The primary benefit of the latest delay in the implementation of ICD-10 is that it allows ample time for additional preparation and testing. One element of preparation that should be on each provider’s to-do list is dual coding and clinical documentation improvement (CDI). The process and scope of any dual coding and CDI effort will differ based on organizational goals. Key factors to consider when planning your dual coding and CDI include staffing availability, budgets, training schedules, and technology improvement initiatives. For example, is your patient accounting system prepared to support ICD-9-CM and ICD-10-CM/PCS codes? Implementing dual coding and CDI only should begin after all planned awareness, biomedical, and role-specific ICD-10 education has been completed.
Dual CDI can be accomplished by developing provider clarifications that capture the specificity demanded by ICD-9-CM, as well as any additional specificity associated with ICD-10. The process of implementing dual CDI provides an excellent opportunity to identify gaps in current documentation, something that will allow for accurate and complete coding once ICD-10 ultimately is implemented. It specifically allows for the development of insight into how current clarifications will need to evolve in order to allow providers to reap the benefits of ICD-10. Leveraging dual CDI also can identify any new clarifications that are unique to ICD-10. When implemented in phases, dual CDI exposes providers to documentation enhancements over time and can prevent a barrage of clarifications after the compliance date arrives.
Dual coding is defined as assigning both ICD-10 and ICD-9 codes simultaneously.
Coding natively in ICD-9-CM and using a translation or mapping tool to assign codes in ICD-10 will not always net the same results. ICD-
10 mapping tools, such as the General Equivalency Mappings (GEMs), were designed to translate large amounts of claims data effectively. And while they are effective in that regard, unfortunately they are not 100 percent accurate. With an error rate assumed to be between 3 and 10 percent, depending on the mapping tool utilized, use in development of data to manage a CDI program can lead to erroneous results that can waste valuable resources. Another practice is having one coder code in ICD-9-CM and another coder (possibly a vendor) translate the ICD-9-CM codes from the claim to ICD-10-CM/PCS codes. This is also not advised, because the only way to code in ICD-10 with any certainty is to have access to the medical record for review. Another spin on this practice is to have two coders review the chart, one focused on assigning ICD-9-CM codes and the second assigning ICD-10 codes. Again, this option is not ideal, as it negates the benefit of allowing each coder the opportunity to identify the additional documentation specificity associated with ICD-10.
The best course of action is to have coders code natively in ICD-9 and then ICD-10 using a selection of discharges from your top 20 DRGs by volume. Don’t forget to include outpatient cases. To ensure that your outpatient documentation will meet medical necessity, select high-volume cases from each patient type for inclusion in your dual review. For both inpatient and outpatient services, dual coding provides insight into the anticipated financial impact of the transition to ICD-10 as well as the impact on coder productivity. While the ICD-10 codes assigned during dual-coding exercises cannot be submitted to payors for reimbursement purposes, some payors may accept ICD-10-coded claims as part of a collaborative testing initiative.
Based on conversations with coders who have begun dual coding, the greatest learning opportunity is associated with ICD-10-PCS. This is not surprising, given that ICD-10-CM is virtually the same as ICD-9-CM. While the codes look different, and there are certainly many more to choose from in certain instances, there are minimal guideline and instructional changes. The ICD-10-PCS code set is a different story. The procedure code set will require more extensive training and practice for both the clinical documentation specialist and the coder. As a result, be sure to include a thorough review of surgical DRGs in your dual-coding efforts. Review of a minimum of three of your top 100 procedures in ICD-9-CM offers a good starting point. Be sure to include a cross-section of providers, as documentation deficiencies may result from increased specificity associated with the new code sets, but also may be provider-specific.
In closing, let’s review some of the key benefits associated with a dual coding and CDI program:
- Offers role-specific, hands-on experience in a testing environment that reduces uncertainty in the minds of key stakeholders (providers, clinical documentation specialists, and coders).
- Produces benefits gleaned from conducting time studies associated with dual coding and CDI, which will assist in planning for staffing and budgeting to ensure that adequate CDI program resources are in place prior to implementation.
- Identifies clinical areas of high risk associated with changes in documentation demands, by volume.
- Provides an opportunity to assess quality and consistency across the CDI program and to identify additional training needs.
- Provides the data necessary to track and trend documentation deficiencies by diagnosis, procedure, and provider in order to assist leadership in deploying focused education for issue resolution.
- Allows for preliminary testing of internal systems.
- Offers experience benefits from dual coding, which is an important precursor to claims testing and payment reconciliation. It also provides data necessary to conduct end-to-end testing with payors, allowing providers to renegotiate payor contracts as warranted.
About the Author
Angela Carmichael is the director of HIM for J.A. Thomas & Associates, a Nuance Company. She is a registered health information administrator, a clinical documentation improvement practitioner and a certified coding specialist for both hospital and physician services. Angela has extensive experience in the health information management field, specializing in various payment methodologies, coding education, compliance, and management. Her experience includes services provided in the hospital, physician office, consulting, and insurance settings. She has expertise in technical writing, public speaking, testing, and training development. In addition, Angela is an American Health Information Management Association (AHIMA)-approved ICD-10-CM/PCS instructor and ambassador.
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