Blog by Sue Belley
A man from a small village in Guinea, West Africa, presented to his village health clinic with a severe headache, vomiting, diarrhea and severe pains in his back. He was initially thought to have malaria, but upon transfer to a special unit at a hospital in Conakry he was diagnosed with Ebola. The patient went on to develop disseminated intravascular coagulopathy, SIRS and shock. The patient was treated with intravenous fluid and electrolytes, vitamin K, oxygen and blood pressure support. He eventually succumbed. Assign codes for this inpatient encounter and sequence appropriately. Continue reading
The small nation of Papua New Guinea was an early adopter of ICD-10, inspired by its neighbor Australia. In the remote provinces of New Guinea, an ICD-10 codebook is considered a precious object. One codebook is granted to each village and entrusted to the care of the village coder, who is held in the highest esteem by the people. The account that follows gives us yet another example of the quiet heroism of the ICD-10 coder.*
There were two warring tribes deep in the hinterlands of Papua New Guinea, one that lived in the valley and the other high in the mountains. One day, the mountain people invaded the valley, and as part of their plundering of the people, they kidnapped an ICD-10 book from one of the villages and took the codebook with them back up into the mountains. Continue reading
Posted in ICD-10
Donna: Hey, Sue – what were your takeaways from the AHIMA Clinical Coding meeting held in New Orleans?
Sue: I really enjoyed the presentation by Dr. Jon Elion. He offered great clinical perspective on some of the diseases that can cause the most difficult documentation and coding conundrums – you know, like malnutrition, encephalopathy, CHF, malignant hypertension . . .
Donna: So interesting! He noted that there is no specific code for hypertensive urgency. If this is documented and there is no current or impending organ failure, one should not query for malignant hypertension in this scenario – instead, it is just reported as unspecified hypertension.
Sue: Which presentation piqued your interest? Continue reading
In my May blog, I talked about the cost of non-compliance versus the cost of implementing ICD-10. My hypothesis: human nature is the real cost driver in health care – not code set changes. A recently released study by OIG revealed that physicians increased the billing of all E/M (Evaluation and Management) services from 2001 to 2010 (the years studied). The higher the level of E/M codes assigned, the greater the reimbursement. CMS found that E/M services are 50 percent more likely to be paid in error than other Part B services. Why? Because they are coded to a higher level which results in more money paid to the provider – physician and non physician alike. CMS identified the root cause of the overpayments – no surprise here, coding error and poor documentation. Continue reading
In Part 12 we looked up unused ICD-9 codes in your policy in the 9-to-10 GEMs cluster table. If we found a code in there, it would lead us to one or more translation alternatives, each of which consists of two or more ICD-10 codes which have to appear on the patient’s record together in order to convey the same meaning as the ICD-9 code.
Here again is one of the examples we looked at:
806.00 Closed fracture of C1-C4 level with unspecified spinal cord injury
for which the GEMs provides four alternative translates, all clusters. Here is the first one: Continue reading
Results of some recent studies evaluating the percentage of coder agreement in ICD-10 both intrigued and concerned me. It was a topic of conversation at three national conferences I attended recently, during which several of the speakers addressed the topic.. One study identified was the HIMSS “ICD-10 National Pilot Program: Outcomes Report,” released in October, 2013, which details findings from 200 patient records coded by two independent ICD-10-CM/PCS AHIMA Approved Trainers. The average accuracy between the two coders was 63 percent. These results made me wonder if the study’s outcome was due to a lack of ICD-10 coding knowledge or something else. Continue reading
Like many in the healthcare industry, I’ve spent the last few weeks reading about the ICD-10 delay. Depending on which camp you are in, the opinions are lining up predictably. I’ve read a lot of comments about the ”cost of ICD-10.” Though many agree the adoption of a more sophisticated code set brings important benefits, the conversation always circles around to the expense of implementation.
If high costs are really the issue with ICD-10, why do we continue to ignore known cost-saving measures that would easily offset the expense of implementation for the average physician practice? For instance, I find the willingness to accept the enormous cost of years of non-compliance with medical necessity perplexing. Or consider the continued practice of submitting poorly coded claims based on subpar clinical documentation. What about the cost of claim denials, write-offs, and fraud in ICD-9 – or any other coding language for that matter? In my opinion, complaints about the cost of doing business have less to do with the expense of implementing ICD-10 and more to do with human nature. Continue reading
Sue: Donna! CMS has finally addressed a new ICD-10 compliance deadline. Looks like we’ll be working toward an October 1, 2015 go-live date.
Donna: Yes, I’m glad we’re not in waiting mode any longer! Even with an extra year to prepare, I’m concerned that nobody is really talking about their Quality Review plans to assure accurate I-10 coding and CDI practices. Talking about their QA plans will really help the prep!
Sue: How so?
Donna: As I talk to people who are practicing with I-10 coding I am hearing that they are identifying discrepancies in their data between I-9 and I-10. I think that reviewing mismatches between MS-DRGs in I-9 and I-10 is a good place to start the QA process in the inpatient setting. Continue reading
This latest ICD-10 implementation delay stinks even more than the first one, when HHS succumbed to pressure and moved the implementation date from 2013 to 2014. I could pretend to be a wine connoisseur, and describe the taste of this delay in great detail—the acidic AMA “mouth feel,” the conspiracy theory “notes,” the voice vote “finish.” But why bother? And there, my friends is the dilemma we all face—why bother indeed? If a massive effort to do something sensible and constructive in health care can have the rug pulled out from under it at the last minute, why do we bother? As a friend said after the “doc fix” bill became law and ICD-10 was put in limbo for (at least) another year, “It makes me feel like moving to Montana to live in a cave.”
Nevertheless, we are going to continue to push for ICD-10 implementation as soon as possible, because it is what we can do. The industry is so thoroughly committed to ICD-10 it cannot turn back now. At the same time, how do we as rational human creatures try to make sense of a situation that has become patently absurd? My advice is, don’t even try. Just let yourself enjoy the absurdity, because it is likely to be with us for some time. Continue reading
To summarize policy translation using the GEMs so far:
Phase 1: Use the 10-to-9 singles GEM with reverse lookup to find all the ICD-10 codes that select patients currently selected by the ICD-9 codes in the policy.
Phase 2: For any unused ICD-9 codes, use the 9-to-10 singles GEMs to find other ICD-10 codes which may, after clinical review, be worth including
Phase 3: Look up all the ICD-9 codes in the 10-to-9 cluster GEM with reverse lookup. ICD-10 codes you find there will have a narrower definition than the ICD-9 code you find them with, so you must review them to ensure they contribute to the intent of your policy. Continue reading