Helping Physicians Succeed in an ICD

WHITE PAPE R
Helping Physicians Succeed
in an ICD-10 World
By Tom Ormondroyd, Vice President and General Manager, Precyse Learning Solutions
Bruce Scott, MD, Practicing Physician/Surgeon and Precyse ICD-10 Physician Consultant
Christian Oliver, Associate Vice President, Catalog and Courseware, HealthStream
HELPING PHYSICIANS SUCCEED IN AN ICD-10 WORLD
White Paper
EXECUTIVE SUMMARY
As the healthcare industry draws closer to the golive date, ICD-10 remains a polarizing topic among
healthcare professionals. While some healthcare
organizations are actively preparing for a strategic
rollout, others are, more or less, bracing for impact.
In April 2012, the Centers for Medicaid & Medicare
Services (CMS) extended the ICD-10 (the
International Classification of Diseases, tenth
revision) implementation deadline to October 1,
2014 at the request of some physicians, hospitals, and
other industry stakeholders. Since then, the
American Medical Association (AMA), in partnership
with other groups, has urged CMS to eliminate ICD10 implementation altogether due to the significant
administrative and financial burden it imposes on
physicians (Linder, 2012). There is no sign this will
happen, however, or indication of any further
postponement. In fact, the acting CMS Administrator,
Marilyn Tavenner, has recently stated, “Many in the
health industry are under way with the necessary
system changes to transition from ICD-9 to ICD-10.
Halting this progress midstream would be costly,
burdensome, and would eliminate the impending
benefits of these investments.” (Fiegl, 2013)
There are many differing opinions concerning the
transition to ICD-10. But, in reality, ICD-10 is
necessary to all levels of a technologically progressive
healthcare system. Given the magnitude of change
happening in the U.S. healthcare delivery system,
ICD-10 is a natural and necessary advancement that
will address the critical gaps and operating flaws
inherent in ICD-9, which was developed over 30
years ago. Since then, healthcare science and
technology have greatly advanced, making ICD-9
inadequate to deal with the to deal with the advances
in healthcare. Moreover, the content of the ICD-9
Clinical Modification (CM) was not designed to be
used as a data system for disease management, nor
was it intended to support reimbursement of medical
services. ICD-9 is an antiquated classification that has
a puzzling mixture of code descriptions—some very
specific, and others that are so broad they fail to
even identify the site of the disorder. Today, we have
a system that does not always fully capture the
severity of our patients’ illnesses, which prevents
physicians from receiving full credit for the care
performed in quality reporting.
To be sure, implementing ICD-10 is a major
undertaking for all healthcare professionals, who are
faced with many other challenges, including meeting
the requirements of Meaningful Use legislation. ICD10 compels greater specificity in documentation
practices; it also involves a new coding classification
system and an increase from 17,000 to more than
140,000 codes (Minich-Pourshadi, 2012).
It is estimated that ICD-10 implementation costs will
range between $83,000 and $2.7 million, depending
on the healthcare organization or physician practice
size, according to the AMA (Fiegl, 2012). The Advisory
Board Company calculates that the three-year
incremental impact of ICD-10 could range from $2.5
to $7.1 million for a typical 250-bed hospital, with
coder productivity decreasing by close to 20% and
physician productivity taking a 10% to 20% hit due to
significant increases in queries (Alex et al., 2011).
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CLINICAL ROOTS:
HOW PHYSICIANS SHAPED ICD-10
Dispelling myths that exist about ICD-10 is vital to
ensure physician buy-in. ICD-10 is not something
physicians are ‘jumping up and down about,’ especially
with so many competing priorities. However, it is key
that they know its origins, purpose, and how
physicians were deeply involved in shaping the new
system to serve not only the reimbursement need,
but also to provide a clinical tool to drive improvement
in care data, reporting, and analysis.
