A WHITEPAPER ON CLINICAL DOCUMENTATION- ICD 10 - In nx Subject Matter Expertise Team - Dipti Bhide & Anju Krishna
ICD 10 Impact Assessment Documentation Transformation An In nx Point of View For today's rapidly changing environment, one of the biggest challenges Radiology practices face is to effectively manage the ICD 9 to ICD 10 transition. It means signi cantly changing the approach, processes & rules of the entire service delivery models in an effort to align to the changed coding dynamics. It does not merely mean a coding system change from the 3 to 5 digit coding of ICD 9 to the 5 to 7 digit ICD 10 coding. Quick View of ICD 10 Transition Change Drivers Coding Methodology will change Clinical Documentation will need speci city Claims & Billing will need to adapt Denial due to coding will need to be resolved differently Billing systems will need modi cation The central force behind the entire transformation is to take a relatively generic communication of treatment / procedures / diagnostics performed to a very speci c, detail oriented communication of events. This aim of speci city is certainly valid given the way it will enable providers to give complete information to Payors for proving aspects such as medical necessity, a dominant denial reason due to lack of suf cient information. From this perspective, the biggest change that organizations need to focus on, apart from highly skilled ICD 10 coders, is to ensure clinical documentation needed to support the coding. Clinical Documentation Transformation in view of ICD 10 In simple terms, this translates to the need for radiology practices to get radiologist to record complete incidence information in the patient le at the time of testing. Complete information includes speci c details of the patient's condition, history as well as details of the test performed. However, this change is more complex within each modality, for each test type, ICD 10 has classi ed codes by certain typical conditions. Radiologists need to align their documentation to these speci c conditions to ensure the medical coder has relevant information at hand during coding. Document orientation of radiologists to document better and deeper. For real ef ciency, it will be critical to educate them to provide speci cally required information for each patient incidence. 1
Following cases discuss the envisioned documentation impact and correlated documentation rules in the view of ICD 10 vis-a-viz ICD 9 coding methodologies. Case I Cerebral Artery Occlusion Patient with a middle cerebral artery occlusion is examined by the ER Physician who orders a CTA brain scan. The radiologist has con rmed after the CTA that a middle cerebral artery occlusion exists. He has accordingly recorded the same in the patient le, which the medical coder will refer to. In case of the current ICD 9 coding methodology the coder will be able to identify the correct code which is 433.11 - Occlusion and stenosis of carotid artery with cerebral infarction. In case of ICD 10 coding methodology, which is substantially more complex the provided input is insuf cient. Based on the current information the claim submitted may get rejected on grounds of incomplete information or even lack of medical necessity. For correct ICD 10 coding the radiologist needs to ensure the following additional information is recorded in the patient le for the coder's reference. First he needs to document laterality so the coder will know whether it is RT or LT. The ICD 10 code will change based on laterality. Next the radiologists needs to record the site of the artery involved whether it is anterior, posterior or middle cerebral artery along with type of artery whether cerebral, cerebellar, carotid, precerebral, basilar or vertebral artery. Another complexity can occur if the medical coder is unaware of the exact anatomical site where infarction has occurred, in which case he will have to proceed with unspeci ed code resulting in denials. Further, if the same patient has been encountered with recurrent infarction, there needs to be de nite documentation stating the same otherwise the coder cannot differentiate whether it occurred in same site or in a different site. The resultant unspeci ed code cannot be billed twice for same condition as it may lead to denial. Finally if a doctor has previously performed an angioplasty or thrombolysis procedure for the patient's left side middle cerebral artery occlusion and the same problem has now occurred to this patient's right side it needs to be recorded so it can be coded accordingly. Unspeci ed code is provided during both encounters, this time (second encounter) the claim will be denied as it will appear the procedure is being performed twice and has been paid for by the payor/payer previously. ICD 10 will thus require complete and accurate documentation of all the above speci cs. Only on successful documentation of all relevant information will the medical coder be able to assign the correct code with all relevant combination of circumstances for accurate billing and claims. 2
Case II Breast Ultrasound During Pregnancy In this case an OB physician has ordered an ultrasound breast for breast abscess for assessing complications in pregnancy of the patient. In ICD 9 coding methodology the radiologist needed to have provided which episode of care delivered, ante-partum, post partum. ICD 10 coding methodology mandates requirement of speci c trimester so the radiologist conducting the ultrasound should document the weeks of gestation, in this case 15 weeks (second trimester). Accordingly the coder can code the ultrasound exam as conducted in the second trimester. Case III Fracture In this case the patient has come in for an X Ray for a bimalleolar fracture of right lower leg which is a displaced fracture. Firstly, the radiologist will have to specify the encounter type whether initial, subsequent or sequela. A record stating the same would have been suf cient for ICD 9 coding methodology which would simply explain the site of the fracture and specify whether it was open or closed in nature. But ICD 10 coding methodology will require substantially more speci cs. Further, he will need to specify, in case of subsequent encounter whether the fracture has healed within the routine expected time period or whether it is a case of delayed healing. Each situation will need a different code. Finally, a non-union fracture or mal-union healing will need to be speci ed for a separate coding rule. Impact of improper documentation in view of ICD 10 It is critical to discuss the impact of incomplete documentation, which will lead to incorrect coding and resultant claim de nials by Payers. A resolution of such a denial leads to a complicated process of correction and addendum to the documentation. Claim is denied due to coding reasons The denial management team will identify it as deined to due to coding issue Then they will send to coding denial team Coding denial team will give appropriate comments and send to They will then communicate the same to the radiology practice/clinical A radiologist (sometimes the same one who conducted the exam) will retrieve the relevant images and patient He will then fill in the information gaps with an addendum to the records. The changed file will again be sent to Coding denial team for Coding team will give appropriate codes and send to Denial management team After coding, the claim will be re-submitted to If documentation is complete, it can be accepted and paid by the 3
As tedious as this process is, it is made even more so by the very nature of fragmented operations in today's radiology business model. There are multiple teams, in-house and outsourced handling various aspects of revenue cycle management. So a case of denial may need to go to multiple vendors and teams before it can be resolved. This is not only costly in terms of manpower and resources, it potentially threatens the feasibility of a resolution because of the sheer amount of time taken, which can surpass the ling limit. This is especially crucial in the case of worker's compensation and private payers who can have an average ling limit of 30 to 90 days. It is thus, very critical that an organization commits to rigorous preparation of clinical documentation during the ICD 10 transition phase by means of a complete process & knowledge overhaul. Solution Approach For addressing this challenge, it is critical that every Radiology group develops speci c and indepth guidelines for clinical documentation for the modalities and types of tests they conduct. It is also important to change the perspective & learned habits of radiologists to ensure that they speedily change their documentation protocols to accommodate for the additional information. Finally, as an organization, it is critical that every person involved in the work ow from the radiologists, the medical coding team, the AR follow up team and the front end teams align to the new documentation protocols. A well thought out, systematic and conscious approach is necessary for effective transition. Being an experienced medical coding & end to end RCM process management company in the Radiology segment, In nx has developed an effective methodology to address this clinical documentation improvement challenge. The In nx Methodology Radiology Speci c Impact Assessment In nx Knowledge on changed documentation for each modality & test Comparative analysis ICD 9 & ICD 10 requirements to identify clear information gaps Trend analysis to identify widely used, common, high value & complex code areas with the practice patient base Development of documentation guidelines speci c to each code area for ICD 10 readiness Radiology Group Speci c 6 Corrective & Insight support during transition to hand hold and incrementally improve clinical documentation practices Transition Support Identi cation of error patterns & resultant AR issues for active monitoring of gaps & focused resolution recommendations 4
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