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ICD-10 Documentation Training, What Your Physicians Need To Know

ICD-10 Documentation Training, What Your Physicians Need To Know. Presented by: Glenda Bosanko CPC-P, CCS-P AHIMA Approved ICD-10-CM/PCS Trainer & Ambassador Director, ICD-10 H.I.M. Education and Training Jzanus Consulting, Inc. Agenda. ICD-10 Delay ICD Overview ICD -10 Documentation

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ICD-10 Documentation Training, What Your Physicians Need To Know

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  1. ICD-10 Documentation Training, What Your Physicians Need To Know Presented by: Glenda Bosanko CPC-P, CCS-P AHIMA Approved ICD-10-CM/PCS Trainer & Ambassador Director, ICD-10 H.I.M. Education and Training Jzanus Consulting, Inc.

  2. Agenda • ICD-10 Delay • ICD Overview • ICD-10 Documentation • ICD-10 Outpatient Services • ICD-10 Physician Training Tips: Why They Should Care • How Do You Get Them To Listen • ICD-10 Physician Training Delivery • ICD-10 Benefits For Physicians • Debridement Example • ICD-11 • ICD-10: A New Countdown

  3. 1997 Sustainable Growth Rate Derails ICD-10 • H.R. 4302: Protecting Access to Medicare Act of 2014 Temporary Sustainable Growth Rate (SGR) “doc fix” Bill. • C.M.S. conservatively estimates that the one year delay will cost the industry $6.6 billion.

  4. ICD-10: The Train Is Delayed, What Now? • The industry adoption of the ICD-10 code set, remains a question of ‘when’ not ‘if’. • ICD-10 is coming, the train is not cancelled. • The benefits of adoption have not changed – • More accurate payments for new procedures. • Fewer rejected claims. • Reduced need for attachments to explain the patient’s condition. • Improved disease management. • Conducting research, epidemiological studies, and clinical trials. • Operational and strategic planning. • Designing health care delivery systems. • Monitoring resource use. • Improving clinical, financial, and administrative performance. • Preventing and detecting health care fraud and abuse. • Harmonized tracking of disease and public health risks with worldwide reporting.

  5. ICD Overview: Who? How? • How did ICD coding get started anyway? • “WHO’s” idea was this?

  6. ICD Overview • Believe it or not, the ICD-9 diagnosis coding system originated in 17th century England during the bubonic plague. • Statistical data was gathered through a system known as the London Bills of Mortality, and arranged into numerical codes. • These codes were used to measure the most frequent causes of death.

  7. ICD Overview • Fast-forward a few hundred years… • The list was taken over by the World Health Organization (WHO) and developed into the International Classification of Diseases (ICD) and is revised every 10 years.

  8. ICD Overview: Revisions

  9. ICD Overview: Background Information • ICD-9-CM: Clinical Modification developed in the US and implemented in 1979. • Volumes 1 & 2 Diagnosis Codes (used by all providers) • Volume 3 Procedure Codes (used by hospitals for inpatient reporting)

  10. ICD Overview: Background Information • ICD-10: Diagnosis classification system developed by the World Health Organization (WHO) as the international standard to replace ICD-9, Issued in 1993. • ICD-10-CM: The United States Clinical Modification for ICD-10 diagnosis classification system is developed to meet the needs of US healthcare systems. • ICD-10-PCS: The United States Procedure Classification System to replace ICD-9-CM Volume 3. 2015

  11. ICD Overview: Volume of the Changes Diagnosis Procedure

  12. ICD-10 Documentation • There is a tendency in this industry to try to resolve documentation issues on the back end of the process. • This means that to correct clinical documentation issues, they are resolved by HIM professionals. • This approach ignores the root of the problem: • The role of the physician to generate a complete, accurate, and legible record of the patient encounter.

