaction Standards with ICD-10

HIPAA Electronic Transaction Standards with ICD-10

(Do You Need to Maintain Both Code Sets in Your Practice – Yes)

Even though everyone will be using ICD-10 codes after Oct. 1, 2014 if they want to get paid, clinicians won’t quite be finished with ICD-9. Patient records prior to ICD-10 implementation must be transitioned to the new coding system. There will be coding, form and procedural changes and there are sure to be glitches along the way. With forethought, planning and understanding, the changeover can proceed easier than many might anticipate.

Clinicians and billers will have new codes to use and new standards they must implement to adhere to HIPAA regulations. Multiple changes will take place over a very short time that will be stressful.  There are strategies that can be used to accomplish all the target goals that don’t require an inordinate amount of effort, excessive overtime, and maintains HIPAA compliance.

For the smoothest transition, clinicians will need patient demographic information and the means to access it at will as they make the change from their old methods to the new EMR systems capable of handling all the new codes. To maintain HIPAA compliance, sensitive data can be stored on-site or in the cloud, providing that necessary security measures are in place.

All new patient information will be coded using ICD-10. Importing ICD-9 into the data into the new coding format for existing patients will take some time, but clinicians will find that as information is transferred and existing patients continue their care, overlaps will become apparent. Practice owners will need to maintain both coding systems for a time to ensure the complete transfer of patient data.

To facilitate the initiation of ICD-10, some EMRs have automatic crosswalks that will convert the coding. To ensure compliance, it’s essential that clinicians contact the clearinghouses and payers they work with and run sufficient testing to make sure all systems can communicate with each other. Each practice should make an effort to practice with converting ICD-9 to ICD-10 to familiarize themselves with its nuances before the official implementation date.

HIPAA version 5010 is the new standard for conducting electronic transactions to ensure patient privacy is maintained. It provides a platform for the use of ICD-10 coding. Practices and billers must implement the new HIPAA 5010 standards before ICD-10 codes can be utilized.

The upgrade to version 5010 was essential, as the old systems couldn’t use or accommodate the greatly expanded code set. HIPPA 5010 applies to “covered entities” that includes payers, providers, clearinghouses and health plan carriers. They all must upgrade to the new standards if they submit claims for reimbursement, transmit patient information, track claim status and verify coverage eligibility.

Clinicians should be aware that there are a couple of potential exceptions when the use of ICD-9 codes may still apply. Those are Workers Compensation and personal injury claims. The Affordable Health Care Act regulations continue to evolve and future legislation may change to encompass those two entities under ICD-10 coding.

The use of both coding systems allows practices to test and troubleshoot any intercommunication problems with payers and providers within its network. The testing process can identify areas where clinicians may need more training in appropriate documentation and provides valuable coding practice for clinicians and billers.

Practitioners aren’t alone – there are numerous sources of online assistance. Free training and resources are available on websites that include Medicare, the American Health Information Management Association (AHIMA), and the American Academy of Professional Coders (AAPC). The Find-A-Code application is also available that offers crosswalks, lookups and tools to simplify coding.

The 10 Advantages of ICD-10 Over ICD-9

The 10 Advantages of ICD-10 Over ICD-9

With the transition from the International Classification of Diseases (ICD)-9 to ICD-10 set to take effect on Oct. 1, 2014, it’s time to look at the advantages of ICDE-10 compared to the old system. ICD-10 provides 68,000 diagnostic codes and creates a new alpha-numeric system of 3-7 digits.

ICD-10 allows for different diagnosis coding according to the venue in which the patient is seen. ICD-10-C will be used by primary physicians and therapists, while ICD-10-PCS is for inpatient hospital procedures. Despite reticence and trepidation on the part of many clinicians, ICD-10 will provide some distinct advantages that will benefit practices in a variety of ways.

    1. The most important advantage to the new codes will be the ability to provide a more in-depth diagnosis for each patient and condition, ultimately leading to fewer claim rejections. Every practitioner has felt the frustration of having a reimbursement claim denied or sent back for more information. The new codes are designed to include a variety of expanded information to facilitate the claims process.
    2. The new coding system employs a new alpha-numeric sequence that allows for easy changes and updates as technology advances.
    3. ICD-10 codes are very specific about each incident in terms of when, where and how an injury took place, along with symptoms and any measures the patient may have taken on their own to gain relief. They provide numerous sub-categories for enhanced scope of reporting.
    4. The ICD-10 system provides clinicians with an updated listing that takes into account changes in technology and practices that have evolved since the implementation of ICD-9 over 30 years ago. New diseases, conditions and terminology allows for a better and broader scope of reporting ranging from animal attacks to conditions arising from space age technology.

  1. The enhanced coding provides detailed data for statistics gathering, analysis and research.
  2. ICD-10 codes allows for better monitoring to assess quality of care.
  3. The new codes should provide greater insight into each patient case and reduce the need for volumes of client records to be transmitted. Electronic transmission of data reduces the need for paper records, offering an environmentally-friendly solution. Practitioners can share standardized information electronically with other caregivers for better patient outcomes.
  4. The greater specificity of ICD-10 has the potential for yielding better reimbursement levels for clinicians. Practitioners can discover which procedures generate the best revenues and bill accordingly when it’s appropriate.
  5. The new coding is designed to increase efficiency within practices, allowing clinicians to better manage their available resources to reduce overall healthcare costs.
  6. The U.S. is the only country that hasn’t already transitions to the ICD-10 codes. A universally accepted standard of coding allows information to flow freely between healthcare professionals any country in the world. This is especially important in the control of contagious diseases and potential epidemics, but has other applications, too. It allows for better monitoring to assess quality of care.

The transition to ICD-10 codes will require clinicians to capture data in new ways, but will provide practitioners with an improved means of documenting the complaints and diseases of each patient. That ability has the potential to generate a significant increase in revenues.