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ICD-10: Time to Change the Conversation

September 25, 2015
by Robert Hitchcock, M.D.
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Robert Hitchcock, M.D.

ICD-10 has been a coding conversation. I think it needs to be a documentation conversation.

With less than a week until the long awaited—and for many, feared—deadline to ICD-10, reactions are at fever pitch. But as we enter the final days of preparation, have we asked all the right questions? Is ICD-10 really, as they say, a coding issue? 

Coders can only code what’s been documented; it’s as simple as that. If physicians don’t document the appropriate amount of specificity during the patient encounter, it will not be possible for the coder to arrive at an accurate ICD-10 code no matter how prepared the coder may be for ICD-10. The right documentation strategy for ICD-10 is critical. And if an effective documentation strategy is not in place, all of the preparation on the coding side will be rendered futile.

The Reality of Documentation for ICD-10

The physician’s role in the ICD-10 transition has certainly been acknowledged, based on the amount of physician training resources I’ve seen out there. But is training really the answer? The new set of codes is extremely complex, requiring extensive and detailed documentation to derive specified codes. Asking physicians to remember all of those details while in the midst of providing clinical care is not reasonable, nor quite frankly likely to happen.

This issue becomes particularly significant in specialty care settings. A recent study published by the American Journal of Emergency Medicine (AJEM)[1] reported that specialty care settings, such as pediatrics, obstetrics and gynecology, and the emergency department will have mapping challenges from ICD-9 to ICD-10 due to the dramatic increase in codes and specificity required by ICD-10. The study found that particularly for the emergency department, the challenges in mapping ICD-9 to ICD-10 codes are significant and have the potential to negatively affect both clinical workflow and finances.

As an ER physician, am I really going to remember exactly what I need to document patients presenting with everything from orthopedic issues to trauma to the flu?  Doubtful. As we transition to ICD-10, the complexities behind each code become substantially more complex, an overwhelming issue for specialty care settings like the emergency department.

Looking Into the Crystal Ball

I imagine that post ICD-10 implementation life for many facilities could look like this:  

A hospital provides extensive ICD-10 training to both clinicians and coders. Their EHR has an embedded code pick list where physicians can select from a list of ICD-10 diagnosis codes. A physician sees a patient with a radius fracture and goes to the pick list, which generates over 1,000 possible codes. The physician selects a code and locks the chart. The coder receives the chart, but the documentation to support the diagnosis is missing. Several days later when the physician is back on duty, the coder then runs through the hallways of the ER trying to track down the physician—who’s seen an additional 25 patients in the meantime—to get a clear picture of the patient encounter. If all goes well, the physician recalls the details of the encounter and updates the visit documentation. Use of resources, efficiency and productivity are all compromised.

Rethinking Documentation as the Key to ICD-10 Success

The good news is by reframing the view of a successful ICD-10 workflow to start with documentation at the point of care instead of coding, the panic can and should begin to wane. It’s important to consider how a physician documents care in the moment, and to ensure that ICD-10 will not result in any major disruption to the clinical encounter or the revenue cycle.

Start by considering the role your documentation solution will play during the patient encounter for the physician. Is it truly ICD-10 ready? That is, does the clinical content within the system guide clinicians to the required amount of specificity? Does the system visually cue clinicians to the necessary documentation for ICD-10 within their current workflow?  

The answers to these questions should be unequivocally yes and if they aren’t, challenge your EHR vendor for a better solution. An EHR should take the work out of ICD-10 with updated and appropriate clinical content and terminology within the system, not just long pick lists. This will result in the right ICD-10 code with no disruption to the workflow, allowing doctors and nurses alike to see more patients.

Don’t put the burden of ICD-10 on expensive and often overwhelmed resources—your clinicians. The right health IT partner can and should carry the burden of providing robust documentation solutions. While the crystal ball is currently blurred, it’s time to get to a place of clarity on what’s needed to achieve a seamless transition from one coding set to the next.

Robert Hitchcock, M.D., is CMIO, VP and GM of Physician Solutions at Dallas, Texas-based T-System. He is a nationally recognized meaningful use expert and active member of the HIMSS Physician Committee and other HIMSS subcommittees advocating usability and responding to regulatory issues..