ED Coding Update

Get a jump start on the transition to ICD-10

[This quarterly column is written by Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates, Baton Rouge, LA.]

Having recently completed an instructor course in ICD-10, I am still processing the magnitude of the transition to this new system. The coding aspects no longer seem paramount. Numerous organizations are primed and ready to go with education of coding professionals. Of primary concern, however, is how we will move our providers ahead with documentation improvement to meet this and other initiatives designed to address quality, performance, and revenue.

Numerous timetables have been published to indicate that if you and your institution haven't started addressing the ICD-10 implementation by now, you are woefully behind. Many payers and hospitals have started transitioning their coding and IT systems. However, you seldom hear about the implementation of process improvement programs to address documentation preparation for ICD-10. Improving the documentation of individual physicians is a tedious and challenging process. Add some complicated electronic medical record formats or conversion to improved record formats and you have a system heading for a stall.

Some projections are that coding productivity will be cut in half for up to 6 months following the October 1, 2013 implementation of the ICD-10 system. Add to that a physician community that hasn't grasped the nuances of documenting and the complications of payer revisions to medical necessity policy to meet ICD-10 standards, and your facility may experience the perfect storm of overall system failure.

Let's discuss some solutions and processes you may want to begin early to better prepare you institution for what is coming:

Auditing for Performance: Consider adding ICD-10 codes to parallel your ICD-9 code assignment on compliance audits. This will help to identify the documentation deficiencies that will impact your revenue after October 2013. Begin to work with your providers to assure their familiarity with the new requirements so your coding process and revenue aren't affected.

Recognizing Your Clinical Issues: Determine the impact of ICD-10 coding on provider documentation and coding of your top 20 most frequently billed clinical scenarios. Chief complaints of altered mental status, shortness of breath, abdominal pain, flank pain, chest pain, upper respiratory conditions, psychiatric complaints, and drug overdose will present documentation and coding challenges.

Underscoring Medical Necessity: As more and more patients use EDs as their primary care provider, you will be challenged to prove medical necessity for routine problems. Documentation and coding will make the critical difference in identifying underlying problems and acute conditions that establish medical necessity. Using examples from current cases, begin to track where additional focus is required.

Appoint Representatives to Provider Liaison Team: Establish an ED provider liaison team with members from your ED physician, nursing, administrative, and coding/compliance areas to perform a needs assessment and design a program to address your department's unique challenges. The type of record you use, whether or not your coding and auditing is performed in-house, the specialization of your ED (trauma, pediatric, urgent care/fast track) will all contribute to how you address the transition.

Design Metrics: Empower your provider liaison team to address these issues with your ED providers and implement metrics that can track each provider's compliance with the documentation policies you are implementing for your site. As of January 1, 2012, you have seven calendar quarters to crunch the numbers that will demonstrate each provider's understanding of what is needed. Improvement can only be gauged over time and a number of clinical scenarios, so a few quick months of preparation can't cover enough of the coding combinations you need to assure documentation improvement.

Identify ED Revenue Issues: Perform "what if" revenue scenarios based on existing medical necessity policies at your major payers to determine your weaknesses. Don't neglect ED documentation that impacts on in-patient revenue or revenue for your hospital medicine providers and other specialists. Your coding department should be able to provide information on such risk areas as critical care, observation, present on admission (POA)/hospital-acquired conditions (HAC), trauma activation, etc.

Track Documentation-Based Denials: Track documentation-based payment denials and share these scenarios with your providers. It's amazing how little most providers know about how documentation transitions into dollars. Real-world examples go a long way!

Improve Collaboration with Facility and Professional Coding and Billing Teams: Develop a shared information process between facility and provider coding processes if coding is performed by separate coding vendors/departments. As we move toward a reformed health care system, collaboration is critical, and much is to be gained from the sharing of information about documentation that impacts each separate area. Diagnosis coding for the professional component has been extremely relaxed when compared to the rules for the facility component. Diagnosis coding for the ED component of a facility bill supports more than just the ED revenue center — it is the foundation of medical necessity for laboratory, radiology, cardiology, pharmacy, and central supply, just to name a few. We will see increasing focus on accuracy and sequencing of physician diagnosis coding as ICD-10 evolves.

Finally, if you doubt the need of a full seven calendar quarters to prepare, consider how well your ED facility coding program has been performing since the October 1, 2000 implementation of the Outpatient Prospective Payment System (OPPS). How long did it take for all of the departments involved in documenting and coding for OPPS to refine their processes? How long have your nurses been appropriately documenting infusion start and stop times accurately? Are your coders able to capture these ED services accurately? How does your documentation of facility AND professional critical care time look? Do your observation coding and documentation policies comply with government policies? These are just a few of the issues that continue to plague EDs. Given the reality that many EDs continue to struggle with documentation and coding issues relating to OPPS policies, October 2013 and ICD-10 are just a blink away!