July 18, 2011

Documenting Death
By Sandra Nunn, MA, RHIA, CHP
For The Record
Vol. 23 No. 13 P. 14

An international network is diligently trying to provide mortality coders with the tools and education necessary to make their work even more meaningful.

There has been a lot of industry buzz regarding the long-anticipated arrival of ICD-10-CM/PCS, including among those in the world of morbidity coding. However, mortality coders have been experiencing a different ICD-10 for more than a decade.

This ICD-10 is the International Statistical Classification of Diseases and Related Health Problems, 10th revision, published by the World Health Organization (WHO). The classification is used to describe causes of death and morbidity in its nearly 200 member states. Nations participate in this effort to compare themselves for purposes of statistical reporting and to measure across time and between populations. The coded data are used to create policy, allocate resources, plan and conduct research, and perform program management.

In “Mortality Coding Marks 10 Years of ICD-10” in the July 2009 edition of the Journal of AHIMA, Chris Dimick wrote that “researchers use mortality data as a baseline to track the progress of health and safety initiatives. Since geographical location is included in the data, researchers can focus in on specific areas and see if health initiatives are causing a decrease in specific deaths or accidents. For example, a group running a diabetes prevention program campaign in Michigan can track diabetes deaths and occurrences during the course of its program in that state. Campaign organizers could see if their program is succeeding or failing by watching whether diabetes rates increase or decrease in mortality data during the course of the campaign.”

Created in the early 1990s, this ICD-10 version was not universally adopted by all WHO entities because of a lack of classification experts and a dearth of education and training resources. As a result, the certainty of data comparisons between countries or even within countries has been questionable due to an absence of standards and a failure to adopt a testing and certification process to guarantee coder competency.

The WHO-FIC (Family of International Classification) Network took notice and began to examine the problem. The organization’s goal is to ensure coded health data are consistent, of high quality, and comparable within and among WHO member states.

Activities and initiatives focus on the following:

• the provision of standardized educational material;

• the promotion of training opportunities;

• the development of recognition and certification processes; and

• the advancement of best practices.

There proved to be many challenges to improving the quality of coded data on the international level. Many countries did not fully spell out causes of death or listed only one cause without underlying information. The lack of financial resources was often at the root of a failure to commit to ICD-10 implementation. Without political commitment, countries often found it difficult to upgrade computer systems, finance coding positions, obtain training and educational materials, and translate resources into local languages.

Without an understanding of the usefulness of coded data, some countries failed to get on board for ICD-10. The WHO-FIC decided to work on increasing the capacity of these countries’ existing schools, including offering scholarships. Through local education, the importance of high-integrity coded data for the nation’s decision makers was emphasized. Recognition and the possibility of a bump in pay were other options discussed.

In her presentation before the International Federation of Health Records Organizations (IFHRO) in 2004, Sue Walker, current director of Australia’s National Centre for Health Information Research and Training, discussed the definitions, skill levels, and functions for mortality coders (separating underlying cause of death and multiple cause coders) and the better known morbidity coders. An underlying cause of death coder assigns an ICD-10 code by using the information on death certificates based on ICD-10, volume 2.

Walker specified the following four functional levels:

• Entry level: assigns codes to certificates that are legible, uses traditional terminology, and contains the required information; work is supervised.

• Intermediate level: assigns codes for cases made more complex by sequencing issues, the nature or manner of death, and incomplete or imprecise information; supervises work of entry-level coders.

• Advanced level: trains others in the use of ICD classification and conventions, performs quality assurance on coded data, and contributes to projects using coded data.

• Nosologist: answers questions posed by peers, has expert knowledge of procedures and techniques used to classify and code deaths, conducts special studies to determine effects of code modifications or comparability, participates in classification revisions and updates, supports statisticians and epidemiologists, and responds to data queries.

Mortality Coding, U.S. Style
Mortality coding begins when a physician, a coroner, or a medical examiner completes a death certificate. The documenter should list the cause of death as well as any contributing conditions or injuries. While a physician may indicate an underlying cause of death on a death certificate, that categorization is not always followed by the mortality coder, who must adhere to a complicated set of rules to select the underlying cause of death.

All death certificates are sent to a state agency, typically the department of health. Some states have automated coding software capable of taking data from electronic death certificates and translating the information into ICD-10 codes. Because the software cannot handle complicated cases, a few mortality coders are necessary to fill in the missing pieces. States also have the option of sending certificates to the National Center for Health Statistics (NCHS), where government mortality coders complete the coding work.

The NCHS uses coded mortality data to generate national health statistics that provide information on the leading causes of death, life expectancies, the frequency of injury due to specific causes, and other types of statistics. The NCHS then sends the completed mortality data to the WHO.