The biggest myth about ICD-10 that must be
dispelled is that it was built solely as a payment
system. In fact, ICD-10 is built on a foundation of
medical science and technology, not as a
reimbursement system. American physicians and
major healthcare organizations worked with the
World Health Organization (WHO) to develop the
advances in ICD-10 and to make it far more clinically
relevant than the current ICD-9 system. The United
States further modified ICD-10 over a 10-year period
to customize it for use in the United States, with key
contributions from a Technical Advisory Panel that
included practicing physicians and clinicians and
“extensive additional consultation with physicians
groups, clinical coders, and others to assure clinical
accuracy and utility,” according to the Centers for
Disease Control and Prevention (CDC, 2013).
Improving clinical information and care is at the heart
of the new system, and many physicians were
involved in its creation. While there is a great
expansion of the numbers of codes available, ICD-10
is logically organized and based upon a limited
number of core concepts.
The United States is one of the few developed nations that
still has not transitioned to the ICD-10 system.
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WHY PHYSICIANS SHOULD CARE
ABOUT ICD-10
Another related myth regarding ICD-10 is that it is
only about hospital reimbursement. To the contrary,
ICD-10 will affect every aspect of the physician’s
practice, including patient encounters, clinical and
financial workflow, and depending on circumstances,
compensation and reimbursement, as well as future
career opportunities. All physician groups will be
touched by ICD-10, including surgeons, hospitalists,
and physicians in ambulatory settings.
From a high-level perspective, ICD-10 will generate
more detailed healthcare data and a greater flow of
specific and viable data that improve medical
communication, which could contribute to advanced
disease protocols and clinical pathways. ICD-10 is
more reflective of the scientific advances that have
occurred in medicine in the last 30 years. The code
descriptions better describe the gravity of a patient’s
illness, which in turn will facilitate validation of a
patient’s condition in support of utilization of goods,
services, and complex procedures. On a more
individual level, ICD-10 will help physicians create an
electronic trail of evidence to receive proper credit
and payment for the high quality of care they provide.
ICD-10 will also help physicians address big
technology and healthcare reform initiatives that will
impact care delivery and financing, including CMS’
Value-Based Purchasing, Pay for Performance
programs (P4P), and coordinated care models such
as Accountable Care Organizations (ACOs) and
Patient-Centered Medical Homes (PCMHs).
Additionally, the government’s Physician Quality
Reporting System (PQRS), which has the potential to
negatively affect physician payments in 2015, along
with the move toward adoption of an electronic
health record (EHR), makes it even more critical to
be ICD-10 ready (CMS, 2013).
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Advancing from ICD-9 to ICD-10 provides crucial
public health and disease surveillance organizations,
like the CDC, with greatly improved data to handle
epidemics such as the swine flu. All of the statistics
about such outbreaks are currently derived from
ICD-9 data, which is basically out of room to add
new diseases and lacks the ability to connect disease
manifestations as optimally as ICD-10. ICD-10 will
continue this work, but will offer many more levels of
data, which will help the CDC, the government,
physicians, hospitals, and insurers to identify broader
trends, prepare for growing health problems, and
view how treatments are working. For instance,
during the outbreaks of the West Nile virus, severe
acute respiratory syndrome (SARS), and the first
anthrax incident, ICD-9 did not have the codes to
describe these events, leading to an inability to
report on current numbers and trends. Remember,
any time you see the news displaying the number of
cases of the flu or the increase in the diagnosis of
diabetes, these numbers often are a direct result of
ICD-9 reporting. Incorrect information derived from
inexact data potentially leads to wrong conclusions
and response.
ICD-10 also feeds current scientific healthcare data
for epidemiological research and population health
management (Grant, 2011). Over time, ICD-10 data
will provide more information on disease progression
and treatment efficacy. ICD-10 codes have the
potential to yield more information about the quality
of care. As a result, this improved data stream will
support better understanding of complications,
better design of clinically robust algorithms, and
improve tracking of patient outcomes.
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I C D -10 DATA W I L L B E N E F I T P H Y S I C I A N S
Physicians have reason to question the timing and
value of ICD-10 as they have many competing
priorities due to a multitude of regulatory, technology,
and industry changes facing them all at the same
time. Many see ICD-10 as ‘salt in the wound.’
