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ICD-10 PCS - We Don't Know What We Don't Know

June 19, 2015
by Dr. Jon Elion, M.D., founder and CEO of ChartWise Medical Systems
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Jonathan Elion, M.D.

After decades of experience with ICD-9, we have learned and come to grips with its quirks. We do not yet have that comfort level with ICD-10—after all, it’s still pretty new to most of us in the U.S. I’m not really concerned about the diagnosis side of ICD-10 and its clinical modification, ICD-10-CM. But what does concern me is ICD-10-PCS (procedure coding system). So far, we don’t have a good idea of how this is going to impact reimbursement, and what documentation requirements are really going to be needed. We really don’t know what we don’t know.

ICD-10-PCS coding demands a new level of documentation and coding specificity. There are few procedure codes in ICD-10 that will allow nonspecific or “not otherwise specified” codes, as are allowed in ICD-9. In the ICD-9 coding environment, it is still possible to generate a code and get reimbursed even with minimal specificity. But under ICD-10, if specificity is lacking, there may not be a procedure code that can be used, and the reimbursement will therefore suffer.

Let’s look at “lysis of adhesions” to see how this applies. If a surgeon performs a laparoscopic procedure to free up something in the abdomen that’s trapped in scar tissue and the operative note concludes that the patient performed a “laparoscopic lysis of adhesions in the peritoneum,” that would be enough information to use ICD-9 code 54.51. But there is no direct equivalent for this in ICD-10, no code that is as vague as the one in ICD-9. Instead, the surgeon needs to describe exactly what organ or organs were “released” or freed up during the procedure. If it was a loop of small bowel caught up in adhesions, then the appropriate ICD-10 code would 0DN84ZZ (release small intestine, percutaneous endoscopic approach). It would require specific mention of the small bowel in order to be coded.

So where does the problem or uncertainty come into play with this? Well, let’s suppose (as is likely to happen) that the surgeon writes his or her usual comprehensive operative note that describes the procedure that includes a description of the dissection that was done around the small intestine. But the note itself simply states in the closing summary that the operation was a “laparoscopic lysis of adhesions in the peritoneum.” Can the coder use the description of the dissection around the small bowl to go ahead and code 0DN84ZZ? This seems to still be open to interpretation, and the last thing coding managers want as we prepare to enter the ICD-10 era is uncertainty.

As I have traveled around the country speaking with various professional groups including national and local AHIMA chapters, ACDIS chapters and coding societies, the opinions on this subject vary. Many boldly state that they would be comfortable coding from this scenario, while others want the physician to be responsible for stating the details explicitly.

Where does this leave the clinical documentation specialist? Will they be left with the responsibility for creating and managing the thousands and thousands of queries that are going to be needed to get the necessary clarification from the surgeons?

We don’t yet know.

Dr. Jonathan Elion, M.D., FACC, is a practicing board-certified cardiologist in Providence, RI and an Associate Professor of Medicine at Brown University. With over 40 years of experience in computing and more than 25 years of experience in medical computing and information standards, Dr. Elion has committed his career to innovations in high value services and healthcare delivery to maximize efficiency and cost effectiveness.  Jon is the founder of ChartWise Medical Systems, Inc., a Rhode Island based company that recently introduced ChartWise 2.0, an interactive software system designed to improve precision in quality clinical documentation and to support revenue assurance.