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ICD-10 Documentation Training, What Your Physicians Need To Know


Title: PowerPoint Presentation Author: Rebecca Heneghan-Gonzalez Last modified by: Glenda Mae Bosanko Created Date: 7/10/2013 5:03:58 AM Document presentation format – PowerPoint PPT presentation

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Title: ICD-10 Documentation Training, What Your Physicians Need To Know

ICD-10 Documentation Training, What Your
Physicians Need To Know
  • Presented by
  • Glenda Bosanko CPC-P, CCS-P
  • AHIMA Approved ICD-10-CM/PCS Trainer Ambassador
  • Director, ICD-10 H.I.M. Education and Training
  • Jzanus Consulting, Inc.

  • ICD-10 Delay
  • ICD Overview
  • ICD-10 Documentation
  • ICD-10 Outpatient Services
  • ICD-10 Physician Training Tips Why They Should
  • How Do You Get Them To Listen
  • ICD-10 Physician Training Delivery
  • ICD-10 Benefits For Physicians
  • Debridement Example
  • ICD-11
  • ICD-10 A New Countdown

1997 Sustainable Growth Rate Derails ICD-10
  • H.R. 4302 Protecting Access to Medicare Act of
    2014 Temporary Sustainable Growth Rate (SGR) doc
    fix Bill.
  • C.M.S. conservatively estimates that the one year
    delay will cost the industry 6.6 billion.

ICD-10 The Train Is Delayed, What Now?
  • The industry adoption of the ICD-10 code set,
    remains a question of when not if.
  • ICD-10 is coming, the train is not cancelled.
  • The benefits of adoption have not changed
  • More accurate payments for new procedures.
  • Fewer rejected claims.
  • Reduced need for attachments to explain the
    patients condition.
  • Improved disease management.
  • Conducting research, epidemiological studies, and
    clinical trials.
  • Operational and strategic planning.
  • Designing health care delivery systems.
  • Monitoring resource use.
  • Improving clinical, financial, and administrative
  • Preventing and detecting health care fraud and
  • Harmonized tracking of disease and public health
    risks with worldwide reporting.

ICD Overview Who? How?
  • How did ICD coding get started anyway?
  • WHOs idea was this?

ICD Overview
  • Believe it or not, the ICD-9 diagnosis coding
    system originated in 17th century England during
    the bubonic plague.
  • Statistical data was gathered through a system
    known as the London Bills of Mortality, and
    arranged into numerical codes.
  • These codes were used to measure the most
    frequent causes of death.

ICD Overview
  • Fast-forward a few hundred years
  • The list was taken over by the World Health
    Organization (WHO) and developed into the
    International Classification of Diseases (ICD)
    and is revised every 10 years.

ICD Overview Revisions
ICD Revision No. Year of Conference When Adopted Year in Use in the U.S. ICD, Clinical Modification Year in Use in the U.S.
First 1900 1900-1909
Second 1909 1910-1920
Third 1920 1921-1929
Fourth 1929 1930-1938
Fifth 1938 1939-1948
Sixth 1948 1949-1957
Seventh 1955 1958-1967
Eighth 1965 1968-1978 ICDA-8 H-ICDA-1 H-ICDA-2 1968-1978 1968-1972 1973-1978
Ninth 1975 1979-1998 ICD-9-CM 1979
Tenth 1989 1999- ICD-10-CM ICD-10-PCS Oct. 1, 2015
ICD Overview Background Information
  • ICD-9-CM Clinical Modification developed in the
    US and implemented in 1979.
  • Volumes 1 2 Diagnosis Codes (used by all
  • Volume 3 Procedure Codes (used by hospitals for
    inpatient reporting)

ICD Overview Background Information
  • ICD-10 Diagnosis classification system
    developed by the World Health Organization (WHO)
    as the international standard to replace ICD-9,
    Issued in 1993.
  • ICD-10-CM The United States Clinical
    Modification for ICD-10 diagnosis classification
    system is developed to meet the needs of US
    healthcare systems.
  • ICD-10-PCS The United States Procedure
    Classification System to replace ICD-9-CM Volume

ICD Overview Volume of the Changes
ICD-10 Documentation
  • There is a tendency in this industry to try to
    resolve documentation issues on the back end of
    the process.
  • This means that to correct clinical documentation
    issues, they are resolved by HIM professionals.
  • This approach ignores the root of the problem
  • The role of the physician to generate a complete,
    accurate, and legible record of the patient

ICD-10 Documentation
ICD-10 Documentation Myth
  • Myth Documentation for ICD-10 is an
    unnecessary burden on physicians.
  • Facts
  • The number and type of new concepts required for
    ICD-10 are not foreign to clinicians.
  • The focus of documentation is good patient care.
  • Patients deserve to have accurate and complete
    documentation of their conditions.

