Establish a game plan for ICD-10 queries

ICD-10-CM/PCS incorporates laterality, acuity, anatomical specificity, and a slew of additional combination and complication codes. Who will submit queries when this information is missing in a medical record? Will coders or CDI specialists take on this role? Perhaps it might be a combination of the two.

Cheryl Ericson, MS, RN, CCDS, CDI-P, CDI education director at HCPro, Inc., in Danvers, Mass., says facilities need to answer these questions now. Hospitals shouldn't default to unspecified codes simply because they don't have a plan for query submission. Unspecified codes lead to poor data, and they may eventually affect reimbursement, she says. Determine which individuals will submit the following types of queries in preparation for ICD-10 and when the new coding system becomes effective in 2014.

Laterality: Documentation regarding laterality will be required to accurately assign some PCS codes, but it's also directly tied to quality reporting, says Ericson, an AHIMA-approved ICD-10-CM/PCS trainer. "Incorrect and inconsistent documentation regarding laterality can be a quality issue," she says. For example, it may raise questions about wrong-site surgeries, which are considered never events. Hospitals must determine who is best suited to obtain this information from physicians when it's not already in the documentation, she says.

Anatomical specificity: Many ICD-10-CM/PCS codes denote more specific anatomical locations than their ICD-9-CM counterparts. Until AHA Coding Clinic publishes guidance ­allowing coders to code from nonphysician ­practitioner documentation, physicians must provide this information, and coders or CDI specialists must be prepared to query when this information is not ­documented, says Ericson.

Coders and CDI specialists should note that in ­ICD-10-CM, some body parts can be classified as overlapping, accoridng to the 2012 ICD-10-CM Official Guidelines for ­Coding and Reporting.

"This is a concept that providers need to be aware of because having an overlapping body part is different than having a mets or a regional mets," says Ericson.

Manifestations: If physicians don't link a condition with its specific manifestation, seek clarification, says Ericson.

"We're going to need physicians to connect the dots for us," says Mary H. Stanfill, MBI, RHIA, CCS, ­CCS-P, FAHIMA, vice president of HIM consulting services at United Audit Systems, Inc., in Cincinnati, Ohio.

For example, when a physician documents dementia due to Parkinson's disease, coders should first report ICD-10-CM code G20, which denotes Parkinson's disease. They should also report F02.80 or F02.81, which denote the manifestation of dementia in disease classified elsewhere (with or without behavioral disturbances). The brackets included in the ICD-10-CM Alphabetic Index following code G20 identify the specific manifestation that coders should consider, says Stanfill.

Combination codes: ICD-10-CM includes many more combination codes than ICD-9-CM. A combination code is a single code that classifies two diagnoses, a diagnosis with an associated secondary process (i.e., manifestation), or a ­diagnosis with an associated complication. Coders must report combination codes when they fully ­identify a diagnosis or when the Alphabetic Index directs them to do so, says Ericson. Don't report multiple codes when a combination code more accurately describes a patient's condition.

Physicians must link two or more conditions before coders may report a combination code. If physicians don't provide a link, or the link is unclear, be prepared to query, says ­Ericson. Auditors are checking whether organizations query when the guidelines direct them to do so, she says.

Also, CDI professionals should be on the lookout for new combination codes in ICD-10-CM that could prompt more queries, says Stanfill. For example, a patient presents with coronary artery disease (CAD) with angina. Coders using ICD-9-CM report codes 414.01 (coronary atherosclerosis of native coronary artery) and 413.9 (other and unspecified angina pectoris). ICD-10 assumes a relationship between the CAD and angina. ICD-10-CM combination code I25.119 denotes atherosclerotic heart disease of native coronary artery with unspecified angina pectoris.

Acuity specificity: ICD-10-CM describes many conditions as acute or chronic. Teach providers to state when a condition is acute or chronic, says Ericson. Distinguishing between them affects reimbursement and can support medical necessity. Acute conditions are often the reason for admission because they require immediate treatment, says Ericson.

Pay close attention to respiratory failure, says Stanfill. In ICD-9-CM, documentation of respiratory failure that doesn't further specify the type defaults to acute respiratory failure (518.84), which is an MCC. However, ICD-10-CM includes a category for unspecified acute respiratory failure (J96.20). A query is necessary to avoid reporting this unspecified code, she says.

Complication codes: ICD-10-CM includes more complication codes than ICD-9-CM, and it distinguishes between intraoperative and post-procedural. If a physician doesn't document a cause-and-effect relationship between care provided and the condition, seek clarification, says Ericson. Coders and CDI staff must look at the record, find the medical history, and see the whole progression of the disease process, she says. Consider the following:

• Intraoperative complications that specify the type of procedure performed (e.g., cardiac catheterization, cardiac bypass, other circulatory system procedures)
• Postprocedural complications that differentiate between cardiac and other surgery (e.g., cardiac insufficiency, cardiac arrest, heart failure, cardiac functional disturbances, cerebrovascular infarct)

ICD-10-PCS: All ICD-10-PCS codes include seven characters. They incorporate greater anatomical specificity, including laterality. If a character is missing, you can't build the code, says Stanfill. Hospitals must determine who will query for this information, she says.

The 7th character (qualifier) may be particularly problematic, she says. For example, ICD-10-PCS requires coders to specify whether a below-the-knee amputation of the lower leg involves the high, mid, or low portion of the leg.

Editor's note: This article originally published in Briefings on Coding Compliance Strategies. The content in this article was presented during the audio conference "Mastering Physician Queries: Tools for Effective Policies, Practices, and ICD-10 Preparation." To learn more, visit http://tinyurl.com/99wcfk4.