However, ICD-10 does offer potential value to
physicians if leveraged and utilized correctly.
Physicians who take decisive steps to fully integrate,
ICD-10 into their clinical practice stand to benefit in
several ways.
So, yes, ICD-10 implementation is an investment in
time, but it presents physicians with five benefits that
have the potential to be major game changers. ICD10 could help physicians:
Some hospital systems with employed physicians
have been offering compensation plans based on
performance for several years. For example,
Geisinger Health System in Danville, PA has a payfor-performance (P4P) program that bases 40% of
incentive payments on quality goals (CheungLarivee, 2012). The New York City Health and
Hospitals Corporation recently announced that
more than 3,500 employee physicians will receive
bonus payments tied to meeting quality measures,
such as lower readmission rates (Caramenico, 2013).
With the arrival of ICD-10, quality incentives are in
jeopardy if the physician does not document to the
level needed to attain the correct and more specific
code selection. This is because the code is a
reflection of how severely ill that patient was, and a
sub-optimal code in ICD-10 will not provide support
on why a certain amount of care was needed.
1.Grow compensation and reimbursement. ICD-9
codes were not originally developed with
reimbursement in mind. ICD-10, however, offers a
more decisive system to determine payments by
offering greater detail on the quality of the care
provided. In turn, government payers, insurers,
hospitals, health systems, medical groups and
others will use ICD-10’s granular data to determine
accurate and fair physician compensation and
reimbursement for goods and services.
ICD-10 PHYSICIAN FAST FACTS
• ICD-10 will be mandated for use on
October 1, 2014.
• ICD-10 impacts more than 50 populations,
including physicians, healthcare executives,
coders, case managers, nurses, and
administrative staff.
• ICD-10 has more than 140,000 codes
compared to only 17,000 ICD-9 codes.
• Physicians typically will require three to 12
hours of training.
• The transition to ICD-10 requires a
significant investment in technology,
including new software and practice system
upgrades.
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On the other hand, it is important to note that ICD-10 does not require a
change in how physicians practice medicine or treat patients. Rather, it demands
more accurate documentation and gives physicians more diagnostic choices to
capture new data to ensure they are paid for the complex work they perform.
Under the government’s Value-Based-Purchasing
program, physicians who do not provide precise
documentation (e.g., laterality, specificity, anatomic
site, etc.) to support the specificity of ICD-10 will
experience reduced payments. On the other hand,
it is important to note that ICD-10 does not require
a change in how physicians practice medicine or
treat patients. Rather, it demands more accurate
documentation and gives physicians more diagnostic
choices to capture new data to ensure they are
paid for the complex work they perform.
Another example is documentation and payment
on new and cutting-edge procedures. New
procedures are problematic for coding purposes.
In both CPT and Volume 3 of ICD-9, they are
often given an unlisted procedure or an unspecified
code. With ICD-10-PCS (Procedure Coding
System), which will be used for inpatient
procedures, the codes are going to be created
based on the surgeon’s documentation in the
operative report. The code will be built based on
the type of surgery, body system, root operation,
body part, approach, device, and any qualifiers that
the surgeon includes in the documentation. So, for
inpatient procedures, there are no limitations in
code selection because ICD-10-PCS codes
accurately reflect the goal, the location, and the
steps of each procedure without the restrictions
of procedural naming conventions and agreed
upon methodology. Often new procedure codes
were not covered by government or private
payers, according to an ICD-10 RAND report
(Libicki & Brahmakulam, 2004). The upshot: payers
may cover more procedures, reject less, pay faster,
and reimburse more accurately.
WHAT’S THE PHYSICIAN ROI?
Over time, physicians could see a substantial
return on their ICD-10 investment.
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Accurate payment for new
procedures. Physicians are projected to
save $100 million to $1.2 billion within a
decade of ICD-10 implementation.
•
Fewer rejected claims. ICD-10 is more
detailed and organized than ICD-9. This
relates to an NCVHS-estimated 10-year
savings of $578 million. (NCVHS serves as
the public advisory body for HHS on health
data, statistics, and national health
information policy).