ICD-10 Documentation
  • If documentation were a spoken language, would
    you be able to understand your physicians?

ICD-10 Documentation
  • During medical school, the elements of thorough
    clinical documentation are taught. So what
  • The pressure of time and the volume of work
    encourages the use of abbreviations and condensed
  • The skill of good clinical documentation, is
    reduced to that of a menial, non-functional
    chore a necessary evil in many physicians eyes.
  • Case managers, Documentation specialists and
    Health Information Management (HIM) staff receive
    more training in documentation than physicians.

Documentation 1889
Documentation 2011
ICD-10 Documentation
  • Documentation What they learned in medical
  • Type of condition
  • Type I or Type II diabetes
  • Onset
  • When did it start?
  • Etiology / Cause
  • Infectious agent
  • Physical agent
  • Internal failure
  • Congenital

ICD-10 Documentation
  • Documentation What They Learned in Medical
    School. (cont.1)
  • Anatomical location
  • Which anatomical structure
  • Proximal, distal, medial, lateral, central,
    peripheral, superior, inferior, anterior,
  • Laterality
  • Right side or left side
  • Severity
  • Mild, moderate or severe
  • Environmental factors
  • Smoking
  • Geographic location

ICD-10 Documentation
  • Documentation What They Learned in Medical
    School. (cont.2)
  • Time parameters
  • Intermittent/Paroxysmal
  • Recurring
  • Acute or chronic
  • Post-op, post delivery
  • Comorbidities or complications
  • Diabetes with neuropathic joint
  • Intracranial injury

ICD-10 Documentation
  • Documentation What They Learned in Medical
    School. (cont.3)
  • Manifestations
  • Paralysis
  • Loss of consciousness
  • Healing level
  • Routine healing, delayed healing, non-union,
  • Findings and symptoms
  • Fever
  • Hypoglycemia/hyperglycemia
  • Wheezing

ICD-10 Documentation
  • Documentation What They Learned in Medical
    School. (cont.4)
  • External causes
  • Motor vehicles, injury locations
  • Assault, accidental, work related, intentional
    self harm
  • Type of encounter
  • Initial encounter, subsequent encounter,
    encounter for condition sequela, routine
    evaluation, administrative encounter

ICD-10 Documentation
What is needed for ICD-10 documentation?
  • Condition
  • Onset
  • Etiology
  • Location
  • Laterality
  • Severity
  • Environmental factors
  • Timing parameters
  • Comorbidities and Complications
  • Manifestations
  • Healing level
  • Findings and Symptoms
  • External Causes
  • Type of Encounter
  • All the same things they learned back in medical

ICD-10 Outpatient Services
  • Myth ICD-10 wont affect my outpatient provider
    services. CPT codes are all they need.
  • Fact ICD-10-CM diagnostic codes will replace
    ICD-9 codes and Payers will use them (the codes)
    to judge the medical necessity and validity of a
    procedure in order to reduce false or inflated
    reimbursement claims.
  • With outpatient procedures making up an average
    of a third of a hospitals revenue, its
    important not to dismiss the effect that ICD-10
    will have on outpatient operations.

Outpatient Example of ICD-10 Specificity
  • Example 1 Diagnosis Patient has acute otitis
  • In ICD-9-CM, we would have reported this with
  • In ICD-10-CM, we would need to know which side
    and if it is recurrent such as
  • Diagnosis Patient has an acute onset of otitis
    media of the right ear, which is recurrent.
  • In ICD-10-CM, this is reported with H65.114.
    (Acute and subacute otitis media recurrent, right
  • In order to assign a code we need to know which
    ear (laterality), and acute, chronic or recurring
    (timing parameters).

