Implementation Advice: Picking last-minute ICD-10-CM/PCS priorities

Dual coding. Reformatting queries. Educating physicians. Let’s face it— the to-do list for ICD-10 preparation is pretty long and can be a bit daunting. With only a few short weeks left before the transition, there’s one thing your facility should do: prioritize.

We’ve rounded up our CDI and coding Boot Camp instructors and asked them to share their top three tasksto help you get your priorities straight and your facility set for ICD-10.

Laurie Prescott, MSN, RN, CCDS, CDIP, CDI education director for ACDIS/ HCPro

1. Get your house in order. We anticipate an increase in query rates resulting from the increased specificity, and we’ll likely be asking more procedure-related queries than [CDI staff] have in the past. Therefore, organizations would benefit from reviewing and updating their query policies and practices. Ask yourself, and your staff, the following questions:

• How will you prioritize queries if you have several identified for a record?
• Should you ask the queries related to CC/MCC capture first (a financial focus), or do you prioritize queries related to quality indicators?
• How will the query process be shared between CDI specialists and coders?

Each organization may have a different focus or mission, and this would influence prioritization decisions.

2. Make sure your physicians know the basics. Make sure they know how they will receive queries and how to answer them. This is also a good time to let them know the purpose of your CDI department. Surgeons especially may not be used to the queries; they should understand the expectations and how to support CDI efforts. It is also important to review existing operative notes now to identify any education needs. Target your high-frequency surgeries for your high-frequency surgeons. Take the time now to teach them about the required documentation. There is a lot of information required to complete a PCS code that many of us may have never noticed within the record because we didn’t previously need it. However, only teach physicians when you find something is missing. Education should be targeted to their specialty and reflect  their specific documentation habits. You may find in your review that their operative notes are better than you thought.

3. Update query templates. Every query template should be reviewed and updated as needed, at least on an annual basis. Now, however, it’s time to double-check all those forms to make sure they reflect ICD-10 specificity. The answers provided in multiple-choice queries should reflect the needed specificity of the new code set and follow the latest, 2013 physician query practice guidance from ACDIS/AHIMA.

Documentation templates or EHR choices or prompts should also be updated to reflect the ICD-10 code set specificity. Updated EHR prompts could help the CDI team obtain the necessary medical record documentation without additional physician queries.

If you do not have electronic records, look at any hard copy dictation templates or forms that include identification of diagnoses. These should all reflect the appropriate wording of diagnoses as needed in ICD-10.

Sharme Brodie, RN, CCDS, CDI Boot Camp instructor for ACDIS/HCPro

1. Use linking language. In ICD-10-CM/PCS, some conditions require linking language, while others require a cause-and-effect relationship to be demonstrated by the use of verbiage such as “due to.” For example, “UTI due to a Foley catheter” tells us much more about the relationship than just “UTI with a Foley catheter.”

In ICD-10-CM, the use of combination codes will increase significantly, and the number of anticipated queries will increase as well.

Talk to physicians now and get them in the habit of identifying conditions that could possibly be linked. Encourage CDI staff to review history and physicals, progress notes, and discharge summaries for these conditions.

Educate physicians on common documentation issues, such as identifying the relationship between two or more conditions, in order to avoid queries later on. The best way to teach our physicians is to choose linking language that works in every situation, such as “due to,” and have them use it. It not only links conditions to complications or manifestations, but it also demonstrates a cause-and-effect relationship.

Similarly, connect organisms and infections. Come ICD-10, specific codes will be chosen based on the possible organism causing the infection. Any time you have an infection, regardless of the location of the infection, have the physician identify the causal organism and, with the use of linking language, have him or her link the organism to the infection.

2. Practice laterality. Even though ICD-9 does not require laterality, many CDI programs started capturing it ahead of time to get physicians in the habit. It never hurts to have greater specificity earlier than required by the code set! Remember, even the abdominal muscles have laterality.