•
Better claims adjudication and
faster approvals. A reduced claims cycle
will lower administrative costs for the
physician. (Precyse Solutions, 2013)
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2.
Determine Severity and Prove Medical
Necessity. ICD-10 codes are much more
granular and provide choices that will allow the
reality of the patient’s condition to be
encapsulated into a code based on the
documentation. Severity of Illness is a term often
used in the inpatient hospital setting that
indicates the seriousness of the pathophysiologic
changes that have occurred, along with an
indication of the disease’s complications. It
provides a basis for evaluating resource
consumption and the patient care provided.
Simply put, Severity of Illness reflects the
patient’s level of sickness. As a general rule,
sicker patients are more expensive to treat
because they utilize more resources, have a
higher rate of complications, and predictably,
have worse outcomes. ICD-10 codes will
support documented Severity of Illness data
capture and reporting, because ICD-10 codes
carry much more descriptive information than
ICD-9 codes. In fact, Severity of Illness is fast
becoming a buzzword that physicians will hear
more and more across all settings with the dawn
of ICD-10. ICD-10 is actually the tool physicians
can use to make sure the chart reflects how sick
their patients really are to a third party payer, an
auditor, or the public.
CASE STUDY:
APPLYING ICD-10 TO
CROHN’S DISEASE
Consider the following scenario: A patient
with ongoing Crohn’s disease presented to the
office with cramping, diarrhea, melena, and
increased abdominal pain. The physician
performed a colonoscopy six months prior and
diagnosed Crohn’s disease. Due to the severity of
the flare up, the physician orders a second
colonoscopy. The colonoscopy reveals an abscess
in the large intestine with bleeding.
ICD-9 code descriptions are too generic.
In ICD-9, the physician uses regional enteritis of
the small and large intestine. This is the same
code that was used six months earlier for the
original colonoscopy. This claim faces edits and
possible denial due to frequency restrictions on
diagnostic colonoscopies.
ICD-10 has better descriptions for
diagnostic code choices. In ICD-10, the
Severity of Illness warranting this additional
colonoscopy would be met with a specific code.
Using the single ICD-10 code for Crohn’s disease
of both small and large intestine with abscess
(K50.814), reflects a progression in the disease
and justifies the repeat colonoscopy.
Closely aligned to this, CMS, with other payers
following suit, is going to increase scrutiny
around the use of the non-specific codes and
lack of documentation for services and
procedures. ICD-10, however, with its improved
code descriptions, offers accurate and specific
disease descriptions, which will better support
the services, treatment, and procedures the
physician has prescribed. The specific codes of
ICD-10 may simplify prior authorization or
eliminate the need for an appeal, saving the
physician and staff valuable time and reducing
payment delays.
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3. Ensure Your Strong Reputation. With the
advent of healthcare industry changes
brought on by Value-Based Purchasing,
documentation becomes akin to a
physician’s social media page. Everybody
sees it. Once the care has been provided,
documentation becomes the basis for the
ICD-10 codes, which will more accurately
reflect the quality of care provided by a
physician. ICD-10 education and utilization
will trigger some needed documentation
improvements, which in turn will reflect a
code selection that will tell a more complete
story of the gravity of the patient’s illness,
the complexity of the services, and
utilization of resources.
4. Reduce the hassle of audits. ICD-10 codes
will allow the physician’s documentation to
be translated into a more accurate clinical
picture, thereby reducing the chances of
misinterpretation by third parties, auditors,
and attorneys. Understanding ICD-10 and
implementing the required documentation
will help save time and resources during a
RAC (recovery audit contractor) audit or
even better, prevent the audit in the first
place. Insufficient documentation, on the
other hand, may lead to scrutiny and
potentially a take-back by CMS or other
payer.
A PHYSICIAN’S DOCUMENTATION
TRAIL WILL INFORM THE
FOLLOWING:
•
Physician profiling/National
Registries. Physician profiling is occurring
more frequently with a concentrated move
towards transparency.
