Getting the ED Ready for ICD-10
ED Coding Update
This quarterly column is written by Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates, Baton Rouge, LA.
The official countdown for ICD-10 implementation is well underway. However, as many hospitals are managing so many different issues, including EMR implementation, two-midnight rules, and revisions to observation documentation and billing, ICD-10 implementation and documentation improvement have yet to begin. Emergency medicine dodged the outpatient prospective payment system (OPPS) bullet that proposed to collapse the emergency medicine facility levels from five to one. Unfortunately, our friends in the clinics and outpatient areas weren't as lucky, and saw 10 levels (new and established) collapsed. Prioritizing issues for 2014 will be a daunting task with ICD-10 scheduled for implementation in October.
Coding professionals seem to have embraced this dramatic conversion well. As future coding certifications will depend on expertise in ICD-10, coders started with early learning on how to train for and implement this new system. Physicians, however, are still dependent on feedback to ramp up to this new coding system, and few health information management (HIM) departments are staffed appropriately to educate physicians and coding staff simultaneously, which guarantees a rocky implementation for this conversion.
There is, however, a quick fix that will address many of the ED diagnosis statements that will be used to determine the ICD-10 codes after October. As the ED manages many acute and chronic conditions with underlying problems, physicians may want to consider the following when developing the diagnosis statement:
- When patients are admitted, a sign and symptom diagnosis often results in a lower relative weight for the hospital diagnosis-related group (DRG), and this equates to lower reimbursement. Hospital inpatient coding guidelines allow the reporting of uncertain diagnoses if they remain uncertain at the time of discharge. Coders should review the health record for clinical indicators and assure that the provider addresses the "probable," "suspected," or "likely" cause of the symptom in the record to facilitate inpatient coding of the probable problem and avoid the symptom diagnosis for inpatient coding of the claim.
- ED physicians should address all underlying problems and chronic diseases that increase the risk of an adverse outcome. Unfortunately, not all conditions documented on the ED record can be reported when the claim is billed. The condition must be relevant to the current episode of care, so the health care performance index (HPI), review of systems (ROS), and ED course should reference any risk factors and/or underlying conditions that affect ED treatment. If the patient has a "history of" condition that is not relevant to the current visit, it cannot be coded. However, those conditions that are relevant should be identified.
- When Medicare patients are admitted following an ED visit, the newly established "two-midnight" rule will apply. Although the admitting physician's documentation will be used to support the need for admission, if the patient is discharged prior to two midnights, the ED documentation of the patient's condition throughout the ED course can be used to establish the need for admission. With ICD-10, this information is used to bill the physician claim. However, the same information will be used to designate the DRG for the inpatient admission. Thus, the more information on the record to support the need for the ED service as well as the subsequent admission, the more likely the hospital will be paid regardless of the discharge before two midnights.
- Medical necessity is the new frontier with many unknowns. Many payers use extremely subjective criteria to deny payment if the final diagnosis does not support medical necessity for the evaluation and management level to be billed. When this occurs, the physician and/or hospital should refute the findings with a copy of a well-documented record to support medical necessity for the visit. Medical necessity may be supported by signs and symptoms in the medical record as recorded in the HPI and ROS. It may be further supported by a detailed description of the ED course illustrating the steps taken to resolve the problem. Signs and symptoms are important for establishing medical necessity even though they may not contribute to the final diagnosis. Therefore, when the chart is sent to the payer for reconsideration of the charge, the documentation should be there to support the entire service.
- By way of definition, a "sign" is objective evidence of a disease that the examining physician can observe; a "symptom" is a subjective observation that the patient reports but that the physician does not objectively confirm. Both contribute to the medical necessity of treatment if corroborated by the actions taken during the ED course or the physician discussion of their effect on treatment during the visit.
- Not otherwise specified (NOS), not elsewhere classified (NEC), and unspecified diagnoses can still be coded under ICD-10 just as they were with ICD-9; however, the use of these terms in ICD-10 is limited. They present a challenge to correct coding and may result in records being held for additional clarification. Any ICD-9 code that ends with a "9" indicates a non-specified diagnosis and offers an opportunity to further educate physicians about adding specificity where possible. For example, with the ICD-9 code 402.9 hypertensive heart disease unspecified, a fifth digit is required to differentiate the heart disease as either without heart failure (ICD-9 402.90) or with heart failure (ICD-9 402.91). These crosswalk to ICD-10 codes specified as either with heart failure or without heart failure, but would not be considered "unspecified" under ICD-10 coding rules. Further, if classified as hypertension with heart failure, ICD-10 requires additional coding of the specific type of heart failure, requiring additional detail from the emergency physician.
This all sounds confusing, but the take-away for documentation improvement is to provide as much detail and clarification as is known at the time of service to help support medical necessity and facilitate correct coding with the ICD-10 rules.