Tip: Prepare for ICD-10-PCS documentation concerns

September 26, 2013

CDI Strategies - Volume 7, Issue 20

By Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA

There are many articles about the enhanced documentation required in ICD-10-CM. However, the real challenge will be ICD-10-PCS. It is a completely new code set and is not used in any other country than our own.

ICD-10-PCS does not include unspecified codes. Thus, clinicians may see an increased number of queries on procedures post-implementation. CDI professionals, inpatient coders, and clinicians should focus on several important documentation areas during the next year to prepare for ICD-10-PCS implementation. These include the following:

Root operations: Coders must understand that physicians are not obligated to use root operation terminology in their documentation, according to the 2014 ICD-10-PCS Official Guidelines for Coding and Reporting. Therefore, inpatient coders and CDI specialists must be proficient in the ICD-10-PCS root operation definitions and be able to apply the correct root operations for procedures performed within their facilities. By learning the root operations now, they can identify and remedy any gaps in documentation prior to implementation.

Anticipated documentation gaps: Each hospital may have its own specific areas for improvement. Hospitals must perform a detailed gap analysis to determine which specific conditions and procedures require remediation, but here are a few to start with:

Lymph nodes: excision vs. resection
Amputations
Embolization: restriction vs. occlusion
Cardiac procedures

Preparation strategies: Facilities should take this final year to dive deep into existing documentation and identify areas that require improvement. Once gaps are identified, focus educational efforts on specific physician groups and/or CDI/coding staff that require training. Also, take advantage of this time to grow trust and respect between CDI specialists, clinicians, and coders. These three groups all bring important pieces of knowledge to the table. Working collaboratively will benefit the quality of patient health record documentation which, in turn, enhances patient care and provides accurate reimbursement to both the facility and the clinician.

Editor’s Note: Endicott is the director of HIM practice excellence at AHIMA in Chicago. This article is an excerpt adapted from JustCoding.com.

Join HCPro at 1 p.m. Friday, September 27, for the live 90-minute audio conference, ICD-10-PCS: Coding, Structure, and Format. Experts Mark N. Dominesey, MBA, RN, CCDS, CDIP, HIT Pro-CP, and Nena Scott, MSEd, RHIA, CCS, CCS-P, will present an overview of ICD-10-PCS structure and format as well as analyze the process of ICD-10-PCS coding.

For more information or to order, call 800/650-6787 and mention Source Code EZINEAD or visit the HCPro Healthcare Marketplace.

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