•
Quality Reporting. CMS has
implemented the Physician Compare website,
which will provide physician quality of care
information to the public starting January 1,
2014. Also, PQRS, mandated through federal
legislation, is a reporting program that
incentivizes physicians to report quality
information.
•
Consumer health sites. Consumers are
turning up the heat as they increasingly
review health sites and publications such as
Healthgrades, Yelp, and Consumer Reports
magazine to gain information about their
hospitals and physicians. For example, some
of the comprehensive physician data that
Healthgrades uses will come from ICD-10
codes and the quality of a physician’s
documentation.
•
Hospital quality assurance
committees. These groups will review
ICD-10 related data on an individual physician
level. These committees report into peer
groups that evaluate performance.
5. Gain access to better clinical information.
ICD-10 will trigger a deeper level of clinical
detail in the medical record. This information
can be used to reduce errors, impact
multidisciplinary care, and provide improved
assurance of appropriate reimbursement. It
also offers significant data mining and
research opportunities. For example, ICD10 codes allow a much greater explanation
and insight into adverse events. This includes
complications, hospital-acquired conditions,
falls, and expected adverse outcomes. “The
increased specificity of the ICD-10 codes is
more flexible, which means that emerging
diseases can be quickly incorporated. The
higher level of detail in the codes provides
the ability to more precisely code the
diagnosis,” (AMA, 2012).
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ICD-10 seems big and unwieldy, but its learning curve is
entirely manageable with a program tailored to the “need to
know” aspects of the new coding system.
TA K I N G C O NTRO L O F I C D -10
With ICD-10 launch time close at hand, how can
physicians minimize productivity loss, avoid financial
pitfalls, and most importantly, ensure they will receive
proper financial and quality credit for the care they
provide in an ICD-10 world? A good starting point is
to create a focused education and training plan that
is very specific to the needs and challenging schedules
of physicians. ICD-10 seems big and unwieldy, but its
learning curve is entirely manageable with a program
tailored to the “need to know” aspects of the new
coding system. As CMS has explained to coders,
ICD-10 is like a phone book; coders do not need to
memorize its entire contents, rather they just need
to know how to find the single code they are selecting
from this ‘book.’ The same holds true for physicians
who will focus on their specialty and some of the
common co-morbid disease codes. Physicians do not
use every code in ICD-9, the same will hold true for
ICD-10. Immediately starting a tailored and specific
ICD-10 awareness program will allow physicians to
mitigate and perhaps overcome those “pitfalls” that
loom on the horizon.
With ICD-10 comes a new dawn in physician
documentation and a much more transparent clinical
footprint. In this new era, physicians will need to
master documentation practices and learn ICD-10’s
primary concepts. In a recent physician needs report,
providers said training is a key need in achieving ICD10 readiness. Providers reported both clinician
training (52%) and coder/staff training (40%) were
their greatest needs (Westerlind, 2012).
Without the physician’s detailed documentation, as
required by ICD-10, coders will be handicapped.
Only well-trained physicians, clinicians, and others
who work within the medical record can provide the
specificity and deep level of detail required.
Ultimately, physicians who learn to document with
specificity will reduce productivity losses by having
fewer queries from coders and position themselves
to receive accurate and higher reimbursement.
Without this specificity, physicians will face an
avalanche of query activity or fail to show the true
Severity of Illness in their patients, which will impact
quality reporting and possible reimbursement.
Create personal learning experiences
ICD-10 learning is not a one-size fits all approach.
Physicians have varying documentation practices and
may prefer differing learning modalities, which is why
it is important to develop a customized plan. It is
estimated that physicians may require as little as
three to upwards of 12 hours of education to learn
ICD-10 strategies. Those physicians who do their
own coding will be closer to the 12-hour mark.
It is estimated that physicians may
require as little as three to upwards
of 12 hours of education to learn
ICD-10 strategies. Those who do
their own coding will be closer to the
12-hour mark.
Physicians must attain education in their practice
area that provides a real-world view of how to apply
ICD-10 core concepts to common diseases and
conditions. ICD-10 training should be targeted
primarily on strengthening documentation skills.