  13. ICD-10 Documentation

  14. ICD-10 Documentation Myth • Myth: ‘Documentation for ICD-10 is an unnecessary burden on physicians’. • Facts: • The number and type of new concepts required for ICD-10 are not foreign to clinicians. • The focus of documentation is good patient care. • Patients deserve to have accurate and complete documentation of their conditions.

  15. ICD-10 Documentation • If documentation were a spoken language, would you be able to understand your physicians?

  16. ICD-10 Documentation • During medical school, the elements of thorough clinical documentation are taught. So what happened? • The pressure of time and the volume of work encourages the use of abbreviations and condensed documentation. • The skill of “good clinical documentation”, is reduced to that of a menial, non-functional chore… a necessary evil in many physicians eyes. • Case managers, Documentation specialists and Health Information Management (HIM) staff receive more training in documentation than physicians.

  17. Documentation 1889 Crosswalks

  18. Documentation 2011 Crosswalks

  19. ICD-10 Documentation • Documentation: What they learned in medical school. • Type of condition • Type I or Type II diabetes • Onset • When did it start? • Etiology / Cause • Infectious agent • Physical agent • Internal failure • Congenital

  20. ICD-10 Documentation • Documentation: What They Learned in Medical School. (cont.1) • Anatomical location • Which anatomical structure • Proximal, distal, medial, lateral, central, peripheral, superior, inferior, anterior, posterior… • Laterality • Right side or left side • Severity • Mild, moderate or severe • Environmental factors • Smoking • Geographic location

  21. ICD-10 Documentation • Documentation: What They Learned in Medical School. (cont.2) • Time parameters • Intermittent/Paroxysmal • Recurring • Acute or chronic • Post-op, post delivery • Comorbidities or complications • Diabetes with neuropathic joint • Intracranial injury

  22. ICD-10 Documentation • Documentation: What They Learned in Medical School. (cont.3) • Manifestations • Paralysis • Loss of consciousness • Healing level • Routine healing, delayed healing, non-union, malunion… • Findings and symptoms • Fever • Hypoglycemia/hyperglycemia • Wheezing

  23. ICD-10 Documentation • Documentation: What They Learned in Medical School. (cont.4) • External causes • Motor vehicles, injury locations • Assault, accidental, work related, intentional self harm • Type of encounter • Initial encounter, subsequent encounter, encounter for condition sequela, routine evaluation, administrative encounter

  24. ICD-10 Documentation What is needed for ICD-10 documentation? • Condition • Onset • Etiology • Location • Laterality • Severity • Environmental factors • Timing parameters • Comorbidities and Complications • Manifestations • Healing level • Findings and Symptoms • External Causes • Type of Encounter • All the same things they learned back in medical school.

  25. ICD-10: Outpatient Services • Myth: ICD-10 won’t affect my outpatient provider services. CPT codes are all they need. • Fact: ICD-10-CM diagnostic codes will replace ICD-9 codes and Payers will use them (the codes) to judge the medical necessity and validity of a procedure in order to reduce false or inflated reimbursement claims. • With outpatient procedures making up an average of a third of a hospital’s revenue, it’s important not to dismiss the effect that ICD-10 will have on outpatient operations.

  26. Outpatient Example of ICD-10 Specificity • Example 1: Diagnosis: Patient has acute otitis media. • In ICD-9-CM, we would have reported this with 381.00 In ICD-10-CM, we would need to know which side and if it is recurrent such as: Diagnosis: Patient has an acute onset of otitis media of the right ear, which is recurrent. • In ICD-10-CM, this is reported with H65.114.(Acute and subacute otitis media recurrent, right ear) • In order to assign a code we need to know which ear (laterality), and acute, chronic or recurring (timing parameters).