Outpatient Example of ICD-10 Specificity
  • Example 2 This is the typical level of
    documentation that is currently seen under ICD-9.
  • Impression Cellulitis and superficial abscess
    index finger.
  • Plan I am recommending debridement and
    irrigation of the digit today. I think the skin
    is dead and that she will tolerate it with
    anesthesia, I would like her to stay on the
    clindamycin and I will check back with her in 3
    days to see how she is doing.
  • (Note that left or right is not documented in
    this case.)
  • In ICD-9 this was coded as 681.00 but in ICD-10
    we would need two codes one for the abscess, one
    for the cellulitis. (Note In ICD-10 this should
    not be coded without further documentation - or
    query of the provider)

Outpatient Example of ICD-10 Specificity
ICD-10 Recurring Concepts
  • No scare tactics.
  • Dont use the sheer number of codes in ICD-10 to
    overwhelm your doctors.
  • Codes in ICD-10-CM are combination codes with
    considerable repetition of the same concepts.
  • This format results in a large number of codes
    that are generally the same, with the exception
    of one or two concepts.
  • Example About 25,000(36) of all ICD-10-CM codes
    are different only in that they distinguish
    right vs. left.

ICD-10 Recurring Concepts
Concept Number of Codes
Initial Encounter 13,932
Subsequent Encounter 21,389
Sequela 11,974
Right 12,704
Left 12,393
Routine Healing 2,913
Delayed Healing 2,913
Nonunion 2,895
Malunion 2,595
Assault 1096
Self-harm 1057
Accidental 1262
ICD-10 Physician Training Tips
  • Physicians dont have to document more.
  • Better documentation does not mean more
    documentation, it means quality documentation.
  • Physicians dont have to be coders.
  • When training physicians, remember that they do
    not need or want to know codes.
  • Physicians should focus on what they are trained
    to do
  • Evaluate patients
  • Document findings
  • Make assessments and diagnoses
  • Determine treatment options Implement treatment,
    based on patients decisions
  • Analyze and synthesize results of studies and
    outcomes to continually improve care

ICD-10 Why They Should Care
  • Tell your physicians why they should care.
  • What is the return on investment (ROI) for the
  • Accurate payment for complex and new procedures
  • Fewer rejected claims - ICD-10 is more detailed
    and organized than ICD-9
  • Better claims adjudication and faster approvals
  • A reduced claims cycle will lower administrative
    costs for physicians

ICD-10 Why They Should Care
  • Tell your physicians why they should care
  • ICD-10 will have a direct impact on physicians
  • Physician quality profiles - mortality and
  • Physician utilization profiles - efficiency of
    treating patients
  • Physicians' current and future evaluation and
    management levels, including pay for performance
  • Daily workflow - (slowed and disrupted if ICD-10
    is not properly implemented)

ICD-10 Why They Should Care
  • Tell your physicians why they should care.
  • Inpatient and outpatient documentation must
    support appropriate and complete ICD-10 code
  • The effects of inaccurate or incomplete clinical
    documentation lead to
  • Inaccurate authorizations which can potentially
    jeopardize reimbursement.
  • Inconsistent coding between physician and
    hospital, potentially delaying claim adjudication.

Example Why They Should Care
  • Inconsistent coding between physician and
    hospital, delayed claim adjudication.
  • Example
  • Claims with valid diagnosis and procedure coding,
    that pass medical necessity edits for both the
    physician (professional) and the hospital
    (technical), but the codes that are documented by
    the physician and the hospital for the surgical
    procedure performed do not match.
  • For Medicare, this can be detected via the Common
    Working File (CWF).
  • A mismatch between the professional and the
    technical codes can potentially delay payment to
    both parties.

How Do You Get Them To Listen?
  • Appeal to their professionalism.
  • ICD-9 codes are inadequate (implemented nearly 40
    years ago). Its is not suited for modern
  • Make the logical argument.
  • The United States is behind the rest of the

How Do You Get Them To Listen?
  • Continued - The appeal to logic.
  • We ran out of space, medical knowledge continues
    to expand, but there is no room to expand any
    more in ICD-9 (which is easily seen at the end of
    the V codes).
  • For example
  • Why do you think the expression of traumatic
    brain injury codes, (780.97- altered mental
    status, 780.93 - memory loss, 784.0 - headache)
    were put in the 700s right along with fussy
    infant and clubbing of fingers?
  • Why not put them in the Neurology section?
  • Because we ran out of space.

How Do You Get Them To Listen?
  • Peer pressure, seriously.
  • Identify and use Physician Champions in your
    training program.
  • Physicians really want to hear from other
    physicians. And it helps if that physician is in
    the same specialty.
  • Neurologists arent interested in hearing from
    plastic surgeons and cardiologists dont care
    what orthopedists have to say.
  • Keep the information relevant to the physicians
  • Dont talk to pulmonologists about
    gastrointestinal procedures.