Accurate mortality coding is critical to researchers who use mortality data as a baseline to track health and safety initiatives to determine their effectiveness. The data’s value stems from its ability to cover a full range of U.S. patients since there is a legal requirement to complete a death certificate for all mortalities.

Progress Toward Better Coded Data
The IFHRO, which changed its name to the International Federation of Health Information Management Associations this past January, has worked with the WHO-FIC since 2000 to develop a training and certification program to improve the international quality of mortality coding. The organizations have moved toward the determination that an international examination for mortality coders is a viable option in spite of numerous challenges.

Some hurdles include countries that create their own coding rules, use various versions of ICD-10, and have no examinations for any kind for morbidity or mortality coders. Two goals of the project have been to promote the development of high-quality, consistent, and timely coded health data and to keep practicing mortality coders in place while increasing the international workforce.

As part of a 2007 pilot, international certificates were issued to ICD-10 mortality coders following six trial tests. A similar international effort to provide morbidity coders with comparable standardized examinations is ongoing.

At the IFHRO’s XVI Congress last November in Milan, Italy, incoming President Margaret Skurka, MS, RHIA, CCS, FAHIMA, spoke about the importance of health information as the basis for identifying needs, health planning, and the development and evaluation of prevention programs, particularly in public health. The International Training and Certification Program (ITCP) has laid groundwork and piloted processes for developing underlying cause of death ICD-10 coders and trainers. Components of the program include the following:

• core curricula to train coders who use the ICD for mortality and morbidity coding;

• core curriculum for cause-of-death certifiers;

• Web-based training tools for ICD-10 coders and cause-of-death certifiers based on the core curricula;

• procedures to review and certify training materials;

• an international underlying cause-of-death exam;

• processes to assess and approve qualified trainers; and

• processes to assess and recognize coder competence.

Other materials include information sheets on the uses of mortality and morbidity data and related classification topics that can be easily updated, translated, and adapted for each country’s use. There is also a checklist for any WHO-FIC members at the country level.

Beyond mortality coding, the organization is developing international curriculum modules for International Classification of Functioning, Disability, and Health training. The ITCP hopes to improve the skills and status of the international HIM workforce, including mortality and morbidity coders in the United States and other member countries. The program reaches out to employers to promote the benefits of certified coding professionals while attempting to improve coder status and salaries and encourage tuition assistance.

In a May 2007 article in the Journal of AHIMA on achieving an international certificate in ICD-10, Kevin Heubusch noted that “individuals wanting to become coders complete the core curriculum requirements, taught by a single recognized institution or trainer or obtained from multiple approved sources. Upon successful completion they are eligible for the certificate. Although different sets of training materials are available, all candidates take the same examination.”

Prior to any examination, mortality coders must conduct a self-assessment that includes questions on their experience and coding’s functions and uses. The examination itself requires them to code a series of sample death certificates and explain which coding rules they selected to establish the underlying cause of death. A score of 80% must be achieved to pass the exam and receive the certificate.

ICD-10 Lessons
For experienced morbidity coders, becoming a mortality coder is a viable career option, particularly in light of the AHIMA’s development of a global services program.

Morbidity coders can learn a great deal from the experiences of mortality coders when transitioning from ICD-9 to ICD-10. Although morbidity coding’s ICD-10-CM/PCS system is quite different from its mortality ICD-10 counterpart, the new morbidity coding system will result in richer data. The level of detail will improve, giving caregivers and policy makers access to better information.

Much like what was necessary during ICD-10’s mortality implementation, greater specificity in documentation is required for the system to produce better results. However, ICD-10-CM/PCS allows for the capture of a vast array of information because ICD-9 has been in place since the late 1970s. Also, the current coding system lacks the depth provided by ICD-10, which has the wherewithal to capture new disease processes and the procedures being invented to treat them.

Just as electronic death certificates have done wonders for documentation in the mortality domain, EHRs are expected to do the same in the morbidity world, producing fuller, more legible patient data to make life less complicated for coders. Physician queries should be less of a hassle just as mortality coders have found it easier to query death certifiers electronically for additional information.

Overall, however, it is expected that morbidity coders will have a smoother transition to ICD-10 than mortality coders who not only faced a whole new coding structure but also had to deal with having all the rules changed. (Morbidity coding rules will remain the same.)

Having mastered ICD-10, mortality coders can now look forward to tackling ICD-11, which is scheduled to take effect in 2015.

— Sandra Nunn, MA, RHIA, CHP, is a contributing editor at For The Record and the enterprise content and information manager at Presbyterian Healthcare Services in Albuquerque, N.M.