ICD-10 will not add a huge amount of new content
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to the medical record. In some cases, it may be a
few more documented words per condition, which
physicians already know from the workup of the
clinical encounter. Most importantly, physicians do
not need to become expert coders or learn how to
specifically document 10,000 different diseases in
order to survive in an ICD-10 world. However,
some knowledge of coding is required for certain
groups of physicians, including those practicing in
hospital and office settings where they do their own
coding. These physicians will need to understand
basic coding rules and definitions and need to know
how to select the right codes for their specialty.
MAJOR ICD-10
DOCUMENTATION CHANGES
• A move to anatomy as the primary axis of
classification in ICD-10-CM.
• Expansion to seven-digit capacity codes.
• Increased focus on laterality;
documentation about the side of the body
being treated will be required.
• A substantial increase in documentation
requirements around substance abuse and
dependence including tobacco.
• Greater detail about complications and
quality of care.
• Addition of combination codes that
combine disease specificity, common sites/
locations, and manifestations of the disease
into one code.
• Increased specificity–Physicians will need
to avoid using umbrella terms, such as
anemia, and begin supplying specific disease
names, etiology, and locations.
• ICD-10-PCS requires the operative report
to contain anatomical, device and approach
specificity for procedures compared to
ICD-9 Volume 3.
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Key ICD-10 learning goals
Focus training around large topic areas. ICD-10 is
rooted in about eight to 10 core documentation
concepts. When physicians learn these basic
constructs, they can then apply them to any disease.
Focus on important concepts of ICD-10-CM,
including site, specificity, laterality, timing,
manifestations, stage, status, and drug/alcohol/
tobacco dependence. However, physicians do not
have to learn the individual strategies for 5,000
different diseases or a rare one, such as Bubonic
plague. Instead, understanding these eight to 10 core
concepts will allow concept application to trigger
improved documentation for any disease a physician
is treating.
Target education on risk areas. The documentation
required by ICD-10 for optimal code assignment is
not something a physician has to learn. The physician
already knows what he or she is treating. Address
gaps in current documentation habits. If risk areas or
high volume conditions are known, targeting
education to the documentation of these identified
conditions is a good strategy to mitigate risk and
prepare for what will be needed in ICD-10.
Concentrate on specificity and underlying conditions.
Physicians need to adopt new tools and strategies to
meet ICD-10’s demand for granularity and severity
within the medical record. Under ICD-10, physicians
must move beyond documenting the principal or
first-listed diagnosis and learn how to properly
document underlying conditions that may not apply
specifically to their specialty to get full reimbursement
and to avoid issues, such as coding queries and payer
denials. For example: An OB-GYN may have a patient
who is losing bone density due to a pregnancy. The
underlying condition, osteopenia, must be properly
documented to show Severity of Illness and medical
necessity for any tests or procedures required.
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Incorporate EHR training. Precise documentation
for ICD-10 purposes can be facilitated through the
use of EHR templates and prompts, as well as clinical
data repurposed throughout the EHR to support the
“collect once, use many times” concept. However,
these templates and prompts must be ICD-10 ready.
It is critical that the vendor has considered not just
the codes and code descriptions, but the specific
documentation requirements needed for ICD-10.
Push your vendor to continually optimize the system
for ICD-10, which will streamline physician workflows
and assist in optimizing the required documentation.
However, it is critical that physicians do not view the
EHR as their ‘savior’ for ICD-10. Physicians must
understand the documentation foundations of ICD10 as no system will be able to fully script or capture
every encounter a physician may face in their complex
clinical work.
Use a variety of learning methods. Physicians have
grueling and challenging schedules with increases in
patient volumes, administrative efforts, and entry of
data into electronic systems. For this reason, it is
critical that physician learning include myriad
approaches to making the education available any
time, anywhere, and any way they can consume it.
We also must accept that there is no way that every
physician can be reached in a classroom setting. Due
to pressure on their schedules and the sheer numbers
of physicians, organizations must rely on multiple
educational modalities.
