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.
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.
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.