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ICD-10, Meaningful Use, and AHIMA

October 1, 2011
by Joe Bormel
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How do they all fit together?












ICD-10, Meaningful Use and AHIMA – How do they all fit together?

The 83rd annual convention of AHIMA is getting underway as I write this, and with it HIM is at the center of the biggest regulatory reforms in most of our careers, ARRA/MU and ICD-10. At this event, new and evolving approaches to coder’s workflow in the MU era, provenance standards, documentation methodologies incorporating natural language processing (NLP), Computer-Assisted-Coding (CAC), Quality Reporting, and related services like Clinical Documentation Improvement (CDI) will be discussed. In many ways, it all gets down to billing and clinical codes. So I thought this would be a good time to take a look at the challenges and issues.

Quality healthcare through quality information?
Physician, policy advocate and certified coder, Dr. Mike Stearns was recently describing the distinction between billing codes and clinical codes. Billing codes are intended to get you into the neighborhood of the specific condition, explains Stearns. The clinical codes are needed for care, quality reporting, identifying appropriate order sets, and creating adequate clarity for medication management and reconciliation.

It will come as no surprise to readers of Healthcare Informatics or this blog that billing codes and clinical codes are fundamentally different. But the temptation to use them interchangeably can be overwhelming. When they don’t overlap, which is often, problems arise. No group of people understands this challenge better than the Health Information Management professionals who have been managing our medical records.

Billing and Clinical Coding
Let’s take a look at diagnosis billing codes, most commonly synonymous with ICD-9 and soon, ICD-10. The other billing codes are the procedure codes; there are several families of these, CPT-4 being the most recognizable set in the US. The simple, bottom line is that those codes are intended to describe the “neighborhood” of a clinical problem, not a specific, clinically accurate diagnosis. Your could think of a clinically accurate diagnosis as a “driveway within the general neighborhood of the diagnosis billing code.”

ICD-10 helps build on ICD-9 by creating more and smaller neighborhood definitions, and are often more anatomically and physiologically specific. That said, even in ICD-10, the notion of accuracy is still a bit schizophrenic in the lay, two-headed sense of the word. Accurate for billing is not the same as accurate for clinical care. When there are two or more possible billing codes, the one that a payer will reimburse will be used, even when another billing code might be a closer depiction of the clinically accurate situation.

One recent example of this comes from a real ENT physician who diagnosed jaw pain coming from the TMJ (the joint between the jaw bone and the skull bone, just beneath and in front of the ear). In order to get the clinical encounter “covered” or reimbursed, he had the give a billing diagnosis of pain coming from the ear. His clinical diagnosis was clearly something very different, pain coming from a boney joint. The ear pain was the neighborhood in this analogy; the TMJ syndrome pain was the specific clinical “driveway within that neighborhood.” But as you can see, that ear pain “driveway” was in a different neighborhood on a nearby street.

Those kinds of inaccuracies are a deliberate consequence of how we pay for and account for care, versus how we classify the clinical condition for diagnostic and therapeutic purposes. This “accuracy for different purposes” dichotomy is well understood and accepted as common by both HIM professionals and clinicians.

When clinicians select codes
When a patient presents to a clinician in a care delivery organization, there ends up being a clinician who declares the clinical diagnostic, as well as billing codes to describe that encounter. That declaration process in the age of EHRs and Meaningful Use is not simple. In addition to impacting reimbursement from payers as it always has, even in the paper world, the declaration has a broader impact. Specifically, quality measures and workflow are directly impacted; the former is required for MU attestation, the latter for clinical adoption.

The relationship of accuracy on Meaningful Use and Adoption
From an accuracy and simply a data perspective, the clinical codes now need to populate an Up-to-Date Problem List (required by MU in Stage One). From a broader MU perspective, these codes also take part in MU quality reporting. Hopefully, it’s obvious that clinical accuracy is far more important than billing accuracy for patient safety. That said, it can be expedient, albeit risky, to use billing codes, even when they are clinically not accurate. And making it easy, fast, and straight-forward for clinicians to even enter or pick an accurate clinical code is often hard or impossible.

Enter Innovation?
Here’s where HIM innovations to be discussed at AHIMA get interesting. There has been increasing interest in using the clinician’s free-text narrative as the primary source of capturing the accurate clinical code, as well as the defensibly accurate and neighborhood-to-driveway accurate billing code. This often involves a combination of voice-recognition, NLP, CAC, and related services CDI, support and real-time compliance adjudication.




Thanks for an interesting post, Dr Joe. I am an RHIT, CCS, and AHIMA Approved ICD10CM/PCS Trainer. What you said is exactly correct for inpatient coding. I've elaborated this in formal language below. The key is that codes correspond "most closely" with the established diagnosis.

[From the CMS 2011 guidelines of ICD9 and 10]
... the ICD9CM diagnosis codes effective 10/1/2011 and for the ICD10CM diagnosis codes 2011 draft: On page 90 of the ICD9CM under section II is the rule for uncertain PDX. I am sure that you will find the other sections as interesting. These guidelines are also for ICD10CM.

Section II. Selection of Principal Diagnosis

The circumstances of inpatient admission always govern the ion of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."

The UHDDS definitions are used by hospitals to report inpatient data elements in a standardized manner. These data elements and their definitions can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp. 31038-40.

Since that time the application of the UHDDS definitions has been expanded to include all non-outpatient settings (acute care, short term, long term care and psychiatric hospitals home health agencies rehab facilities nursing homes, etc).

In determining principal diagnosis the coding conventions in the ICD-9-CM, Volumes I and II take precedence over these official coding guidelines.
(See Section I.A., Conventions for the ICD-9-CM)

On 90:

H. Uncertain Diagnosis

If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

For outpt hospital care and physician reporting we the code based on the highest degree of certainty at the time which can be a definitive diagnosis or it may take more than one visit to have a definitive diagnosis.

Word to use hint...since classification codes (aka administrative code sets) were around long before billing use, we use the term "reporting" (hospital, local, state and national stats, World Health Organization morbidity/mortality stats, research, etc.). Meaningful use and quality reporting think reporting.

Hope this helps. There is much to know!

Thanks IA for your kind words and insights from CMS / UHDSS defintions.

One thing is abundantly clear from the AHIMA meeting so far. The revenue dollars at risk and related attestations dwarf the the MU dollars by one or two orders of magnitude. More on this in my follow-up AHIMA blog post, currently under construction.