  27. Outpatient Example of ICD-10 Specificity • Example 2: This is the typical level of documentation that is currently seen under ICD-9. Impression: Cellulitis and superficial abscess index finger. Plan: I am recommending debridement and irrigation of the digit today. I think the skin is dead and that she will tolerate it with anesthesia, I would like her to stay on the clindamycin and I will check back with her in 3 days to see how she is doing. (Note that left or right is not documented in this case.) • In ICD-9 this was coded as 681.00 but in ICD-10 we would need two codes: one for the abscess, one for the cellulitis. (Note: In ICD-10 this should not be coded without further documentation - or query of the provider)

  28. Outpatient Example of ICD-10 Specificity

  29. ICD-10 Recurring Concepts • No scare tactics. • Don’t use the sheer number of codes in ICD-10 to overwhelm your doctors. • Codes in ICD-10-CM are combination codes with considerable repetition of the same concepts. • This format results in a large number of codes that are generally the same, with the exception of one or two concepts. • Example: About 25,000(36%) of all ICD-10-CM codes are different only in that they distinguish “right” vs. “left”.

  30. ICD-10 Recurring Concepts

  31. ICD-10 Physician Training Tips • Physicians don’t have to document more. • Better documentation does not mean more documentation, it means quality documentation. • Physicians don’t have to be coders. • When training physicians, remember that they do not need or want to know “codes”. • Physicians should focus on what they are trained to do: • Evaluate patients • Document findings • Make assessments and diagnoses • Determine treatment optionsImplement treatment, based on patients’ decisions • Analyze and synthesize results of studies and outcomes to continually improve care

  32. ICD-10 Why They Should Care • Tell your physicians why they should care. • What is the return on investment (ROI) for the physicians? • Accurate payment for complex and new procedures • Fewer rejected claims - ICD-10 is more detailed and organized than ICD-9 • Better claims adjudication and faster approvals • A reduced claims cycle will lower administrative costs for physicians

  33. ICD-10 Why They Should Care • Tell your physicians why they should care(cont.). • ICD-10 will have a direct impact on physicians through: • Physician quality profiles - mortality and morbidity • Physician utilization profiles - efficiency of treating patients • Physicians' current and future evaluation and management levels, including pay for performance • Daily workflow - (slowed and disrupted if ICD-10 is not properly implemented)

  34. ICD-10 Why They Should Care • Tell your physicians why they should care. (cont.1) • Inpatient and outpatient documentation must support appropriate and complete ICD-10 code assignment. • The effects of inaccurate or incomplete clinical documentation lead to: • Inaccurate authorizations which can potentially jeopardize reimbursement. • Inconsistent coding between physician and hospital, potentially delaying claim adjudication.

  35. Example: Why They Should Care • Inconsistent coding between physician and hospital, delayed claim adjudication. • Example: Claims with valid diagnosis and procedure coding, that pass medical necessity edits for both the physician (professional) and the hospital (technical), but the codes that are documented by the physician and the hospital for the surgical procedure performed do not match. • For Medicare, this can be detected via the Common Working File (CWF). • A mismatch between the professional and the technical codes can potentially delay payment to both parties.

  36. How Do You Get Them To Listen? • Appeal to their professionalism. • ICD-9 codes are inadequate (implemented nearly 40 years ago). It’s is not suited for modern medicine. • Make the logical argument. • The United States is behind the rest of the world.

  37. How Do You Get Them To Listen? • Continued - The appeal to logic. • We ran out of space, medical knowledge continues to expand, but there is no room to expand any more in ICD-9 (which is easily seen at the end of the V codes). • For example: • Why do you think the expression of traumatic brain injury codes, (780.97- altered mental status, 780.93 - memory loss, 784.0 - headache) were put in the 700’s right along with “fussy infant” and “clubbing of fingers”? • Why not put them in the Neurology section? • Because we ran out of space.

  38. How Do You Get Them To Listen? • Peer pressure, seriously. • Identify and use ‘Physician Champions’ in your training program. • Physicians really want to hear from other physicians. And it helps if that physician is in the same specialty. • Neurologists aren’t interested in hearing from plastic surgeons and cardiologists don’t care what orthopedists have to say. • Keep the information relevant to the physician’s specialty. • Don’t talk to pulmonologists about gastrointestinal procedures.

