Saturday, April 12, 2014

ICD-10 cm/pcs documentation: Adding “wordsmith” to your Coders’ job function!

ICD-10 cm/pcs documentation:  Adding “wordsmith” to your Coders’ job function!

As the countdown to the ICD10 implementation draws ever closer, one of the new challenge is to overcome and understand many of the new “words” that are in the code books, and knowing what they mean, and to discover if the documentation holds up to that new coding definition.

According to the Merriam-Webster dictionary a “wordsmith” is one who is an expert in the use of words; a person who works with words, or an especially skillful writer.  As a coder,  think about this.  Most coders fall into this category of expertise.  Coders are constantly challenged by the documentation noted from providers, to applying that which is written into a numeric format; such as ICD-9cm.  However, when ICD-10cm is implemented, coders will need an excellent understanding of, not only, medical terminology, but anatomy, physiology, disease process, the numeric codes, and a little bit of “wordsmithing” to correctly apply the diagnoses per the documentation in the new ICD-10cm format.

Many new terms have been put forth to coders, and certain codes will now require documentation to be more precise and complete to give us the best “picture” of the care the patient received via a numeric format.  Our challenge as good coders, is to communicate these new criteria to our providers, so we can all share the same understanding of the words needed to document important patient information.  Providers don’t normally have the inside track to what criteria or “words” need documented in ICD-9, and now we are challenged even more by the specificity needed in ICD-10.  A coder, or clinical documentation specialist is going to be looked up to as the expert to help educate and inform providers how to document more clearly, to get to the desired goal of clear, concise, correct documentation, which can be interpreted correctly, and most closely to ICD-10cm definitions.  If we succeed in this endeavor, everyone benefits.

Let’s start with some unusual words, found throughout ICD-9 and ICD-10.  Coders will need specificity in documentation.  Physicians and providers are accustomed to documenting descriptive and narrative processes in the patients’ medical record documentation (eg H&P, Operative Note, Discharge Summary etc) .  The impending go-live of ICD-10 will challenge us to “come together” with our physicians and providers to utilize specific, descriptive narratives to enable coders to append the correct ICD-10 diagnosis once the go-live date has come into effect.  In the example below, note the word “iatrogenic”

Outlined below is a challenging documentation excerpt.  The provider needs to more clearly document not only the procedure, but the diagnosis of the particular case.  In order to get this criteria “up to standard”  we, as coders will need to clearly understand what the procedure is, and why it’s being performed, then accurately code the current ICD-9 diagnosis.  Once that is done, we should cross-code/dual-code for to determine if the documentation can hold up to an appropriate and specific ICD-10cm code, prior to go-live on October 1, 2014.

Coding excerpt:  “………. the intention was on placing the Port-A-Cath in the left neck, given that this is the side of the patient's pathologic lung (eg lung cancer) , and we did not want to risk him having a pneumothorax in his right lung.  At this point, we considered that there was a very low likelihood of the patient having an iatrogenic pneumothorax.  The patient has a pleurodesis on the left, and likely has a trapped left lung already. Our concern is to avoid a pneumothorax in both lobes.”

As we focus on the words “iatrogenic”, “pneumothorax” and “pleurodesis”  We should verify what those definitions are in the medical dictionary.  There are many types and definitions of pneumothorax, and pleurodesis.  
primary pneumothorax:  is one that occurs without an apparent cause and in the absence of significant lung disease
secondary pneumothorax occurs in the presence of existing lung pathology
closed pneumothorax: air leaks from a discontinuity in the lung into the pleural cavity.
false pneumothorax: artifactual increased radiolucency of the thorax resembling free air in the pleural cavity.
iatrogenic pneumothorax: may occur following intrathoracic surgery or in association with procedures which involve entry into the pleural cavity, such as thoracentesis or placement of a chest drain.
open pneumothorax: caused by an open wound in the chest wall.
spontaneous pneumothorax: due to an unknown cause.
tension pneumothorax: a particularly dangerous form of pneumothorax that occurs when air escapes into the pleural cavity from a bronchus but cannot regain entry into the bronchus. As a result, continuously increasing air pressure in the pleural cavity causes progressive collapse of the lung tissue. If not relieved, it can lead to lung collapse and mediastinal shift.

Of course, the main diagnosis for the placement of the port-a-cath, is the lung neoplasm, (which in itself, neoplasms can be a coding challenge)  but a complication from this specific port-a-cath procedure, could result in a pnumothorax coupled with the fact the patient already has a pleurodesis.

Upon review of this small documentation example, it brings to light many documentation issues that arise in our quest for good documentation for coders to follow.  To get optimal coding specificity for each medical specialty, it is, and will continue to be, critical that coders communicate with the physicians and providers in a way that both get what they need, to achieve good, positive outcomes. (revenue, and quality patient care).  The coder is charged with translating the medical care documentation into a code-set, to be used  for payment and data analaysis; the provider needs to document the care of the patient for quality and medical necessity of care, combined with medical ethics and thus,  accuracy, for what was truly provided during the patients’ length of stay.

The coding query process can help.  The query process is a very useful tool, but real 1-1, face to face communication, combined with good ICD-10cm  training for the coder,  providers and physicians will be a critical point for ICD-10cm and pcs coding success.  Currently none of us are “good” or “expert” at ICD-10, so we all are struggling to become proficient at what we need.

The need for good documentation brings us back to the term “wordsmith”.  Again, both the coder and the physician/provider will need to add this to their job proficiencies.  A good way to get the conversation started with your physicians/providers’, is to conduct a review of the current physician/provider documentation by the coder.  The coder can develop, or may have a feel, as to how best to ascertain the top 5 or top 10 commonly mis-coded or difficult to code diagnoses in the practice.  If the coders’ are currently struggling with appending these “difficult” diagnoses now, utilizing ICD-9, this challenge now is amplified by dual coding/cross coding with ICD-10cm codes.  Document and analyze what is found.  This quick analysis will help define where better documentation is needed for both the coder and provider.   Below outlines this quick process to help enhance communication processes for both the coder and the physician/provider of care.

1. Ask the coder(s)  and provider(s) for the top 5 mis-coded or difficult to code diagnoses
2. Pull the operative/procedure notes that were associated with these diagnoses
3. Cross-code the documentation with both ICD-9 and ICD-10 codes
4. Identify areas that need to be clarified for the coder with the physician or provider
5. Schedule a meeting (face to face)  with the coder and the provider and include
a. The actual provider notes
b. The ICD-9 codes (using the code -book)
c. The ICD-10 codes (using the code-book)
Then, once this is all in place, you then have a terrific “learning opportunity” to share and commit to learning from each other how best to document or “wordsmith” so all get what they need.

Amazingly, the communication process is not only an informative session, but the opportunity to get to know and understand what each area needs for a successful transition and implementation to ICD-10

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