January 17, 2011

Game Changer: How ICD-10 Will Reshape Documentation Processes
By Selena Chavis
For The Record
Vol. 23 No. 1 P. 14

Come 2013, the playing field will change significantly for coders, CDI specialists, and physicians.

Set to go into effect October 1, 2013, the countdown to ICD-10 has been under way for some time. During the ramp-up, healthcare organizations are being confronted by the harsh realities they will have to overcome in order to be compliant.

It’s no secret that documentation practices that have defined the industry for the past 30 years will no longer be sufficient. The new order of the day is specificity, and it will take a solid team of well-trained professionals from HIM and clinical staff to ensure that physician documentation contains the details needed to code accurately.

It’s also no secret that healthcare organizations that have not formally embraced clinical documentation improvement (CDI) practices will have a much higher mountain to climb in the race to meet the deadline looming in the not-so-distant future.

“Facilities that haven’t jumped on the [CDI] bandwagon yet are going to be way behind,” says Eric Riebel, RHIA, CCS, HIM manager at Lafayette General Medical Center in Louisiana. “It’s going to be a very big uphill battle all the way around. … Documentation has always been a challenge, and with ICD-10, it’s even more so.”

Going forward, industry professionals agree that the relationship between coding and CDI professionals who interface with physicians will be a “make-or-break” ingredient when it comes to a facility’s chances of meeting ICD-10 demands.

According to Jim Kennedy, MD, CCS, a managing director of Atlanta-based FTI Healthcare, these relationships are important going forward because “CDI is a process, not a person.” The process, he notes, includes concurrent documentation and retrospective physician queries that will lead HIM professionals to the most specific ICD code that can be reported. With experience as a physician as well as a coding professional (since 2001), Kennedy has experience on both sides of the aisle and knows the challenges facing doctors as well as the problems associated with inconsistent documentation that prohibits the appropriate specificity of a diagnosis.

“I don’t see the process of CDI changing [with ICD-10], but there will be increased requirement of physicians to be more precise,” Kennedy explains, adding that clear understanding by CDI staff of what the coder needs will be paramount to make sure such precision happens with concurrent review.

The end result, according to many professionals, is that the United States will finally catch up with the rest of the industrialized world by adopting ICD-10. Riebel notes that other countries have been successfully using ICD-10 for nearly 20 years, and that ICD-11 is already undergoing beta testing.

“From a national perspective, we should not be this far behind in the world,” Riebel says, adding that newer classification systems do a much better job of addressing advances in medical knowledge and issues associated with morbidity and mortality reporting. “It does help to verify severity better than ICD-9. … That’s huge improvement. From a WHO [World Health Organization] perspective, it’s about time we get there.”

Relationships That Work
Healthcare teams that work toward a common goal are the ones that will transition better to ICD-10, says Robert Gold, MD, CEO of DCBA, an Atlanta-based CDI firm. “In some organizations, there is an antagonistic relationship between coders and documentation specialists that exists,” he says, pointing out from his own experience that many documentation specialists have been trained to expect coders to be wrong.

Because the two contingents must be in agreement, Gold believes ICD-10 training should be a joint effort between CDI professionals and coders. He goes as far as to say that without an established baseline consensus of what is required, the coder will not receive the necessary information. “If physicians have been trained right by the documentation specialist, they will be able to easily do what is necessary,” he says, emphasizing that the key word is “right.”

Kennedy also recognizes the importance of physicians being properly trained because no matter how knowledgeable coders and documentation specialists may be, the clinician has the last word. Therefore, from a philosophical standpoint, the primary relationship exists between the coder and the physician, with everyone else—nurses, documentation specialists, and other clinicians—becoming “servants” to the doctors.

“The doctor is the ultimate authority in saying a patient has a certain condition,” Kennedy explains. “The nurse [or another CDI professional] doing the concurrent review has to know the needs of the coder.”

Riebel concurs, noting that physicians do not currently provide the level of specificity needed for ICD-10. “You see it documented well by nurses, but that doesn’t do a coder any good,” he says. “It’s going to require a level of specificity that we have always been able to get around.”

For example, Riebel cites the coding for the suture of an artery. Under ICD-9, there was one code; however, under ICD-10, there are more than 180 ways to code the procedure.

Communication skills become paramount for documentation specialists, who need to solidify the relationship between the other parties, Kennedy says, adding that the question often becomes what type of professional can most effectively establish the link between coders and physicians.

