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.
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.
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).
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.
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 Equivalence Mapping (GEM) system offers the best industry-wide standard currently available for the forward and backward mapping of ICD – 10 Codes. GEMs can be practically applied as long as clinicians remain aware of their limitations, use them as a starting point, and receive ICD-10 training and education.
A GEM contains an alphabetical index to entries, classification system for procedures, and the appropriate code numbers. The major difference is that GEMs provide clinicians with the ability to forward map from ICD-9 to ICD-10 codes, and backward map from ICD-10 to ICD-9 coding.
An alphabetical list provides the starting point to begin a search for the appropriate code. Just as the words in a language translation guide can contain multiple meanings, the same is true of a GEM. When the index is accessed, it will return as many related items as possible. It’s up to the clinician to narrow the parameters and choose the appropriate code meaning.
A GEM will return a source code for ICD-10 and ICD-9, along with “flags” that are divided into different categories. Flag identify if the system has identified an approximate, combination or no mapping equivalent. A scenario and choice list are also available to provide more information for combination possibilities and the choice list provides alternatives for a combination entry.
Many terms, procedures and concepts have been changed or included in other categories. Adjunct codes are included to provide additional information about a specific procedure and clinicians may be faced with a combination of codes that must be used to identify a specific procedure.
The GEM results will vary depending upon the entity that created it. Additional options are available to help clinicians narrow the data for further specificity, along with instructional notes to help clarify a patient’s particular situation. GEM mapping between ICD – 10 sets isn’t a mirror copy and there will be discrepancies.
Numerous GEMs exist from multiple sources and clinicians would do well to examine the GEM from their preferred source to ascertain which would be more beneficial and the most applicable within their practice. GEMs return a variety of potentially applicable results for each situation and some are more helpful than others in a particular practice environment.
The number of new codes, greater specificity and multiple options makes the documentation process much more involved, time-consuming and frustrating for clinicians. Searches will result in multiple options that must be examined in-depth to create a match that accurately represents the illness or injury, the type of encounter and the specifics related to an individual patient.
Coders and billers will be using coding books and software systems to make their conversions and many have argued that it may be easier, quicker and more convenient for clinicians to do the same. A GEM can literally return thousands of results for a single conversion query. GEMS are meant to be a short-term solution until clinicians become fluent with the ICD – 10 coding system or design their own crosswalk system.
Utilizing a GEM system will help clinicians ease into the ICD-10 transition, but they should be aware that it isn’t a magic wand or a one-size-fits-all solution. It offers possibilities, potential and helps bridge the gap in coding, but isn’t a definitive solution.
The ability to backward and forward code is the primary attribute and advantage of a GEM system. They’re essentially reference guides that can help clinicians during the ICD-10 transitional period, but should be combined with the clinician’s expert judgment.
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.
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.
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.
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.
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.
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.
(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.