ICD-10 means better documentation is a must

Clock is ticking to implementation

After a series of delays, the U. S. Department of Health and Human Services has set Oct. 1, 2014, as the firm date for implementation of the ICD-10 procedure and diagnostic coding set.

The implementation has been delayed several times in the past, but that's not likely to happen again, says Deborah Hale, CCS, CCDS, president and chief executive officer of Administrative Consultant Service, a healthcare consulting firm based in Shawnee, OK.

Unlike many other healthcare requirements, there's no grace period for the use of ICD-10, Hale points out. All claims submitted to any payer, Medicare, Medicaid, or commercial insurance on or after Oct. 1, 2014, for services provided in all healthcare settings, must use the ICD-10 codes for medical diagnoses and inpatient procedures. Otherwise, the claims may be rejected and providers will have to resubmit them using the ICD-10 codes, she says.

While ICD-9 uses five-digit numeric codes, ICD-10 is a seven-digit alpha-numeric coding system. The expanded fields make it possible to track much more detailed information about the patient's condition.

"The primary difference in ICD-9 and ICD-10 is the specificity of the documentation required," says Kristen Lilly, RHIA, CPHQ, MHA, consulting manager, clinical advisor services for Pershing, Yoakley & Associates in Atlanta. "For instance, in the ICD-9 code set, a diagnosis of a broken foot can be coded as 'closed fracture of metatarsal bone(s).'" ICD-10 documentation is required to specify which foot and which bones.

"There's a snowball effect because better documentation not only leads to greater specificity when coding but also has a positive impact to core measures reporting and quality measures such as value-based purchasing and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Improved specificity in documentation should lead to more accurate and thorough diagnoses and better outcomes," Lilly says.

When hospitals begin using ICD-10, establishing medical necessity will be much easier because the documentation must be so specific, adds Joanna Malcolm, RN, CCM, BSN, consulting manager, clinical advisory services for Pershing, Yoakley & Associates in Atlanta.

Hospitals already should be assessing the impact of ICD-10 implementation throughout the organization, Lilly says. Conduct a gap analysis to see where the potential problems lie, she suggests.

Malcolm recommends that case management directors work closely with their hospital's information technology department to make sure the case management software can accommodate the changes. She suggests meeting at least monthly with information technology and coding representatives to look for deficits in the technology case managers use.

"ICD-9 codes are used in all the reports that case management directors use every day, such as quality indicators and core measures compliance. Case management software has to be updated to accept the expanded fields and to interface with all of the other information technology that uses ICD-10 codes," Malcolm adds.

Case management directors should be part of the overall ICD-10 team at their hospitals, Malcolm says. "They don't necessarily need to serve on the steering committee, but they should be part of the team. Case managers won't drive the changes, but they are going to be impacted by the changes and they should have a seat at the table when the hospital's strategy is discussed," she says.

Case managers might not need formal training on the specific codes, but they do need to understand the level of documentation specificity required by the new coding system, Malcolm adds. "Case managers need to understand the impact of ICD-10 and how specific the information needs to be so they can work with the physician team to make sure the documentation is what is needed for the hospital to get paid," she says.


Joanna Malcolm, RN, CCM, BSN, Senior Consultant, Pershing, Yoakley & Associates, Atlanta. email: JMalcolm@pyapc.com