ICD-10 Diagnosis Coding and Anesthesiologists’ New Documentation Responsibilities

ICD-10 is coming, as we have all heard many times.  Will full implementation be here on October 1, 2014, though, or on October 1, 2015?  As of the time this is written, the Senate is expected quickly to take up the House-passed Protecting Access to Medicare Act of 2014 (H.R. 4302), legislation that will prevent Medicare payment cuts from going into effect on April 1st—and that contains a provision delaying the implementation of ICD-10 for a year.  Whether we are six months or 18 months from the start date, however, it is none too early for clinicians to gain an understanding of what ICD-10 will require of them, as well as to practice meeting the new requirements.

We have all heard, too, that ICD-10-CM (“CM” stands for “Clinical Modification” and distinguishes the codes used for diagnosis from those used to identify procedures, the ICD-10-PCS or “Procedural Coding System” codes) requires more specificity.  ICD-10-CM codes provide much more detail than ICD-9 codes about severity, comorbidities, site/laterality, complications, sequelae, manifestations, causes and encounter history.  The table below shows the greatest differences between the two systems and some examples of the greater level of specificity of ICD-10 codes:

	ICD-9-CM	ICD-10-CM
Number of codes	Approximately 14,000	Approximately 69,000
Field length	3-5 digits	3-7 digits
Example 1	813.21 Fracture of radius and ulna, shaft closed, radius alone	S52.324A Non-displaced transverse fracture of right radius, initial encounter for closed fracture
Example 2	550.9 Inguinal hernia	K40.11 Bilateral inguinal hernia with gangrene, recurrent
Example 3	721.3 Lumbosacral spondylosis without myelopathy	M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region

The information needed to choose the right code is going to have to come from the clinicians who perform the case—from the anesthesiologist, who must make sure that he or she has the right information from the surgeon, or from the pain physician.  Documentation of sufficient detail is particularly important because of the long-standing principle that no code is ever considered valid or complete unless it is coded to the highest level of specificity in its category.

In ICD-9 diagnosis coding, it was enough for the anesthesia record to contain the phrase (Example 1) “fracture radius shaft.”  The ICD-10 code requires information as to the anatomic site, laterality, the type of fracture and the nature of the episode of care, whether initial or subsequent.  The type of detail varies between codes.  If this sounds daunting, realize that half of the ICD-10-CM codes are related to the musculoskeletal system, that 50 percent of those to fractures, and that 62 percent of the fracture codes serve to distinguish the right from the left side.  Still, how are clinicians to know what specific information they must now have?

Rather than attempt to master the relevant sections of the ICD-10 book, physicians should concentrate on their commonly-used diagnoses.  A total of 10-20 diagnoses should be adequate in most instances, and it may be easiest to work through subsets of just three to five diagnoses at a time.  The goal will be to identify gaps in the documentation that would prevent a coder from choosing the right ICD-10 for those codes.  There are several ways to identify such gaps, such as having staff assign ICD-9 and ICD-10 codes in parallel to current claims, or having coders review successfully adjudicated ICD-9 claims and start to select the appropriate ICD-10 diagnoses.  There are various print manuals and websites that map ICD-9 codes to the one or several ICD-10 codes that will replace them and in the process point to the additional information needed.  The AAPC’s tool at http://www.aapc.com/icd-10/codes/, for example, produces the following three possible ICD-10 codes for ICD-9 729.1, Myalgia and myositis NOS:

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The medical record will need to signal which of the three diagnoses specifically applies.

In pain medicine, it is up to the pain physician to document the information from which coding personnel can determine the applicable diagnosis code.  In surgical anesthesia, ideally, the details will be noted in the anesthesia record by the anesthesiologist who asks the necessary questions of the surgeon in the operating room to confirm or update the information posted when the case was booked.  The op report should also have the diagnosis information, of course, but anesthesiologists should not depend on coding personnel to obtain and dig through op reports, which may not be readily available to them.  Leaving the correct ICD-10 code determination up to coders who must refer to records and reports controlled by the hospital or the surgeon’s office could easily lead to errors that might cause claims to be rejected and payment denied, or at least delayed.  Complete documentation in the anesthesia record will also be helpful in the event of an audit.

Most pain physicians will need to make other workflow changes.  They will not need to organize ongoing coordination of ICD-10 code selection with surgeons, unlike anesthesiologists, but if they use superbills or other lists (paper or electronic, e.g. EMRs)  of common diagnoses for code selection, they will need to work with their coding staff to redesign and expand the superbills.  Fortunately for pain specialists, many of the ICD-9 codes map or “cross over” to a single ICD-10 code.

Complete and accurate documentation of the services provided will be the foundation on which a smooth transition to ICD-10 will rest.  It is the transition issue in which physician involvement and control are indispensable. Managing system upgrades, training staff, revising policies and procedures associated with diagnosis codes, analyzing and updating payer and vendor contracts and the many other transition tasks can be led by nonphysician personnel.  Clinical documentation is different.  Because of its fundamental importance, ABC is offering our clients a number of webinars that will explain the coming changes and the requirements of ICD-10 diagnostic documentation.  (Clients who have not yet registered for a webinar should obtain the assistance of their Account Managers.)  Hospitals, medical societies, health plans, EHR vendors and other trading partners are also providing physicians and nurses with ICD-10 education.  We urge all our readers to take advantage of these opportunities so as to minimize disruptions when the new coding system is implemented.