How Do You Get Them To Listen?
  • Why ICD-10 Physician Champions?
  • Physician written, created, or delivered ICD-10
    education in your training program creates
    immediate rapport from their peers.
  • They know the physician champion gets where
    theyre coming from and what they really need.

How Do You Get Them To Listen?
  • Additionally -
  • Remind physicians that you didnt invent ICD-10
    to make their lives more difficult.
  • Tell physicians that ICD-10 will improve patient
    care by providing better information about the
    patients health.
  • For your physicians who are overworked because
    their patients are sicker
  • When they say their patients are sicker than
    everyone elses, and that is why they have to
    provide more care, with ICD-10 they will be able
    to prove it.

How Do You Get Them To Listen?
  • Dont over train them
  • Only train on what is needed.
  • If they are already documenting laterality, dont
    discuss it.
  • Focus the training on their own individual needs
    for compliant documentation.
  • Individualize Show them their actual
    documentation and then show them the codes.
  • Give them concrete examples from their own
    documentation. This takes a bit of work, but it
    will pay off.
  • Take the physicians note, open the ICD-10
    manual, and physically show them what information
    is in the documentation and what information the
    coders need.

ICD-10 Physician Training Delivery
  • Focus on the top 10 clinical diagnoses.
  • Run a report of the top 20 MS/APR DRGs for the
    last fiscal year.
  • Review the diagnoses, select the top 10.
  • Tailor ICD-10 training for the common clinical
    diagnoses that your physicians manage.

ICD-10 Physician Training Delivery
  • Revise current query forms and focus on these
    specific areas
  • Asthma
  • Coma
  • Fracture
  • Stroke
  • Cardiac-hypertension, CAD, CHF
  • Diabetes
  • OB
  • Sepsis/SIRS
  • SIRS due to an infectious process is no longer
    assumed to be sepsis

ICD-10 Physician Training Delivery
  • Even with all the detail in ICD-10, queries are
    expected to increase to lessen this impact make
    sure physician documentation meets these current
  • Legibility
  • Completeness
  • Clarity
  • Consistency
  • Precision
  • Just as in ICD-9, queries should not be used to
    question a providers clinical judgment emphasis
    added, but rather to clarify documentation when
    it fails to meet any of the five criteria listed

Example Of A Sepsis Query Form
ICD-10 Physician Training Delivery
  • Consider having physicians stop using the term
  • ICD-10-CM doesnt include a default code for
    this condition.
  • Documentation of urosepsis will not yield an
    ICD-10-CM code.
  • Instead encourage physicians to document sepsis
    from a urinary origin or simply UTI, when

ICD-10 Physician Training Delivery
  • Schedule regular training sessions between now
    and go-live date.
  • Keep the sessions short, just ten minute
  • This shows that you value and respect their time.
  • Begin with small doses of information delivered
    in small groups.
  • Provide quick reference materials and have them
    available in multiple mediums and locations.
  • Getting all physicians together at one time just
    does not happen.

ICD-10 Physician Training Delivery
  • Finally Provide Feedback
  • Physician behavior will not change without
    ongoing feedback.
  • This should include re-visiting educational
  • Most importantly, provide feedback based on
    specific analysis of their individual
    documentation patterns and variation from the
    expected results.
  • Physicians will give a lot more attention to
    comparative data that is specific to them.

ICD-10 Physician Training Delivery
  • Continued feedback is needed to provide awareness
    of the potential impact that inadequate and
    inaccurate documentation will have on
  • Their reputations
  • Their reimbursement
  • Most importantly, the best care for their

ICD-10 Physician Training Delivery
  • Here are some training delivery formats
  • Internal Courses
  • External Courses (off-site, vendor)
  • Computer-based Training
  • Web-based Training
  • Seminars/Classes
  • Try to piggy back onto existing seminars or
    meetings inviting physician office managers to
    attend is a bonus.
  • In Person, Instructor-led-classroom
  • Led by your organizations ICD-10 trained HIM
  • Physician Champions
  • Train-the-Trainer Approach

ICD-10 Benefits for Physicians
  • ICD-10 offers a more decisive system to determine
    payments by offering
  • Greater detail on the type and quality of care
  • Government payers, insurers, hospitals, health
    systems, medical groups and others will use
    ICD-10's granular data to determine
  • Accurate and fair physician compensation
  • Reimbursement for goods and services
  • Under the government's Value-Based Purchasing
    program, physicians who do not provide precise
    documentation will experience reduced payments

