Guest post: Understand physicians’ perspectives on ICD-10

by Sam Antonios, MD, FACP, FHM, CCDS

Physicians are constantly reminded that healthcare is undergoing significant change. October 2015 marked one more landmark change: the shift to ICD-10. Many physicians have worried about the transition and likely dreaded the loss of familiar terms, efficiency, or income. How can coders, HIM professionals, and clinical documentation improvement (CDI) specialists engage with physicians to help them now that ICD-10 has been implemented?

Let’s explore some strategies.

Time crunch: The main reason physicians have been concerned about ICD-10 is time, or more specifically the lack of it. In the ambulatory setting, providers–who are in a chronic time crunch–will need to pick a code, or an alias of a code, on every patient encounter. Acclimating to the change will take time, but most physicians will eventually only have to deal with what pertains to their specialty.

In the hospital, physicians will need to document more. However, by now, CDI programs should have been strengthened. It’s more important than ever to explain the underlying goal of the new code set: better documentation will mean more accurate data, which will mean better risk adjustments for quality measures. Better documentation also means a more appropriate DRG that justifies the length of stay or resource utilization for each patient.

Avoid the cliché: ICD-10-CM/PCS is not used in the rest of the world, and the U.S. is not the last nation to implement ICD-10. That’s because ICD-10-CM is modified to fit the needs of the U.S. and is therefore different than the World Health Organization’s ICD-10. ICD-10-PCS is new, unique to the U.S., and untested anywhere else. Furthermore, ICD-10 in the rest of the world is not used for direct physician reimbursement. However, the rest of the world’s countries have implemented their own versions of ICD-10. So their data is already more precise than ours.

Explain the added codes: When ICD-10 became a reality, the first thing everyone focused on was the number of new codes. There should not be a strict emphasis on this fact. Although it is true that the number of codes has increased, the increase can be explained in the context of the concepts that have been added to each coding element. About one-third of the new codes are due to added laterality. Also, a single additional concept for a combination code will have a multiplicative effect. As an example, Crohn’s disease can be of the large intestine, the small intestine, both the large and small intestine, or an unspecified intestine (four locations). Adding one of seven complication concepts to each location of Crohn’s disease will multiply these four codes by seven, resulting in 28 codes. Yet Crohn’s disease did not change, nor did ICD-10-CM add 24 new types of Crohn’s disease pathology.

Outdated ICD-9: Because ICD-9-CM is old, its design limits the ability to include new diagnoses. Instead of intra-cardiac thrombus, a condition diagnosed with a modern echocardiogram, ICD-9-CM provides “certain sequelae of myocardial infarction, not elsewhere classified.” ICD-10-CM will provide a much better descriptor of the code. ICD-10-CM is not only newer, but also better incorporates specificity coming from clinically validated scales such as the Glasgow Coma Scale or scale of visual acuity, as well as basic classifications such as pregnancy terms. These improvements resonate with practicing providers.

ICD-10 for research: A quick search on www.pubmed.gov reveals that many academic studies on outcomes and quality rely on administrative data from ICD-9-CM codes. However, ICD-9’s lack of detail limits the value of these findings. Disease and specialty registries suffer from the same weakness. The value of ICD-10 for national health statistics, analysis, and monitoring is real. Although most providers are not conducting research, as we move more into management of populations and sub-populations of patients, physicians will realize that the added knowledge gained from ICD-10 may help them take care of their patients using new analytics tools. Furthermore, risk adjustment can be refined to more accurately reflect patients’ true severity of illness.

Debunk myths: In some cases, added specificity is needed under ICD-10. In others, it is not. A common miscommunication has been that all unspecified codes will be denied. This is unfounded, yet it has generated unnecessary fear among providers. While it’s true that certain codes lacking specificity would not be expected to be approved (for example, the laterality of an amputation), it is unreasonable to generalize this notion. The degree of specificity is clinically driven. There should be no embellishment of specificity, nor is it appropriate to order extra testing to identify a more specific diagnosis if it is unknown. In many cases, the added detail present in ICD-10’s codes may limit the need for additional records and documentation requests, since the required detail is already included in the code description. This will actually please providers.

Who participates in code creation: Physicians are often surprised to learn that professional societies and associations themselves are behind the requesting of many additional codes. The American College of Obstetrics and Gynecology, the American Urological Association, and the American Gastroenterological Association do so, for example, as well as several other medical groups and foundations.

In order to move forward effectively, understanding the physician perspective about ICD-10 is vital. Physicians’ workflow greatly impacts that of HIM professionals and coders. If we are to succeed in the transition to ICD-10, we need to dispel all myths about the new code set that raise providers’ apprehension level, we have to be objective and honest about ICD-10 facts, and we must be empathetic to the physicians and always offer support and help.

Editor’s Note: Antonios, at the time of this article's release, was medical director of medical information and ICD-10 physician advisor for Via Christi Health in Wichita, Kansas. This article was originally published in the HIM Briefings newsletter.