Although he is an advocate of coding or nonnursing professionals performing concurrent reviews, Kennedy acknowledges that not all coders have the ability to establish effective rapport with physicians to achieve the desired outcome. “Many coders have some trepidation with physicians,” he notes, pointing out that nurses tend to have more camaraderie with physicians and are better able to develop a rapport. “They have to be able to have those communication skills. … Some coders are very good at it. Well-functioning [CDI] programs have seamless communication, but there’s no perfection.”

With those realities in mind, Kennedy suggests the process of choosing the best person for concurrent review should focus more on the person than the function.

Time Is of the Essence
Experts agree that education and training for ICD-10 should begin now.

“You need to start training all coding staff now and start rolling out programs for physician champions through 2012,” Riebel says, adding that in 2012, education programs should be planned and running. Then by 2013, organizations will have 10 months to be fully compliant. “I’m finding that most hospitals are not even looking at this yet,” he says.

Riebel recommends that the program be presented under the guise of CDI rather than as a big push for ICD-10. This will avoid pushback that is likely to come from those professionals who have been entrenched with ICD-9. “Those who have been doing ICD-9 five or more years will fight it tooth and nail,” he says.

Gold says education and training will help minimize some of the panic that currently exists in the industry. “The general impression is that folks are approaching ICD-10 like they did Y2K—total panic without really understanding what it’s going to be,” he says, pointing out that training will need to occur on two levels: diagnostic and procedural. “The concepts governing diagnostic are no different than ICD-9,” but the procedural level will be foreign to coders.

At the Tennessee Health Information Management Association (THIMA), the goal is to create a unified front for education so healthcare organizations are well prepared to meet the demands of the transition. The association is taking a proactive approach by providing training to all healthcare professionals so best practices are implemented across the state from the outset.

“We’re rolling this out to all healthcare professionals in the state of Tennessee,” says Kathy Hallock, RHIA, medical coding quality consultant with Vanderbilt University Medical Center (VUMC) and a member of THIMA’s ICD-10 committee. “Our goal is to be the educators of choice.”

Kennedy , who, like Hallock, is a THIMA ICD-10 committee member, says training sessions aim to clear up the differences in primary clinical issues between ICD-9 and ICD-10. “My hope is that we can communicate to [coding and CDI professionals] what areas are going to affect code assignment,” he says.

This month’s THIMA symposium featured two tracks, one for CDI programs in general that included a session on ICD-10 and a track geared specifically for coding professionals. Hallock says healthcare organizations should already have a CDI program in place, and those that do not are way behind the curve. “Your CDI program is a place you need to be doing stuff right now,” she says.

VUMC’s CDI program has matured well beyond its initial reimbursement focus. “It’s really grown into a much bigger process than just documentation and coding,” Hallock says, pointing out that the program now delves into areas such as quality and risk management.

A More Clinically Focused Skill Set
In the past, some hospitals would take individuals with no coding background and train them to become coders. “That’s going to go away,” says Riebel. The complexities of ICD-10 will require coders as well as CDI specialists to have a more expansive medical knowledge base.

In the near future, coders and CDI specialists involved with concurrent review will need to become anatomy experts. “These professionals will need to know anatomy,” he says. “It’s critical. You just won’t be able to get around it.”

Those who perform concurrent review will have to indicate specificity on all organs and body systems, even down to defining lateral location, Riebel says. As a result, he believes facilities using nurses for concurrent review will have greater success meeting ICD-10 requirements.

Gold agrees with the new focus on anatomy, pointing out that documentation specialists will need to go through the body systems to determine where specificity must be added. Kennedy says coders may need to supplement their education to get up to speed. “This is going to be a big emphasis—the need to learn anatomy,” he says.

In a nutshell, physicians will have to be more precise in their operating notes and coders will need to understand what they are reading and what they are looking for in operative notes.

Those coders who have been trained to do a specific task in the HIM department—such as diagnosis-related group optimizers—will likely struggle with the complexity of ICD-10, Gold says. On the flip side, coders who have worked in the outpatient arena will likely have a much easier time with the transition than their inpatient counterparts because ICD-10 appears to be structured in much the same way CPT codes have been in the past.

“Those who have done outpatient coding will probably have little difficulty transitioning to outpatient ICD-10,” he says. “There are a lot of folks who have done both inpatient and outpatient. They will find it a lot easier.”

The good news for coders, according to Riebel, is that ICD-10 will be harder to memorize than ICD-9, ultimately slowing down productivity and increasing the demand for coders. “We’re going to need more,” he notes.

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications.