With the viability of the Affordable Care Act (ACA) now largely settled by the U.S. Supreme Court, providers must now turn their attention to the next big hurdle: the long-delayed transition to the International Classification of Diseases, Clinical Modification administrative codes (ICD-10-CM), set to take place in October. While EPs tend to stay so busy with the work in front of them, it can be difficult to plan for the future. New research suggests now is the time for both administrators and clinicians to get up to speed on the new coding system.
What’s the urgency? ICD-10-CM represents a massive expansion in the number of codes that will be available to providers as they document their activities so they can be reimbursed. However, the level of detail required in ICD-10-CM will present a host of challenges, especially for smaller practices that do their own coding rather than pass the task on to vendors. However, investigators suggest even providers working for the largest and busiest EDs in the country are going to have to familiarize themselves with the new system, and that it may well change their approach to charting and documentation. While the long-term impact of this transition is hard to gauge, experts say there is no question ICD-10-CM will demand more of providers.
Be careful with reports
In the new analysis, investigators from the University of Illinois in Chicago looked specifically at how the transition to ICD-10-CM will impact emergency medicine and where the biggest challenges are likely to surface. Using government files that enable providers to map ICD-9-CM codes to ICD-10-CM codes and vice versa, investigators found that nearly 25% of all clinical encounters in the ED may present coding difficulties, ranging from coding accuracy issues and problems in justifying hospital admissions to challenges in preparing the kinds of reports that hospitals routinely create to ensure they have adequate supplies and staffing to meet future needs.
“We applied a mathematical technique that labeled the convoluted or the complex areas of the transition,” explains Andrew Boyd, MD, a co-author of the analysis and an assistant professor in the Department of Biomedical and Health Information Sciences in the College of Applied Health Sciences at the University of Illinois in Chicago. “The initial finding of the study was that 23% of the visits, or 27% of the codes emergency medicine physicians use, are complex.”
For instance, in the case of a patient who presents with abdominal pain, ICD-10-CM will require providers to specify whether this pain is upper, lower, or pelvic and perineal.
“That initially sounds OK. We are just specifying more information, but when you look at the overall complexity of the transition, [the government files] also map [from ICD-9-CM] unspecified symptoms associated with female genital organs,” Boyd notes. “If you run emergency room reports about how many female-specific diagnoses you have in a shift, when you map it forward to ICD-10-CM, that gender information isn’t encoded…so your new report, when you are looking at pelvic and perineal pain, you would also actually have to import gender information in order to make sure you are actually getting that information on the report.”
The reason why it is critical for ED administrators to have information about gender is because if they have an all-male physician staff, they will need to know whether or not they need extra nurses in order to have chaperones, Boyd explains.
“Knowing what your baseline is or how many gender-specific exams you need will help you plan staffing, especially when you look at the number of individuals or the gender of the individuals,” he says. “You might have delayed service if you are short nurses or you don’t have an appropriate chaperone for the EPs.”
When ED administrators make planning decisions, they don’t want to have too many staff or supplies, but they also don’t want to have too few, Boyd notes.
“By highlighting the hard parts [of the new coding system] — the convoluted or complex areas — we are saying, ‘hey, here are the areas you really need to understand.’”
Note changing definitions
Another potential problem area involves the way EPs use codes to establish the medical necessity of a hospital admission. For example, malignant essential hypertension can now be used as a justification for hospital admission, but the ICD-9-CM codes used to describe this condition are going away, Boyd observes.
“That concept — malignant essential hypertension — does not exist in ICD-10-CM, so you just have to label it as essential hypertension and then add additional codes for end-organ damage and complications,” he explains. “If you just follow the direct mapping of malignant essential hypertension [from ICD-9-CM] to essential hypertension [in ICD-10-CM] … you don’t adequately portray the severity of the disease in front of you.”
If EPs fail to grasp this nuance it will likely be costly.
“Because we are changing definitions, and this is what determines what hospital admissions are medically necessary, there could be challenges for EPs or hospital physicians in getting reimbursement,” Boyd adds.
Another code that doesn’t quite exist in the same way in ICD-10-CM is accidental poisoning by an unspecified drug.
“They do have the concept [in ICD-10-CM] … but you have to specify what class of drug is involved. If a 5-year-old plays in the medicine cabinet, uses all sorts of medicines, and you don’t know which one they ingested, you actually have to specify the class of drug in the coding system,” Boyd observes.
Ongoing physician education and guidance are going to be very important, according to Mark Mackey, MD, MBA, FACEP, a co-author of the analysis and vice chairman of the Department of Emergency Medicine at the University of Illinois Hospital and Health Sciences System in Chicago.
“A distal radius fracture could have 44 different descriptions [in ICD-10-CM] depending on what it is,” he advises. “There are going to be some situations that are frequent occurrences, and we will have to get feedback to the physicians so that they provide specificity within their final diagnoses.”
Mackey also sees some additional challenges for academic medical centers, where much of the documentation is done by residents.
“Some of those are emergency medicine residents who are doing this with some regularity on site, so they will get that feedback on how much specificity they need to provide, but some of them are rotating residents,” he explains, noting that keeping these physicians apprised of the specificity required in emergency medicine is going to require more effort.
Consider impact on workflow
Erik Kulstad, MD, a co-author of the analysis and a faculty attending physician at Advocate Christ Medical Center in Oak Lawn, IL, is hardly sanguine about the upcoming transition, predicting it will be a quagmire.
“It really does look like a major change to our workflow,” he says, noting complications will stem from the minute-to-minute charting that physicians do when they take care of patients. “It is really a very different thought process that has to occur and a different eventual charting process that has to happen.”
