Health Information Management

Effectively manage ICD-10 documentation and coding assessments

JustCoding News: Inpatient, May 23, 2012

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Do not view the proposed rule extending the ICD-10 implementation date from October 1, 2013, to October 1, 2014, as a year-long break from ICD-10 preparations. Rather, focus on using the additional time allotted to your advantage. This includes conducting documentation and coding assessments to gauge ICD-10 readiness. 

Facilities should start assessing the readiness of their coding staff and documentation procedures in relation to ICD-10 requirements and create strategies to manage any deficiencies, according to Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, an HIM professional and leader for more than 30 years. Bryant spoke March 1 during JustCoding’s Virtual Summit: ICD-10-CM and ICD-10-PCS.

Clinical documentation has and will continue to be a hot topic through the various phases of ICD-10 implementation. The increased granularity of ICD-10 will impact code assignments throughout the medical record, according to Bryant. “We have a greater opportunity for specificity as well as clinical details and we need to plan for that,” said Bryant.

For example, a patient presents to the ED and the physician documents possible pneumonia. The coder must determine whether the clinical course and finding support the coding of a diagnosis of pneumonia, according to coding guidelines. Additionally, the physician should document whether the patient had a specific type of pneumonia, if known (e.g., aspiration pneumonia). Further, outpatient coders cannot report a diagnosis listed as possible or probable; they can only code a confirmed diagnosis..

The benefit of ICD-10 lies in the level to which the coder can convert the required documentation to corresponding codes.

“The specificity required for ICD-10, such as etiology, anatomical site, and severity should all be contained in the physician documentation. Today we wouldn’t code some of those things because the ICD-9 code set does not require it. But with ICD-10, [it will be required,]” said Bryant.

Documentation assessment

Studies indicate that if hospital administrators performed an internal chart audit today, they would find approximately 15%–20% of existing medical records would require additional physician documentation, according to Bryant.

Bryant encouraged organizations to perform these chart audits to gauge exactly where their facility falls within those generalized statistics. “We don’t know what our facility would be, what our practices are, unless we have a documentation assessment,” she said.

Facilities with implemented electronic health records (EHR) will likely notice an increase in effective documentation when compared to those facilities still relying on manual documentation, said Bryant. Bryant noted one of the many advantages of EHR implementation is the resulting improvement in clinical documentation that EHRs encourage.

Providers in certain specialties may find the specificity required of ICD-10 impacts their documentation practices more than others, said Bryant. For example, orthopedic and cardiology providers will see many differences between ICD-9-CM and ICD-10 coding requirements as the specificity required in these areas increases dramatically.

For example, if a patients presents with a fracture of the left ulna, coding in ICD-9-CM would not allow for laterality, while ICD-10-CM does.

Focus on the most frequently reported diagnoses codes when assessing documentation. Bryant suggested HIM directors run a report to identify not otherwise specified and not elsewhere classified diagnoses codes used in the following settings:

  • ED
  • Ancillary visits
  • Outpatient surgery
  • Inpatient services

Identifying procedure codes may be a little trickier, Bryant cautioned; however she recommended running a report of procedure volumes and examine documentation for the top 20 procedures in that report.

“When we see the data, it’s going to require that we conduct an actual audit to assess specific documentation gaps that may exist there. This means coding the chart into ICD-10 to see the level of code detail arrived at with current documentation. It’s critically important that physicians understand the depth of information required for diagnoses selection and procedure code selection,” said Bryant.

Sample assessment structure

These chart audits may be at random, for example all charts over a given time frame, or they can target certain diagnoses or procedures, for example:

  • Chest pain
  • Pneumonia
  • Heart failure
  • Asthma
  • Fractures

Bryant suggested that HIM directors structure chart audits as follows:

  • Plan to assess between 100–200 charts, depending on available resources.
  • Talk to the HIM and clinical documentation improvement (CDI) departments to assess the current top physician queries.
  • Evaluate samples of medical records to determine whether current documentation supports the level of detail required for ICD-10. This will require someone with in-depth ICD-10 knowledge.
  • Discuss assessment findings with physician and coders.
  • Implement documentation improvement strategies based on assessment results.

“Remember, you need to have a very experienced auditor perform this kind of documentation assessment,” said Bryant. This would include someone who has ICD-10 experience and expertise (i.e., an approved ICD-10 trainer).

Consider using a color coding system when evaluating charts for audits, said Bryant. Red indicates the highest level of priority, yellow represents a medium level of priority, while green indicates a low priority level. This allows coders and administrators quickly evaluate at a glance what issues exist and why.

For example, Bryant evaluated charts for instances of laterality documentation and found the physicians were documenting it even though ICD-9-CM doesn’t require it for coding.

“It’s not that the physician said, ‘The laterality is…,’ rather, in the mere assessment of the patient the left and right sides are indicated. So we felt comfortable labeling that green for the assessment of laterality element,” said Bryant.

Coding assessment

Bryant also stressed the importance of assessing coding quality after reviewing the documentation assessment. HIM managers should review coded ICD-9-CM charts to look for any trends indicating problem areas that must be corrected prior to ICD-10 implementation.

Using the same color coding system, for those charts determined to fall within the red and yellow classification, how were they coded? She recommended HIM directors perform a gap analysis on those charts to determine the competency of existing coding staff and, where applicable, coding auditors and educators.

Bryant outlined four core competencies identified by the American Health Information Management Association (AHIMA), CMS, and the AAPC as prerequisites of coding staff:

  • Medical terminology
  • Anatomy and physiology
  • Disease process
  • Advanced pharmacology

“These have been determined to be foundational for understanding ICD-10,” said Bryant, who believes evaluation of these skills is vital. She added that HIM managers may also include general coding requirements, such as an understanding of sequencing rules, in the coding assessment.

The assessment of the coders’ knowledge of the biomedical sciences will be one of the most critical aspects of the gap analysis, Bryant noted. Coders who do not meet certain knowledge level standards may require further training and education.

The impact and gap analysis highlights the necessary areas on which HIM directors will need to focus attention and develop procedure and processes changes, said Bryant.

In addition to internal resources and training seminars, Bryant recommended HIM directors look into train the trainer seminars, boot camps, and other externally developed educational programs to see if any meet the needs highlighted in the gap analysis. Online resources exist to supplement internally developed tip sheets and tools, she said.

Lastly, Bryant indicated HIM directors and coding leaders should provide coders with actual sample charts to code in ICD-10. The additional practice allows coders to test their ICD-10 knowledge in addition to the core competencies outlined above. This proves another resource for evaluating what future training may be required for coding staff and this may provide a peek at the impact to productivity.

Ultimately, proactive documentation and coding assessments will serve as a guide for HIM directors and coding leaders as the ICD-10 implementation date approaches. This type of assessment insight may prove helpful even during the next few years when coders are still using ICD-9-CM.

Regardless of whether the implementation date for ICD-10 changes, Bryant stressed the assessments should take place in 2012. “With ICD-9, we know it’s going to be obsolete in a few years anyway. We are still going to go with ICD-10, so we need to assess, be prepared, and be ready,” said Bryant.

Email your questions to Senior Managing Editor Andrea Kraynak, CPC, at

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