Now that the Centers for Medicare & Medicaid Services (CMS) has issued the final rule establishing Oct. 1, 2014 as the official date for implementation of ICD-10, physicians, hospitals, and health systems are recommitting to their preparatory efforts – which, perhaps, were dormant during the extended period of ambiguity. As we now resume comprehensive efforts to prepare for the transition, I would like to raise the issue of inclusion of medical students and resident physicians within the spectrum of ICD-10 education.

Historically, medical schools and residencies have done an abysmal job of preparing physicians for the non-clinical aspects of their professional practice. I speak to many graduating residents who have yet to learn CPT evaluation and management codes, know little about ICD-9, and lack understanding of MS-DRGs and other systems.

In the past, risks associated with such a lack of institutional knowledge were limited to inadequate payment for professional services. Today, in our highly volatile clinical environment, untrained graduating physicians face not only the likelihood of underpayment for services rendered, but also a very real and significant risk of recovery from audits identifying coding errors. Even the risk of fraud investigation can arise if medical necessity for services rendered is not documented clearly in the medical record. As more graduating physicians take employment positions rather than entering private practice, the risk is somewhat diminished, however, parent organizations often struggle to produce the necessary clinical documentation to support accurate levels of billing.

Why does this void in medical education exist? There are probably multiple reasons. First, very few academic physicians themselves understand even the basic principles of ICD-9 diagnosis and procedural coding, E/M professional fee billing, comorbidity and major comorbidity documentation, or MS-DRG assignment.  It is particularly difficult for academic physicians to teach what they do not know. Furthermore, many in the academic sphere feel that these issues of documentation, coding and reimbursement are topics that somehow fall below the level appropriate for medical education.

ICD-10 will bring such issues into sharper focus. Many academic centers still teach using eponyms, crediting leaders of healthcare for their procedural innovations. However, under ICD-10, eponyms largely have been eliminated from the lexicon of inpatient procedural coding. This increases the clinical specificity of procedures and avoids terminology that presents risk of ambiguous interpretation. For example, for the general surgery resident, which is the more appropriate term to learn during training: “Billroth II procedure” or “partial gastrectomy with gastrojejunostomy”? Billroth II, which still remains in common use, is not even in the index of ICD-10-PCS, let alone in the coding tables. Would it not be even better to teach residents to document as accurately as possible under the ICD-10 procedural coding system? The resident could be taught fundamentals of describing the actual procedure performed, such as a “partial resection (excision) of the stomach with a gastric-to-jejunum bypass.”

Medical students and residents should be apprised that ICD-10 cites more current terminology, such as STEMI and NSTEMI for acute myocardial infarctions. Residents also need to learn to provide the specificity necessary for diagnosis coding. Many diagnoses will be unable to be coded without subsequent query unless the physician provides sufficient detail. The result at many hospitals will be an exceedingly annoying series of coding queries that will continue until the necessary detail is provided. Consider the example of femoral head and neck fractures. There are currently 12 ICD-9 codes for this classification of fracture. ICD-10 has 576 codes for femoral head and neck fractures. Consider the challenge for coders. Untrained physicians will provide such information as “non-union femoral neck fracture.” This statement cannot be coded. Why not teach our physicians-in-training what elements typically would be required for coding? Here’s an example of one of the 576 codes that would apply to the above partial description: S72042K. That is, “a displaced fracture of the base of the neck of the left femur, with subsequent encounter for a closed fracture with non-union.” The resident would know those facts at the time of the procedure and typically would be glad to dictate them if someone merely instructed him or her on the general principles of ICD-10 coding for orthopedists.

Healthcare is fundamentally changing. Physicians leaving residencies increasingly are seeking employment status. CMS has indicated its intent to move toward accountable care, with severity-adjusted, population-based compensation mechanisms (bundled payments). Even on the clinical floor, we have moved from the “captain of the ship” to the “clinical team” approach to patient care. Physicians need not be at odds with health information management (HIM) departments and coders. If medical school and residency training programs were to incorporate ICD-10 training as well as CPT evaluation and treatment education, coupling that with global understanding of MS-DRGs and emerging methodologies such as the CMS-HCC system, physicians, documentation specialists and coders could better collaborate to document severity of illness accurately and improve treatment of patients under their care.

About the Author

Paul Weygandt, MD, JD, MPH, MBA, CPE, is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Dr. Weygandt is vice president of physician services for J.A. Thomas & Associates and is a partner in the firm.

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