A strong ICD-10 education program and plan
should use some or all of the following:
• Online, self-paced eLearning
• Peer-to-Peer ICD-10 education,
workshops, and staff meetings
• Smart phone apps and mobile resources
• Audio webinars
• Well-trained, adept CDI professionals
able to educate the physicians at point of
opportunity
• Simulation training
• Communication initiatives and collaterals
• Job aids/printed resources
• Video games
• One-on-one meetings
• Quarterly follow-up
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Develop an education and training matrix.
1. Identify physicians and staff members who
need training and form a training timeline for
these groups.
2. Assess physician documentation modalities.
Physicians and other clinical staff can be assessed
in terms of the specificity they currently use in
their documentation and code selection and the
deficiencies that exist today that will pose risks in
ICD-10. These assessments will reveal the degree
and type of ICD-10 education that physicians will
require and the potential documentation gaps
that exist. Over the long-term, make these types
of assessments and audits a recurring program to
ensure optimal documentation and identify
educational opportunities.
3. Develop recommended bundles/tracks for
physicians and their staffs based on their role and
function. It is key that physicians are only required
to take education they need, nothing more and
nothing less.
4. Estimate the total number of ICD-10 education
hours for physicians based on the level of
education they need.
5. Identify start and end dates for each impacted
population.
Start now.
Although ICD-10 will not be live until October 1,
2014, there is no reason to wait. Preparing physicians
now for the enhanced documentation required in
ICD-10 has no drawback. Unlike teaching coders too
early who will ‘lose it without using it,’ these concepts
are ones physicians can incorporate today. In fact, this
more specific and improved documentation will
actually drive benefits in ICD-9 by reducing queries,
maximizing reimbursement, and reflecting accurate
Severity of Illness and medical necessity. This is not
something that will be lost if you start too soon.
Ultimately, the longer the period of the education,
the more opportunities there will be to repeat,
refresh, and promote.
THE HISTORY OF ICD-10
The forty-third World
Health Assembly
endorses ICD-10.
Clinical modifications
are made to create
ICD-10-CM to classify
diagnoses.
CMS overhauls how it
classifies inpatient
procedures and
develops ICD-10-PCS.
1990
1994-1996
The strict
requirements of The
Health Insurance
Portability and
Accountability Act of
1996 (HIPAA) stall
the adoption of
ICD-10.
The United States
adopts ICD-10 as the
official U.S. standard
for recording
mortality data.
1996
1999
HHS publishes final
rule adopting
ICD-10-CM (and
ICD-10-PCS) to
replace ICD-9-CM in
HIPAA transactions.
ICD-10
implementation is
delayed from
October 1, 2013 to
October 1, 2014,
2009
2012
(Libicki & Brahmakulam, 2004; CDC, 2013).
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UNDERSTANDING ICD-10-CM
VS. ICD-10-PCS
• ICD-10 includes both the ICD-10-Clinical
Modification (CM) and ICD-10-Procedure
Coding System (PCS) classification
systems. These two systems are separate
but interrelated. ICD-10-CM/PCS are
more logical and specific, providing a
better clinical picture to support quality
communication and fair compensation for
services rendered.
• ICD-10-CM and ICD-9-CM, which are the
diagnostic portions of the coding systems,
were developed for use in all U.S.
healthcare treatment settings. They differ
very little in their method and standards.
The diagnosis coding under ICD-10-CM
uses 3-7 alpha and numeric digits and full
code titles.
• ICD-10-PCS was developed for use in U.S.
inpatient hospital settings. ICD-10-PCS is
a complete departure from the old
inpatient procedural classification system.
It is very different from the ICD-9-CM,
Volume 3 procedural portion of the
classification system. ICD-10-PCS uses 7
alpha or numeric digits, while the
ICD-9-CM coding system uses 3 or 4
numeric digits.
• ICD-10-PCS houses large tables with a
primary index and specific secondary
tables. These allow classification of a
procedure based on the documentation of
the services provided. All diagnostic
information is excluded from ICD-10
procedure codes, whereas ICD-9-CM,
Volume 3 codes often contain the diagnosis
in the body of the static code title.
