Rhonda Buckholtz, CPC, CPMA

With less than a year left before the "go-live" date for ICD-10, industry focus is turning more and more to clinical documentation improvement (CDI), as it will be even more vital to every facility.

Under ICD-10’s more rigorous specificity requirements, physician documentation will need to meet the higher standard as well. If your practice is fully prepared for ICD-10 in every other aspect, but clinical documentation has not improved, accurate coding and proper payment will not be possible.

A recent study of more than 20,000 audits of physicians’ clinical documentation revealed that only 63 percent of current documentation is sufficient for ICD-10’s specificity levels. Keep in mind, the insufficient documentation found in these audits often represented a larger percentage of at-risk revenue. For example, in one larger assessment, findings indicated seven of the most commonly used diagnosis codes accounted for 93 percent of the facility’s revenue.

Here are a few examples of where documentation changes will likely be needed:


• Type of diabetes
• Body system affected
• Complication or manifestation
• If a patient with type 2 diabetes is using insulin, a secondary code for long term insulin use is required


•Type:
Malignant (Primary, Secondary, Ca in situ)
Benign
Uncertain
Unspecified behavior
• Location(s) (site specific)
• If malignant, any secondary sites should also be determined
• Laterality, in some cases


• Severity of disease:
Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
• Acute exacerbation
• Status asthmaticus
• Other types (exercise induced, cough variant, other)

These are only a few examples of the more specific documentation requirements.

To avoid an increase in denied claims under ICD-10, perform an ICD-10 readiness assessment. Here's how:



Start by running a report in your computer system and sorting it by diagnosis code. Next, take your top 10 most commonly used diagnoses and run another report of patients that had those diagnoses appended to them. Pull 10 to 20 charts for your most commonly used diagnosis code. Review the ICD-10-CM guidelines (if there are any) for the chapter in which the diagnosis is located. Then, review the notes for diagnosis only. Look at the history and the assessment, and see how much can be coded under ICD-10-CM.

Based on the documentation, determine how many of these notes:
• Could be coded under ICD-10-CM
• Need more specific information to code
• Had to be coded to an unspecified code

Each provider in your facility should review these findings so they understand what documentation is needed to support this specific diagnosis in ICD-10. Then, move on to the next diagnosis on your top 10 list, and keep evaluating until your list is complete.

The facility should have a target percentage for the assessments and schedule future readiness evaluations, even if the goal is reached along the way.

How often these evaluations take place will depend on the number of providers at your facility, the number of different specialties, the type of specialties (some are seeing more changes in ICD-10 than others), and how providers perform. To ensure a smooth transition and a minimal impact on revenue, these assessments should become part of the regular audit process even after implementation of ICD-10.

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Clinical documentation must be improved to meet the more rigorous ICD-10 specificity requirements. Prepare physicians with an ICD-10 readiness assessment.

Improve Clinical Documentation for ICD-10

Some see ICD-10 implementation as an obstacle, but it’s really a chance to improve your healthcare business skills and knowledge. Certainly there will be a learning curve with ICD-10. Codes are very different, guidelines have changed in some spots, and physician documentation needs to be more precise. You will undoubtedly need to learn the new guidelines and coding processes quickly. However, these are manageable tasks, provided you start preparing now. Failure to prepare early enough will result in lost productivity.

There are many ways the ICD-10 implementation will affect productivity. The largest and most obvious area is provider documentation. Whenever documentation lacks certain specific elements, which are required for accurate and precise code selection, a query for additional information will need to go to the provider. If the physician is not immediately available, the service can’t be billed until clarifying information is received.

Another potential productivity challenge with documentation involves charge tickets, or “superbills.” These forms may become obsolete in ICD-10 because there will be more code choices in some fields. If the provider does not understand what is required to differentiate between the new codes, documentation will likely be insufficient.

Medical coders and physicians should begin training now to reduce potential productivity loss. Procrastinating will only result in extensive educational needs right before or immediately following the ICD-10 transition. At the very least, this would result in time away from work during the most stressful part of implementation.

Coders should devote roughly 20 hours to 40 hours of training to ICD-10 education prior to the transition. Physicians should plan on about eight hours to 16 hours of ICD-10 training.

In all likelihood, productivity will not return to normal after implementation. There will be an inevitable delay as assessments are made of how the payers are interpreting the new coding system. Each payment and remittance advice will need to be scrutinized to make sure claims have been correctly processed and, whenever extra information is needed, it should be sent in a timely fashion. Recurring deficiencies must be identified and rectified as soon as possible.

Current diagnosis codes are mostly numeric (V and E codes are the exception), but ICD-10 codes are alphanumeric. Entering new codes will single-handedly slow productivity because a number keypad will not be exclusively used to do so anymore. In addition, distinguishing between letters and numbers will take extra time when a diagnosis code is written (as opposed to a narrative description). Depending on penmanship, which is not stereotypically a common strength for most physicians, the number “2” may be mistaken for the letter “Z,” or the number “0” for the letter “O.”

It is crucial to start raising provider awareness regarding how documentation will be specifically affected by ICD-10, and to encourage providers to quickly become familiar with the specificity of their specialties. Doing so will allow enough time for providers to understand the requirements, so ICD-10 will not feel like a massive change all at once.

Assuming the practice has anticipated, learned, and prepared for the changes and potential setbacks, productivity should return to normal within about four to six months after ICD-10 implementation. In such circumstances, the practice’s bottom line will be only minimally affected.

For any office that waits until the last minute to prepare for the transition, or simply relies too much on outside sources (i.e., EHR vendor, billing company, etc.), the staff will be constantly striving to catch up. Seeing an increase in claim denials, such practices may not be able to remediate the situation because the staff doesn’t understand the guidelines. Awareness and timing are critical to minimizing the negative impact on a practice’s productivity.



, CPC-I, CGSC, COBGC, CPEDC, CENTC, AAPC vice president of ICD-10 education and training, has more than 20 years of experience in healthcare, working in the reimbursement, billing, and coding sectors, in addition to being an instructor. She is responsible for all ICD-10 training and curriculum at AAPC. She has authored many articles for healthcare publications and has spoken at conferences across the country. She is co-chair for the WEDI ICD-10 Implementation workgroup and has provided ongoing testimony for ICD-10 and standardization of data for NCVHS. She also sits on the Provider Outreach and Education committee for Novitas Solutions (formerly Highmark Medicare Services).

Learn what you need to focus on now to adequately prepare for the ICD-10 transition.  