In particular, Kulstad is worried about all the detailed information EPs will be expected to supply that they simply do not have the ability to discern while patients are in the ED.
“We see a lot of chest pain patients coming into the ED, and all we can do is rule out a few bad things,” he says. “But with ICD-10-CM, we are supposed to [indicate] things like acute vs chronic, anatomically related due to coronary event, and specify by the artery, and we can’t do any of that. It is a system that has not been well-tailored to emergency medicine.”
Similarly, Kulstad says EPs are not in a position to supply all the required information with respect to stroke patients.
“The best we can do is say maybe [transient ischemic attack] because the patient hasn’t been in our care long enough to discern whether [it] is going to resolve or not and therefore meet the definition of TIA,” he says. “Maybe you can say ischemic vs hemorrhagic because that, again, is sort of a binary decision point that is determined in the ED, but beyond that we can’t discern any more.”
However, for charging purposes, the ICD-10-CM system will want physicians to indicate detailed information about what anatomical part of the brain is affected and what caused the stroke, Kulstad notes. “All of those things are not information that is obtained in the ED,” he says. “The net effect is going to be that we can chart only what we see and what we have, and that is going to be very limited. It is going to reduce the level of reimbursement that these charts obtain.”
Mackey expects at least some of this coding information will eventually be provided for patients who are admitted to the hospital.
“The inpatient folks will have another bite at the apple ... so if it is an inpatient case, then the information can be captured on the back end. If it involves a patient who is discharged, then that is going to be more challenging,” he says. “I think it is going to require some vigilance on both the ED staff and ED coding entities, and the revenue cycle people for the ED.”
Mackey anticipates the challenge of implementing the new coding system will be similar to what providers experienced in adopting electronic medical records.
“I think capturing more accurately and more robustly what we all manage every day is important, and there is potentially an upside … but I don’t think there is a good understanding of how this should be done in a way that minimizes the problems it presents,” he says. “I don’t think we all know what the ultimate effects are going to be.”
There are some easy concepts in the transition to ICD-10-CM. For example, the only change to the ICD-9-CM definition for ear infection is that you have to indicate whether the infected ear is on the right, left, bilateral, or unspecified, Boyd offers. Unfortunately, not all the codes transition quite so easily.
“When ICD-10-CM was first proposed, we all thought with more codes it was going to be better and that we could make better decisions,” Boyd notes. “But in the 27% of codes, or 23% of visits, the definitions are convoluted. The definitions from ICD-9-CM don’t just [require] more information, they actually take information and mix it together, and the concepts aren’t the same,” he explains.
For this reason, the quality of reporting from EDs to public health departments could be problematic, at least early on in the transition to the new coding system, Boyd advises.
“It is going to take a huge learning curve for both the professional coders as well as the physicians to understand what all the 80,000 new codes are,” he says. “As people learn, [the reporting] will become more stable, but for the first several months there could be significant variations in disease reporting, not necessarily because there is a disease outbreak, but because we are all in the process of learning the new codes.”
Learn the common codes
What steps can administrators and clinicians take to ensure a smoother transition to ICD-10-CM? First, the people who assign the individual codes need to get a handle on the new code set, Boyd advises.
“The professional coders, the physicians, and the nurse practitioners — anyone in your team who needs to use ICD-10-CM — needs to learn the common codes,” he says.
Next, staff, providers, and anyone who makes strategic decisions can take advantage of a free online tool, available at www.lussierlab.org/transition-to-ICD10CM, which visually shows just how complex the top codes are, Boyd explains. He observes the task is not as daunting as it could be. “When we look just generically across all the codes, the convolutedness or complexity is 36%, but when we look at only ED-specific codes, it is actually much less,” he says.
For the complex codes, Boyd suggests decision-makers consider why they are running specific reports that rely on codes, what they are trying to decide, and whether the reports in question make sense in the new coding system.
“If a report does not make sense, you might have to make decisions without the same level of information that you had before [the transition to ICD-10-CM],” he says.
For instance, it may make sense to base some decisions regarding staffing or supplies, for example, on historical data rather than diagnosis codes.
“Many of the large systems have whole teams [devoted to the ICD-10-CM transition],” Boyd observes. “What we are really concerned about are the smaller EDs and physician groups where clinicians may rotate around through multiple hospitals. They don’t have a huge, 100-person ICD-10-CM implementation team.”
Despite all the anticipated headaches and confusion, there are huge potential benefits from the new coding system, according to Boyd, although he acknowledges there will be a steep learning curve.
“You don’t just jump from 14,000 to 80,000 codes overnight and magically have the same fidelity,” he says. “However, in three to five years, when all of our decisions can be based on ICD-10-CM, we will be able to make better, more intelligent, and informed decisions. The challenge is that during the transition we just have to be very careful to be making appropriate decisions. We have to know what we don’t know.”
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Krive J, et al. The complexity and challenges of the International Classification of Diseases, Ninth Revision, Clinical Modification to International Classification of Diseases, 10th Revision, Clinical Modification transition in EDs. Am J Emerg Med 2015;33:713-718.
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Andrew Boyd, MD, Assistant Professor, Department of Biomedical and Health Information Sciences, College of Applied Health Sciences, University of Illinois, Chicago. E-mail: [email protected].
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Erik Kulstad, MD, Faculty Attending Physician, Advocate Christ Medical Center, Oak Lawn, IL. E-mail: [email protected].
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Mark Mackey, MD, MBA, FACEP, Vice Chairman, Department of Emergency Medicine, University of Illinois Hospital and Health Sciences System, Chicago. E-mail: [email protected].