  39. How Do You Get Them To Listen? • Why ICD-10 Physician Champions? • Physician written, created, or delivered ICD-10 education in your training program creates immediate rapport from their peers. • They know the physician champion gets where they’re coming from and what they really need.

  40. How Do You Get Them To Listen? • Additionally - • Remind physicians that you didn’t invent ICD-10 to make their lives more difficult. • Tell physicians that ICD-10 will improve patient care by providing better information about the patient’s health. • For your physicians who are overworked because their patients are sicker – • When they say their patients are sicker than everyone else’s, and that is why they have to provide more care, with ICD-10 they will be able to prove it.

  41. How Do You Get Them To Listen? • Don’t over train them: • Only train on what is needed. • If they are already documenting laterality, don’t discuss it. • Focus the training on their own individual needs for compliant documentation. • Individualize: Show them their actual documentation and then show them the codes. • Give them concrete examples from their own documentation. This takes a bit of work, but it will pay off. • Take the physician’s note, open the ICD-10 manual, and physically show them what information is in the documentation and what information the coders need.

  42. ICD-10 Physician Training Delivery • Focus on the top 10 clinical diagnoses. • Run a report of the top 20 MS/APR DRGs for the last fiscal year. • Review the diagnoses, select the top 10. • Tailor ICD-10 training for the common clinical diagnoses that your physicians manage.

  43. ICD-10 Physician Training Delivery • Revise current query forms and focus on these specific areas: • Asthma • Coma • Fracture • Stroke • Cardiac-hypertension, CAD, CHF • Diabetes • OB • Sepsis/SIRS • SIRS due to an infectious process is no longer assumed to be sepsis

  44. ICD-10 Physician Training Delivery • Even with all the detail in ICD-10, queries are expected to increase – to lessen this impact make sure physician documentation meets these current standards: • Legibility • Completeness • Clarity • Consistency • Precision • Just as in ICD-9, queries should not be used to question a provider’s clinical judgment [emphasis added], but rather to clarify documentation when it fails to meet any of the five criteria listed above.

  45. Example Of A Sepsis Query Form

  46. ICD-10 Physician Training Delivery • Consider having physicians stop using the term “urosepsis”. • ICD-10-CM doesn’t include a default code for this condition. • Documentation of urosepsis will not yield an ICD-10-CM code. • Instead encourage physicians to document “sepsis from a urinary origin” or simply “UTI”, when applicable.

  47. ICD-10 Physician Training Delivery • Schedule regular training sessions between now and go-live date. • Keep the sessions short, just ten minute segments. • This shows that you value and respect their time. • Begin with small doses of information delivered in small groups. • Provide quick reference materials and have them available in multiple mediums and locations. • Getting all physicians together at one time just does not happen.

  48. ICD-10 Physician Training Delivery • Finally – Provide Feedback • Physician behavior will not change without ongoing feedback. • This should include re-visiting educational programs. • Most importantly, provide feedback based on specific analysis of their individual documentation patterns and variation from the expected results. • Physicians will give a lot more attention to comparative data that is specific to them.

  49. ICD-10 Physician Training Delivery • Continued feedback is needed to provide awareness of the potential impact that inadequate and inaccurate documentation will have on: • Their reputations • Their reimbursement • Most importantly, the best care for their patients

  50. ICD-10 Physician Training Delivery • Here are some training delivery formats: • Internal Courses • External Courses (off-site, vendor) • Computer-based Training • Web-based Training • Seminars/Classes • Try to “piggy back” onto existing seminars or meetings; inviting physician office managers to attend is a bonus. • In Person, Instructor-led-classroom • Led by your organizations ICD-10 trained HIM staff • Physician Champions • Train-the-Trainer Approach

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