ICD-10-PCS FEATURES:
• Completeness: Offers a unique code for
all substantially different procedures.
• Expandability: Allows for easy integration
of unique codes for new procedures.
• Uniform structure: Ensures consistent
meaning.
• Standardized definitions and terminology:
No multiple definitions for one term.
Procedural complexity is precisely
represented by the code that is built.
(Precyse Solutions, 2012; CMS, 2012)
www.healthstream.com • 800.933.9293 • [email protected]
13
ABOUT THE AUTHORS
Thomas Ormondroyd, BS, MBA, is Vice President
and General Manager of Precyse Learning Solutions,
a division of Precyse, where he oversees several
business lines, including Precyse University, ICD-10
Consulting, and Educational Services. Tom is the
creator of Precyse University, a revolutionary on-line
Learning System and Program built to deliver
education to prepare healthcare professionals for
the challenges of today and tomorrow. He is also
responsible for the development of the Precyse
University ICD-10 education program, which is the
leading ICD-10 education solution in the country and
is working with the largest and most prestigious
healthcare companies in the country on the education
of all their ICD-10 impacted populations. Prior to
Precyse, Tom was the Global Director of Education
and Employee Development at a billion dollar
technology company overseeing education across its
global sales, customer service, and operation sites.
He was also a consultant for hospitals, healthcare
systems, and other entities assisting in employee
development, motivation, and team collaboration.
Bruce A. Scott, MD, is Precyse’s Physician Consultant.
As a professional speaker, Dr. Scott brings a wealth of
knowledge and experience presenting on vital topics
such as “Documentation and Severity: A Physician’s
Perspective,” “Inpatient PPS Changes: Physician
Documentation and Severity,” and “Improving
Documentation and Coding.” Dr. Scott has over 20
years of experience as a physician specializing in
otolaryngology, head & neck surgery. He is President
of the Kentuckiana Ear, Nose and Throat, PSC;
Founder and President of the Operative Ventures,
LLC; and Medical Director of the Louisville
SurgeCenter. In addition, Dr. Scott is Clinical Assistant
Professor at the University of Louisville Medical
HealthStream White Paper
School and has affiliation with several hospitals. He
serves on the board of the Kentucky Medical
Association, the Greater Louisville Medical Society;
and Surgical Care Affiliates. Previously he was on the
board of the American Medical Association, Health
Enterprise Network; and the American Medical
Association Foundation. Dr. Scott received his
medical education from the University of Texas
Medical Branch at Galveston, Texas. He has written
several scientific publications. He has been recognized
as a “Best Physician” and “Top Surgeon” multiple
times by local and national publications. Dr. Scott has
also been Precyse’s Chief Physician Champion,
Faculty Advisor, and Educator for several years
working with Precyse on the development,
deployment, and delivery of ICD-10 and physician
education.
Christian Oliver, Associate Vice President, Catalog
and Courseware, works with associations,
universities, training companies, and other subject
matter experts to bring online courses and other
content to HealthStream’s customers. He has held
many roles during his career in online education as a
project manager, instructional designer, and product
manager and has had the opportunity to work with a
wide range of organizations, from Fortune 500
companies to the American Red Cross and the Bill
and Melinda Gates Foundation. He has a Master’s in
education from Columbia University and a B.A. from
Franklin and Marshall College.
14
A B O U T H E A LT H S T R E A M
HealthStream (NASDAQ: HSTM) is dedicated to
improving patient outcomes through the
development of healthcare organizations’ greatest
asset: their people. Our unified suite of software-asa-service (SaaS) solutions are used by healthcare
organizations for training & learning management,
talent management, performance assessment, and
managing simulation-based education programs. Our
research solutions provide valuable insight to
healthcare
providers
to
meet
HCAHPS
requirements, engage their workforce, and enhance
physician alignment. Based in Nashville, Tennessee,
HealthStream has an additional office in Laurel,
Maryland.
www.healthstream.com • 800.933.9293 • [email protected]
15
209 10th Avenue South - Suite 450
Nashville, TN 37203
800.473.1771
www.healthstream.com
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