Introducing the ICD-10 Documentation Series: Where Is Your ED? And Where Should It Be? (Part 1 of 4)

Jim Strafford , CEDC, MCS-P

Principal

Published February 12, 2014

As of this writing, we are 233 days from the scheduled implementation of ICD-10 — not that we are counting! The industry has been gearing up for ICD-10 for several years. Predictions range from "10:1 odds of doom" to "it won't be so bad." Despite industry rumblings to the contrary, CMS continues to insist that implementation will take effect on Oct. 1. (We will discuss the "implementation controversy" in Part 4.)

Our view is that it is difficult to accurately predict the precise impact of such a fundamental change in the revenue cycle continuum. But predictions of a negative impact on coder productivity are certainly reasonable based on previous implementations in other countries. As to the impact on the "back end" of the revenue cycle — things like cash flow, reimbursement, denials, rejections — the magnitude is difficult to predict. The United States' unique, multi-payer reimbursement system does not compare well with other developed countries that have already implemented ICD-10. But there will certainly be impact.

Stakeholders in the revenue cycle process, including entities like billing/coding services providers, EMR companies, payers, consultants, trainers and so on, have invested a great deal of time, effort and money in preparation for the Oct. 1 deadline. However, in preparing for ICD-10, we at Healthcare Administrative Partners (HAP) have identified several common disconnects among the stakeholders. The most significant for emergency medicine appears to be between the documentation/coding community and the provider community.

An AAPC national board member and I recently surveyed members of an online ED coding group about ICD-10 readiness. Eighty percent of the respondents were confident that they themselves were prepared for ICD-10 implementation. However, only 30 percent stated that their organizations/employers were prepared.

Some of this could be due to coders' perceptions that documentation is never ideal. However, most ED coders have already received ICD-10 training and documentation. Often, these coders are tasked to review ED charts with an eye toward whether the documentation they are seeing will be sufficient under ICD-10. As we at HAP have found in reviewing thousands of ED charts, current sign, symptom and diagnosis documentation will often not result in the most specific ICD-10 code available come Oct 1.

At this point in time, pretty much all stakeholders in the Acute Care Continuum are aware of the increased "granularity" of ICD-10 codes. (The new system covers over 70,000 diagnostic codes.) Despite some understandable anxiety on the part of coders and providers, ICD-10 is a significant improvement over ICD-9. Not only is it more intuitive, it provides a better framework for completely describing the reason for each clinical encounter. For example, ICD-10 has laceration codes for type of wounds (puncture, bite) and wound location (a specific finger, for example).

The good news is that most ED physicians already document wound type and exact location. For more general injuries, they document laterality — whether location of the injury is left or right. But there are also specific descriptions in ICD-10 that ED providers have not been in the habit of documenting. For example, in the case of a finger laceration, the physician must note whether the fingernail is damaged in order for the coder to code at all.

Over the course of this four-part series on ICD-10 for emergency department providers and administrators, I hope to provide tools that can be used going forward to achieve that "granularity" necessary for optimum ICD-10 coding. However no amount of tools, feedback or training will replace the need for ED providers to approach ICD-10 documentation with a different mindset. In some cases, this will mean documenting beyond what was taught in medical school and residency.

The correct bias of an ED physician is to diagnose and treat patients rapidly — particularly when a life-threatening illness or injury is present. But ICD-10 requires the physician to step back and consider which documentation will result in the optimum ICD-10 code. And in emergency medicine, there will inevitably be situations where a very specific diagnosis is simply not available at the point of service. In these cases, the ED physician still needs to understand ICD-10 symptom documentation and how it differs from that of ICD-9.

Part 2 of our series will present practical steps that ED providers and coders can take now (in early 2014) to prepare for ICD-10 implementation. Part 3 will cover some common ED scenarios and appropriate ICD-10 documentation for each. And Part 4, which will be of special interest to administrators, will discuss where organizations should be on Oct. 1 and beyond to assure that the ICD-10 documentation process is working in terms of coding, billing cash flow and revenue.

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