EDITOR’S NOTE: This is the first installment in a two-part series on clinical documentation improvement.

Because of the greater specificity of ICD-10-CM and ICD-10-PCS along with the opportunity to report the severity of a patient’s condition in more detail, it is anticipated most health plans will require a more detailed level of specificity in reporting.  Using an unspecified ICD-10 code routinely might cause further review by the carrier.

While procedure coding will not change for outpatient and professional services, it is still not clear what impact the change in the diagnosis code sets will have on payment rates. Medical Practices would need to do some projections to determine the scope.  Keep in mind that even though physicians are paid differently than in hospitals, diagnosis coding supports medical necessity for all services reported on the claim form.  It is accurate that many hospitals, but not all, are paid based on the MS-DRG which drives payment with the diagnosis code supporting medical necessity.  Physicians are paid on a fee schedule and diagnosis codes support medical necessity. According to the CMS Comprehensive Error Rate Program “Medical necessity is the overarching criterion for selection of a procedure and/or service.”

The ICD-10 Implementation Team will need to spend time analyzing the documentation impact. While payment is based on procedure codes in the outpatient setting (coding for procedures would not change) diagnoses codes are used for medical review, auditing, and coverage.  In the hospital setting many services are based on the MS-DRG and/or the severity of the patient’s condition.

The level of detail required in medical record documentation for assignment of ICD-10-CM and or PCS codes will require in most cases, additional information in order to code the service and support the treatment plan.  The patient record must include specific terminology and provide more detail in the documentation.  In order to move readiness forward, it is important to identify current documentation deficiencies when reporting diagnoses in the medical record. In the clinical area, the largest impact to ICD-10-CM implementation is documentation. Since ICD-10-CM is more robust and has up to seven digits of specificity, assess whether documentation currently in the medical record will support ICD-10-CM on the “go-live” date.

Steps that should be taken include:

  • Identify limitations in current use of ICD-9-CM, including:
    • Not all diagnosis codes allowed by health plans
    • More patients have complications and comorbidities that may require several diagnosis codes to describe their condition
    • MS-DRG’s will be affected
    • Lack of documentation to support the level of specificity allowed in
  • Review existing policies and procedures related to ICD-9-CM. Identify any changes needed in existing policy and procedures, including:
    • ICD-9-CM reporting
    • Auditing of clinical documentation
    • Review of specific clinical events – adverse events

For example, if a patient presents to the medical office with severe ear pain, and the physician performs and documents an assessment including a history pertinent to the reason for the visit, an examination, the physician can make a medical determination based on the patient’s history and examination.  Most likely you will see the diagnosis documented as “acute otitis media” without further elaboration. The diagnosis code reported in ICD-9-CM would be unspecified (381.00-unspecified acute nonsuppurative otitis media).

However, in ICD-10-CM the diagnosis of acute otitis media (H65.1-other acute nonsuppurative otitis media) cannot be coded without additional information such as what ear is affected, and identifying if the problem is initial or recurrent.  More information must be documented in the medical record to support selection of an ICD-10-CM code.  The documentation should look more like this:

Patient has an acute onset of otitis media of the right ear, which is recurrent.

In ICD-10-CM this is report with H65.114 (Acute and subacute otitis media recurrent, right ear).

What impact will documentation have to the organization when implementing ICD-10-CM?  If the physician or provider is not documenting currently to the level of specificity to report the clinical condition, the increased documentation requirements will increase the amount of time and effort the organization spends on each patient encounter.  This will decrease productivity due to not only learning the new code set, but learning documentation requirements for the codes.  Keep in mind when the documentation is not clear, you must query the physician.

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