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Five Things Every Physician Needs to Know About ICD-10 Documentation
By Stephanie L. Cecchini, CPC, CEMC, CHISP

Physicians have been told the ICD-9 sky is falling, and their practice will grind to a halt if they don’t properly prepare for ICD-10. For more than a decade, physician practices have been fighting tangible tigers—stiff regulatory compliance, decreased fee schedules, and increasing expenses. The result is that tuning out the ICD-10 chatter became easy. Now, however, the time for action has arrived.

Although the impact of ICD-10 on physicians remains ambiguous for many, the bottom line is clear: There is a danger of revenue cycle performance issues, decreased productivity, and time lost from patient care. What does the physician practice need to do to minimize the effect of uncertainty on objectives?

Find the Starting Line
Underdocumentation is a costly mistake. The Centers for Medicare & Medicaid Services (CMS) argues with the adage that “if it isn’t documented [correctly], it didn’t happen,” and the organization won’t hesitate to deny claims or request postpayment recovery on omission errors. Just scratch the surface of ICD-10 and you’ll hear of increased complexity and charting requirements; there are five times as many codes. This leaves many practices unsure of where to begin.

More than one-third of the changes made by ICD-10-CM are intended to distinguish right from left or bilateral. Taking into account the medical specialty and unique needs of the individual practice, an ICD-10 expert can explain the remaining two-thirds as easily. A good consultant will help target the right level of training at the right time and for the right staff. This preparation helps spot potential problems ahead of time, which could save big bucks in the long haul.

Cookie-Cutter Training Won’t Cut It
Most physicians don’t need to be as fluent in ICD-10 as a coder. They need to provide enough detail in their documentation for the coder to select a code with finer granularity. This means efficiently tailoring ICD-10 training to match a physician’s unique style of practice.

The physician’s medical specialty plays a big part in narrowing the learning curve. For example, an orthopedic surgeon won’t usually need to learn documentation requirements for trimester notations in obstetrician care, nor do many cardiologists have interest in learning the requirements for documenting open fractures according to Gustilo classification.

“Physicians don’t want to waste time learning to document for coders,” says Cathy Brownfield, RHIA, CCS, vice president of operations at Trust Healthcare Consulting Services, LLC. “We’ve seen great success with customized training for physicians on documentation requirements. The easier it is for the physician, the better the results for everyone.”

Educate Staff Today to Support Physicians Tomorrow
Training staff to anticipate the impact of ICD-10 changes can give your practice a big advantage. Brownfield recommends that practices begin with a review of their superbill to make a comparative study using CMS General Equivalence Mappings (GEMs) to crosswalk the old and new codes. GEMs aren’t a substitute for learning how to use ICD-10-CM, which will take most coders an average of 15 to 25 hours. It will help identify where to focus training for maximum efficiency. Trained staff become the fastest and easiest resource for the physician.

“With properly trained staff, you can generally keep physician training to about an hour,” Brownfield says. “Knowledgeable staff can provide short follow-ups after ICD-10 implementation to ensure [the physician’s] understanding and clean claims.”

Use the Right Tools
Changes to practice management software and other systems are a necessary part of ICD-10 implementation, and leading vendors are offering new documentation tools. If your practice hasn’t already implemented an EMR, this is your best time to look into adoption because HITECH stimulus funds are still available. Customizable templates are offered by many EMR vendors.

Embrace the Data Advances
No one likes change, but ICD-10 offers new opportunities to evaluate patient trends and outcomes. Changes occurring from HIPAA 5010 paved the way for industry advances such as real-time claims comparisons on nationwide 835 remittances, which lets physicians compare their utilization, reimbursement, productivity, and audit risks to determine if they are an outlier next to peers in their state and nationally. ICD-10 is more detailed but also provides the benefits of increased transparency.

Practices that haven’t started gearing up for the ICD-10 transition will lose an important advantage. Preparing now spreads the necessary work and training across nearly two years rather than facing it all at one time and sacrificing focus from patient care. Educated staff and tailored documentation training for physicians are the most important steps a practice can take now to reduce revenue cycle and productivity risks.

— Stephanie L. Cecchini, CPC, CEMC, CHISP, is an executive-level healthcare operations consultant at Trust Healthcare Consulting Services, LLC who has provider, payer, and third-party expertise.