Health Information Management

A view from the physician side of the ICD-10 debate

HIM-HIPAA Insider, December 15, 2014

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Usually in the ICD-10 Trainer blog, I talk about ICD-10 implementation and coding from the coder or HIM point of view. But I wanted to share some suggestions from James S. Kennedy, MD, CCS, CDIP, president of CDIMD – Physician Champions in Smyrna, Tennessee. You’ll notice that Kennedy is not only a physician, he also holds coding and CDI credentials.

Recently, Kennedy wrote a column for our sister publication, Medical Records Briefing, about ICD-10 implementation. It’s a great piece (as Kennedy’s columns always are) and gives us a view from the physician side of the debate.
Kennedy emphasizes that he’s not against ICD-10; however, he is concerned that the way ICD-10 is constructed, managed, and being implemented creates undue burden for physician practices and that, unless addressed, will give physician groups ammunition to convince Congress to delay its implementation for another two years, if not forever. Witness statements recently made by the Texas Medical Association that do just that.
Given that ICD-10 is a political football, Kennedy believes that a deal can be struck between organized physician groups such as the AMA and the Coalition for ICD-10 that:
  • Engages physicians in ICD-10’s governance
  • Simplifies ICD-10 documentation and coding requirements
  • Reduces claim denials
  • Enhances the utility of the ICD-10 datasets essential to health planning, reimbursement, and outcomes measurement
  • Guarantees an implementation date
What I wanted to share are  Kennedy’s negotiating points, things that the AMA, medical specialty societies, and the Coalition for ICD-10 can use to make implementation better for everyone.
Kennedy: Ask your specialty society to advocate with Congress for a fifth Cooperating Party for ICD-10 to represent physician interests so that we can have a direct say in the maintenance of ICD-10. This will also promote the physician-coder partnership in the ICD-10 Official Guidelines, ensuring a level playing field.
  • My two cents: Why don’t physicians have a seat at the table? We’ve complained for years about Recovery Auditors not using clinical people to review records. Having a physician presence among the Cooperative Parties would benefit everyone.
Kennedy: Call your congressional representatives to ask that the ICD-10 documentation requirements be loosened such that a competent coder can clinically interpret the record within reasonable parameters and assign a defendable code, preventing a payer or Recovery Auditor from denying reimbursement when the circumstances are obvious.
  • My two cents: I love this idea. I do think we need to be careful about making sure the coding professional is competent, but the coding professional organizations can surely create a certification. Coders who have been on the job for a number of years probably have a pretty good idea of what certain clinical information means.
Kennedy: Partner with your hospitals to ask the Cooperating Parties to let coders and clinical documentation improvement specialists be more direct with what they need from us in real time, instead of playing “20 questions” to get the exact ICD-10-based documentation supporting the correct code.
  • My two cents: Fantastic idea! Let’s make the work easier for everyone. Coders and CDI specialists get frustrated when they can’t get the physician to give them the words they need. Physicians get fed up with endless queries about things they believe they have already documented. Make it easier for everyone and reduce the frustration and animosity.
Kennedy: Advocate with your EHR companies to develop ICD-10-oriented clinical documentation templates and tools promoting problem-oriented charting (especially in the problem list), emphasizing the ability to link conditions to each other (e.g., fractures with osteoporosis, congestive heart failure with cardiomyopathies) and to express uncertainty or working diagnoses (e.g., pneumonia likely due to methicillin-resistant Staphylococcus aureus) where appropriate.
  • My two cents: Clinicians (physicians, nurses, physician assistants, nurse practitioners, etc.) are the ones who need to work the most in the EHR. I’ve heard various other people speak about EHR improvements to make the transition to ICD-10 easier. Physicians will need to document specific information for ICD-10 codes. Make it easier for them, but include them in the conversation. Get a group of physicians, coders, and CDI specialists together. Look at your top codes by volume and by money. What information will you need in ICD-10 for these codes? What templates can you ask your vendor to build? If you have a physician willing to work with the vendor, get them together so the physician can explain to the vendor what would make sense from a clinical standpoint. Is there a prompt that can be added? Or if you’re building a template, where should the information be located to make it easy for the clinician?
Kennedy: Tell the ICD-10 Coalition (which includes Blue Cross) that it must publish its ICD-9-CM to ICD-10-CM crosswalks and medical necessity criteria as a condition of our acceptance of ICD-10 so that our claims are not denied just because we unwittingly documented or used an unspecified code.
  • My two cents: I’m a little worried about the payers’ refusal to publish their ICD-9-CM to ICD-10 crosswalks and ICD-10-based medical necessity criteria. CMS has had both ICD-10-CM and ICD-10-PCS GEMs out for years and is publishing ICD-10-based medical necessity criteria on its website. One of the problems with crosswalks is they aren’t a one-to-one comparison. If they were, why bother moving to a new code set? Crosswalks aren’t perfect. They are only as good as the people who created them and the work put into building them. If we have the crosswalks in advance, we might be able to find places where we think the code assignment isn’t correct (assuming of course you have time to look at the crosswalk and compare the codes). Also, in some cases, an unspecified code is perfectly legit. The physician don’t always know the causative organism. An outpatient physician may not know at the time of the encounter where a fracture is or which ligament is sprained. Granted I think you should never report unspecified laterality, but odds are physicians are already documenting that.
These are great points to consider not only for physicians, but for coders and HIM as well. Work with your physicians to find out what you and they can do to make the transition better for everyone.
This article originally appeared on HCPro’s ICD-10 Trainer blog.

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