ICD-10 Training Camp: Documentation – the Silent Witness in Medical Billing

Nancy Maguire, ACS, PCS, FCS, HCS-D, CRT April 11th, 2011

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We’ve come a long way, Coders! But it’s about to get very bumpy!

The buzzword of the ICD-10 diagnosis classification is “DETAIL.”  It is a fact that the I-10 diagnosis codes, as well as the procedural coding system (PCS), will require an increase in physician documentation.  It is quite possible, and probable, that this increase in documentation will change patient scheduling, resulting in fewer patients seen on a daily basis (for example, 3 less patients per day).  The old order for documentation standards will no longer be enough on and after October 1, 2013. 

The new order requires greater detail and will be a permanent change in documentation habits. Teamwork, or lack thereof, between the clinical staff and the coding professional will make or break the smooth transition to ICD-10 compliance.  The brutal fact is that many physicians do not document for specificity with current ICD-9-CM codes and this will make implementation of ICD-10 coding a frustrating experience. Improved physician medical documentation is critical to reimbursement and data collection.

The coding professional cannot diagnose, nor can he/she assume a diagnosis.  The physician and non-physician clinicians must specifically document (gray matter to white matter) the presenting symptoms or chronic and acute conditions, in detail.  ICD-10-CM diagnosis codes have laterality in many code descriptors and many require a 7th Character Extension (A, D, S) Initial, Subsequent, Sequela, to identify the type of encounter.  It is reassuring to realize that the rules, conventions, and guidelines in ICD-10 are very similar to what is currently in ICD-9, with only a few changes.  Also on the plus side is an increase in “combination codes” and this means one code would be assigned in place of 2 or 3 separate codes required in the ICD-9-CM system (for example, I25.110 ASHD of native coronary artery with unstable angina required 414.01 and 411.1 in ICD-9). 

The most critical area of impact for physicians will be on documentation. Physicians must understand the expanded code descriptors and these should be mirrored in their medical record dictation/documentation.  Education should focus on diagnoses frequently assigned and then cross-walked to ICD-10 codes. Identify current and future documentation challenges and train accordingly.  The new codes are alphanumeric and could contain seven characters (injuries, coma, OB, external causes), and they are organized differently. For example, injuries are grouped by anatomical site rather than injury category (S63.293A, Dislocation of distal interphalangeal joint of left middle finger, initial encounter). 

The Center for Medicare and Medicaid Services (CMS) feels the increased specificity will make it easier to assign codes correctly, which should result in fewer errors, fewer unpaid claims and therefore fewer requests to resubmit claims with supporting documentation.  Time alone will show if this assumption plays out as anticipated.  It won’t be easy putting ICD-9 codes to rest. Physicians use (and frequently struggle with) these codes on a daily basis, but they are familiar with the three-five digit codes; change may not be their choice, but it will happen.

Other concerns are payer contracts, dealing with coverage determinations, local and national, and “increased documentation costs.”   Pre-authorizations and treatment plans may require additional diagnosis documentation to specify the detail of the patient condition(s).  Assess whether documentation currently in your medical records will support the level of specificity necessary for ICD-10-CM.  This transition will be time intensive and will involve costs and additional resources. It will impact your entire practice and will require patience and persistence.

The one word that flows throughout this article is “documentation.”  The definition of this term is “an act or an instance of the supplying of documents or supporting references or records.”  Documentation also allows the clinician to give documentary evidence of the patient encounter or hospital service. It establishes medical necessity for services rendered.  ICD-10 is a coding of diseases and signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as classified by the World Health Organization (WHO). Our documentation history has taken us from the ancient Egyptians and their practice of the scientific arts and hieroglyphics to the recording of epidemics during the plague all leading up to where we are today, a long way indeed!

Complete and detailed documentation helps physicians organize their observations and examination, justify their treatment plan, support the diagnoses, and document patients’ progress and outcomes. The medical record is a vehicle of communication for providers to evaluate, plan, and monitor patients’ care and treatment.  Documentation also supports severity of illness, length of hospital stay, and risk of morbidity/mortality data.

Physicians must understand the coding methodology not only with ICD-9 codes, but during the conversion to ICD-10 codes.  Proper documentation does improve quality issues and impacts the physician’s profile for case-mix decisions. In the outpatient setting diagnosis code(s) regulate the level of service provided.  Improving physician documentation ensures that the patient’s clinical course is clearly recorded.  Physicians should be involved in the transition process and communication between team members should be frequent and positive.  Gripe sessions will go nowhere and will sabotage the road to compliance.

Medicare has documentation guidelines for the Evaluation and Management codes and these should be reviewed by all providers (https://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp).  Documentation errors and omissions clearly put hospitals and physicians at risk for denials and audit liability.  Does your physician clearly explain the impact of co-morbid conditions and complications in the medical record? If diagnostic tests are ordered does the medical record document “why” or “because”?  Answers to these questions will lead to a diagnosis code assignment(s).  The diagnosis should link to the service provided (medical necessity). 

Physicians should document the patient’s severity of illness, including: severity of the signs and symptoms exhibited by the patient; the medical predictability of something adverse happening to the patient; the need for diagnostic studies; and the availability of diagnostic procedures at the time when and at the location where the patient presents. The documentation of medical necessity needs to be legible, complete (including checklists and templates) and consistent with the presenting problem(s) or condition(s).

The information written and maintained in patient health records, once it is collected and aggregated, is used by payers, clinicians, health system planners, researchers, and decision-makers as the basis for important decisions related to health care.  The medical record is the silent witness to support services rendered and reimbursed. Good physician documentation ensures that a better quality of data will be available on which to base critical health care sector decisions.

Next – Building a strong foundation- your blueprint to compliance

Learn more about ICD-10-CM and how to make a smooth transition in your office – register now for our complimentary webinar, How to Prepare for ICD-10/5010 to Reduce F41.1 (Anxiety Reaction) featuring Nancy Maguire, ACS, PCS, FCS, HCS-D, CRT

Nancy Maguire, author of “The Nancy Maguire GPS to ICD-10-CM Planning and Implementation Guide”, teaches how to transition to ICD-10-CMNancy Maguire, ACS, PCS, FCS, HCS-D, CRT, author of The Nancy Maguire GPS to ICD-10-CM Planning and Implementation Guide, is a nationally-renowned procedural and diagnostic coding instructor, bootcamp trainer, and workshop leader. She has spent more than 30 years as a hands-on coder and has authored countless coding articles and presentations. In her expansive career, she has transitioned from nursing, to coding, to practice management, auditing and consulting. Nancy served as Director of Coding and Reimbursement at UTMB in Galveston Texas for four years. She served the first two terms as president of AAPC in the early 1990s.

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