ICD-10 Benefits for Physicians
  • Improved physician documentation will lead to
  • Quality reporting
  • CMS has implemented the
  • Physician Compare website (provides public
    quality of care participation information)
  • PQRS (Physician Quality Reporting System)
    mandated through federal legislation,
    incentivizes physicians to report quality

ICD-10 Benefits for Physicians
  • Ensure their strong reputation.
  • Physician profiling and National Registries are
    occurring more frequently with a concentrated
    move towards transparency, for example
  • Today, Physician Compare only includes
    information about whether individual physicians
    and other healthcare professionals participate in
    PQRS, not about their performance.
  • However, CMS plans to post performance ratings
    for physicians and other healthcare professionals
    on the site in 2015.

ICD-10 Benefits for Physicians
  • Example Good documentation of debridement under
    ICD-10 will benefit physicians.
  • ICD-10-PCS Root Operations
  • Excision - Cutting out or off, without
    replacement, a portion of a body part.
  • Excisional debridement involves cutting, with a
    sharp instrument. Like a scalpel.
  • Extraction - Pulling or stripping out or off all
    or a portion of a body part by the use of force.
  • Non-excisional debridement can be performed using
    various methods, such as using enzymes,
    ultrasound, or simply sloughing off the tissue
    with gauze.

Example Skin Ulcer with Excisional Debridement
ICD-10-CM Diagnosis codes L98.419 Non-pressure
chronic ulcer of buttock with unspecified
severity MC I50.41 Acute combined systolic
(congestive) and diastolic (congestive) heart
failure CC C25.9 Malignant neoplasm of
pancreas, unspecified ICD-10-PCS Procedure
Codes OHB8XZZ Excision of Buttock Skin,
External Approach DRG 570 Skin Debridement
with MCC MDC 9 Diseases and Disorders of the
Skin, Subcutaneous Tissue and Breast DRG
Weight 2.4688 AMLOS 9.9 GMLOS 7.5
Hospital Wage Index 1.2971 DRG
Reimb 33,688.15
Example Skin Ulcer without Excisional Debridement
ICD-10-CM Diagnosis codes L98.419 Non-pressure
chronic ulcer of buttock with unspecified
severity MC I50.41 Acute combined systolic
(congestive) and diastolic (congestive) heart
failure CC C25.9 Malignant neoplasm of pancreas,
unspecified ICD-10-PCS Procedure Codes
OHD8XZZ Extraction of Buttock Skin, External
Approach DRG 592 Skin Ulcers with MCC
MDC 9 Diseases and Disorders of the Skin,
Subcutaneous Tissue and Breast DRG
Weight 1.4632 AMLOS 6.9 GMLOS 5.5
Hospital Wage Index 1.2971 DRG
Reimb 19,966.18
Documentation Elements for Debridement
  • The International Classification of Diseases 11th
    Revision (ICD-11) is due for release in 2017.
  • Why not wait for ICD-11?

  • Because ICD-10 to ICD-11 will be a more seamless
  • A transition from ICD-9 to ICD-11 would not be
  • WHO is working to ensure countries can switch to
    the ICD-11 version as easily as possible.
  • ICD-11 will better reflect progress in health
    sciences and medical practice.
  • In line with advances in Information technology,
    ICD-11 will be used with electronic health
    applications and information systems (electronic
    health record ready).
  • Links to standardized terminologies like
    SNOMED-CT, GeneOntology, etc.

  • Imagine you are building an important
  • Sue Bowman, director of coding policy and
    compliance for the American Health Information
    Management Association (AHIMA), stated,
  • ICD-10 is the pathway to ICD-11, she said, You
    have to treat it like youre building a structure
    starting with a first floor. You cant build a
    fourth one without constructing a second and

Closing Comment
  • NO ONE likes change.
  • Period
  • Remember, its not about changing how they care
    for their patients.
  • Empathy is important.
  • At the end of the day it really should be all
    about providing excellent patient care.
  • The rest just falls into place

ICD-10 Countdown
  • We have more time.
  • October 1, 2015
  • 540 Business Days
  • 71 Mondays
  • Use it wisely

End of Presentation
We decided the candy bars just werent working
as a documentation incentive.
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