Forum Focus – ICD-10 implementation: We’ve only just begun

By Nelly Leon-Chisen, RHIA, American Hospital Association Director, Coding and Classification

On Oct. 1, 2015, the United States turned the switch on the long-awaited (and several times delayed) implementation of the ICD-10 clinical coding system. This was no small feat as this was the biggest change in the coding field in 30 years. Hospitals, physicians, payers and practically everyone involved with the health care field had planned, trained, tested, and in general worked very, very hard to make the transition. At press time, all signs are positive that all that hard work has paid off. Physicians have continued to see their patients. Hospitals have kept their doors open. And the world as we know it did not end. Payers are beginning to report successful processing of claims with low rejection rates and no major issues in the early days of ICD-10. “Cautious optimism” is a phrase that has been repeated by many during the first two weeks of ICD-10 as we wait for the volume of submitted claims to increase.

The one-year delay has been touted by some as having been beneficial to allow the field to conduct more thorough testing of provider and payer systems. Others had feared that the delay would make it more difficult to continue the momentum that had been steadily building up early 2014. And hopefully no one was left behind believing that another delay would “save” them. One thing is clear–hospitals and physicians have had the closest collaboration ever on coding and documentation, admittedly a not very exciting topic for most physicians. Hospitals feared significant cash flow problems if coders would need to stop and ask every physician for clarification on vague documentation. Instead, hospitals proactively identified documentation gaps and steadily worked with medical staffs on specialty-specific issues rather than broad ICD-10 codes that would never be used. “Documentation, documentation, documentation” (or rather the lack thereof) has been the perennial challenge for coding professionals working in any coding system.

“What’s in it for the physicians” was a recurrent theme of many such conversations. After all, physicians’ payment was never meant to be directly affected by the conversion to ICD-10. While ICD-10-CM (diagnosis) codes provide justification for the need to provide a particular service, physician fees are not calculated on the basis of the diagnosis code. On the other hand, hospital payments can vary significantly based on the ICD diagnosis and procedure codes, to the point where even whether a code is listed in the first position (principal diagnosis) or a secondary position can make a great deal of difference in the payment the hospital would receive. The preparations for ICD-10 implementation were an excellent opportunity to improve coding and documentation that will provide a solid foundation for information that can be used towards implementing shared physician and hospital goals to advance excellence in patient care and improving health and health care in our communities. The more detailed ICD-10 codes coupled with improved documentation will help paint a more complete and accurate picture of the patients we jointly serve. As the field moves from the current volume-based fee-for-service (FFS) payment system to a value-based system that pays for patient outcomes rather than individual services, good documentation resulting in specific coding can provide better data to help identify best practices to deliver value-based care. Physicians have become increasingly familiar with broad sets of performance-based payment strategies that attempt to use financial incentives to influence provider performance. More specific coding can also help explain and justify the perennial “my patients are sicker” with solid facts rather than generic-sounding excuses. Describing a patient as having “type 2 diabetes on insulin with peripheral neuropathy, diabetic ketoacidosis and diabetic renal disease” can provide a different clinical picture from just saying that the patient is diabetic.

What will still remain a challenge ahead? ICD-10-PCS, the procedure classification system to be used by hospitals reporting inpatient procedures, will continue to be challenging for hospital coding professionals. The coding system requires a level of detail and clinical understanding much beyond what ICD-9-CM ever required. That detail is not only about the specific veins, arteries, muscles, or nerves operated on, but also an understanding of the objective of the procedure in order to select the appropriate code. It’s important that coding professionals have access to physician resources – surgeons for example – who can answer questions about surgical procedures when assigning ICD-10-PCS codes for those difficult or unusual surgical cases. Perhaps this will be a new area for physician advisors to provide assistance. It’s now the physicians’ turn to educate the coders on the most common procedures they perform.

According to the ICD-10-PCS Official Coding Guidelines physicians are not expected to use the terms used in the ICD-10-PCS code description, nor is the coder required to query the physician when the correlation between the documentation and the defined ICD-10-PCS term is clear. Nevertheless, information that is abundantly clear to a surgeon may not be so clear to a professional coder. For example, a stent insertion is no longer only about inserting a device as the correct code will depend on the intent of the procedure. Is it done to dilate an occluded vessel, to relieve a ureteral obstruction, to provide assistance to drain a ureteral stone, or to restrict the lumen of an aneurysm? Physicians and hospital coding professionals will need to continue to collaborate as both learn the nuances and terminology associated with the ICD-10-PCS codes.

While a lot of progress has been made in improving physician documentation to meet the needs of a future that involves an increasing reliance on claims data to represent clinical differences between patients and the services provided to them, a lot still remains to be done. This is only the beginning as there are still a number of areas where a close collaboration between hospitals and physicians will continue to be an essential component of every hospital’s strategic plan. In fact, it’s more like the beginning of a hopefully long lasting collaboration as the 1970’s hit single “We’ve Only Just Begun” that became popular for weddings reminds us.