Health Information Management

Jump-start ICD-10 efforts with coding and documentation assessments

HIM-HIPAA Insider, July 26, 2011

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There’s no time like the present to conduct a coding and documentation assessment in preparation for ICD-10-CM, says Gloryanne Bryant, RHIA, CCS, CCDS, regional managing director of HIM, NCAL revenue cycle, at Kaiser Foundation Health Plan, Inc. & Hospitals in Oakland, CA. 

A coding assessment should target these four areas:
  • Anatomy and physiology
  • Disease process
  • Medical terminology
  • Pharmacology
Bryant agrees with other industry experts that inpatient coders will need at least 40–50 hours of total training time to prepare for ICD-10-CM/PCS. This time includes in-depth, hands-on training. A coding assessment will help reveal whether additional training beyond 40–50 hours is necessary.
“There are certain areas that nobody is going to be ready for [without significant training],” says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta. Regarding strokes, for example, Gold says coders will need to look for and understand the implications of laterality and which specific artery is blocked when a stroke occurs. It’s in coders’ best interest to identify and improve upon knowledge gaps now rather than wait until ICD-10-CM/PCS takes effect October 1, 2013, Gold says.
Hospitals could conduct a documentation assessment in one of two ways, says Bryant. They can either take a broad-spectrum look at documentation across the board as it relates to ICD-10-CM specificity or hone in on one or two high-volume specialty areas, such as orthopedics, OB/GYN, or cardiac care. After reviewing documentation on 75–100 charts, an auditor trained in ICD-10-CM can determine whether the documentation would yield a specified ICD-10-CM code, or whether it would result in the assignment of an unspecified code or prompt a physician query.
Coding managers should consider structuring a documentation assessment around their most frequently reported diagnoses. These diagnoses could potentially cross several service lines, says Gold, adding that an auditor trained in ICD-10-CM can review documentation of these diagnoses to ensure that it supports the new coding system.
Review your most frequently reported operative procedures as well, says Gold. For example, consider examining how each surgeon dictates his or her top five procedures. Does the dictation support the assignment of an ICD-10-PCS code? If not, the assessment can identify ways in which coders can coordinate templates with surgeons for each of these operative procedures to prompt more specific documentation.
Editor’s note: These tips originally appeared in the July issue of Briefings on Coding Compliance Strategies.

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