3. Start documenting time frame in days. The time frame for acute myocardial infarction codes has changed from eight weeks or less in ICD-9-CM to four weeks or less in ICD-10-CM. Even though this change from eight weeks to four weeks will not begin until October 1, you can adopt it now by documenting the number of weeks in days. You’ll have one less issue to deal with come implementation.

Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding for HCPro

1. Work on procedure codes. Ensure that physicians’ operative reports contain adequate documentation in order to support all seven characters required for correct ICD- 10-PCS assignment.

2. Plan for productivity decreases. CDI and coding should expect productivity decreases at first with ICD-10 implementation and plan accordingly so that revenue is not affected more than necessary.

3. Meet with your staff. Organize meetings to identify and communicate documentation issues encountered on a weekly or biweekly basis after the go-live date to ensure energy is focused on the biggest areas of concern from all departments. Good communication  and a team effort is the best way to tackle the upcoming challenges. It’s a new system for everyone, so use the strength of your numbers and experience to capture those problems and uncover solutions.

Cindy Basham, MHA, MSCCS, BSN, CCS, CPC, CCDS, regulatory specialist and instructor for the Certified Coder Boot Camp® for HCPro

1. Continue dual coding. Facilities who do well after ICD-10-CM/ PCS implementation will be those who have practiced dual coding cases. It is reasonable to assume those facilities who’ve done so will cross the learning curve with fewer errors than those who waited until the end to begin practicing ICD-10 code assignment.

2. Engage leadership. Leadership—including chief medical officers, physician advisors, and CDI department managers—will play a vital role in whether a facility moves seamlessly into ICD-10. CDI specialists should try to be as involved with these important decision-makers as possible. Work with leadership to schedule department meetings and set goals or standards for CDI and coding practices. Help them with educational activities and bring forward any opportunities for education. Those who are able to look at the big picture and recognize the importance of the changes related to ICD-10 can help the entire facility understand the importance of ICD-10 and help the organization be better prepared to handle the challenges.

3. Have a post-implementation plan. Understand how decreases or delays in productivity will be addressed, and work with CDI staff members to address the anticipated learning curve beyond implementation. CDI managers should create a plan to track and target any improvement opportunities with continued training and education efforts, addressing ICD-10’s challenges as well as its proposed ability to drive quality initiatives and more.

Jennifer Avery, CCS, COC, CPC, CPC-I, regulatory specialist and lead instructor for the Certified Coder Boot Camp

1. Look at facility statistics. One of the biggest things facilities need to consider is whether they want to capture ICD-10-PCS on their outpatient facility cases. There is a lot of difference between ICD- 10-PCS and CPT codes, so it could cause a lot of confusion for outpatient coders.

Many facilities have coders specialized by either inpatient or outpatient cases. Outpatient will still be financially reimbursed by CPT/ HCPCS II codes, and so there may be no financial rationale for capturing the ICD-10-PCS codes on outpatient claims.

That said, however, some facilities have captured Volume 3 ICD-9 codes for ease of statistical data reporting for facilities. This could cause coders additional confusion and slow down productivity significantly. Therefore, in my opinion, it is important to look for other ways to run statistical reports in order to capture this same information.

2. Train coders beyond the basics. Ensure coder training goes beyond an ICD-10-CM/PCS overview and really delves into the specifics. Facilities should verify with the vendors—such as their encoder systems—to ensure that their pathways or decision trees do not rely on the General Equivalency Mappings. Coders need to learn to rely on documentation, the ICD-10 code books, and ICD-10 guidance to help them find the appropriate answers to their coding dilemmas.

3. Educate your nurses and physicians. Ensure appropriate documentation of clinical terms that will help coders capture the specificity and/or cause and effect required to capture good statistical data. ICD- 10-CM/PCS is only as good as the people who use and understand it.

The data we collect can help a facility not only financially, but also help us capture data to help shape our healthcare in the future. Although physicians may not have a stake in the facility financially, both facilities and physicians have one goal in mind: patient care. Many people are concerned that the decision to give a “grace period” for reporting will have a negative impact on hospital data. It is our responsibility as coders, CDI specialists, and physicians to strive for the appropriate reporting regardless.