Observations from Paul Weygandt, MD

Industry-wide, there is substantial interest in specialty-specific ICD-10 education for physicians. Recognizing that physicians will not, and reasonably cannot, take a broad approach to learning ICD-10 as do coders and clinical documentation specialists, education is increasingly being focused on those specific areas relevant to a given clinical practice. This is coming at a time when more and more hospital care is being coordinated by hospitalists, who typically act as the attending physician or “captain of the ship.”

Recently, a certain clinical documentation specialist asked a very thought-provoking question: What will be the impact of subspecialty physician ICD-10 training on coding practices, including issues of conflicting documentation?

Consider, for example, a hospitalist who admits a patient with a hip fracture and multiple medical problems. The hospitalist documents “hip fracture” and consults the orthopedic surgeon (who, by the way, was well-trained for orthopedic applications of ICD-10) ,and he or she documents “displaced fracture base left femoral neck, initial encounter, closed fracture.” Throughout the admission, both physicians continue to document as they had initially. Does this situation describe conflicting documentation? Clearly, it does not. First, “hip fracture” is not a codeable diagnosis. It is a non-specific clinical description. The coder should look at the entire chart to achieve the most accurate ICD-10-CM coding. Similarly, the orthopedic surgeon also may have documented diabetes somewhere in the chart, but the hospitalist provides the necessary specificity (appropriate to the specialty of internal medicine) of “Type I diabetes mellitus with diabetic neuropathy.” If coding queries were to be generated to address such conflicting documentation, the physician outcry would be predictable and appropriate. It would be unreasonable to expect every physician in every specialty to understand the documentation requirements across the broad spectrum of ICD-10. That is why multiple specialists are often involved in care.

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