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ICD-10 surprises in the hospital

Doctors can expect many more new ICD-10 codes later this year

June 2016
Choosing codes for incisions and codes for incision and drainage procedures

Published in the June 2016 issue of Today’s Hospitalist.

ICD-10 IS NO LONGER NEW NEWS. Last Oct. 1, the U.S. converted to the new classification system and, so far, the transition has been relatively smooth. There have been no major financial disasters, nor am I aware of any practices that have thrown up their hands and gone out of business.

The Centers for Medicare and Medicaid Services (CMS) continue to process an average of 4.6 million claims a day, with only 1.9% of those claims rejected. That is actually lower than the pre-ICD-10 baseline of 2%, and private payers and claim processing companies have reported similar figures.

In my health care system, we have not had a tremendous amount of pushback from physicians, even though the new coding system may not reflect how doctors think about or process diseases. For example, under ICD-10, doctors need to document hepatic encephalopathy whether or not it coexists with coma. This is somewhat foreign to how hospitalists think. To them, the term “encephalopathy” inherently states the level of consciousness, and having to explain further seems redundant.

The CMS is rejecting only 1.9% of claims, 
which is actually lower than the pre-ICD-10 baseline.

But the advent of ICD-10 did include some disruptions and unanticipated surprises. Let’s take a look at these issues before the next batch of ICD-10 codes arrives later this year.

Coder productivity
A smooth transition doesn’t mean that there was no negative impact at all. The biggest hit that I have seen has been on coder productivity. This has been particularly true with the ICD-10 PCS (procedural coding system), which has not been used in any other country and was rolled out here for the first time last October.

The PCS coding system is complex and requires a significant amount of training. Obviously, it will take time for all of us to get accustomed to this new system, but many in the coding world worry that productivity may never return to pre-ICD-10 benchmarks.

For us, we are bouncing back slowly from the drop we saw in coder productivity, and we continue to educate clinicians about documentation. (That never stopped.) Hospitalists frequently receive queries from coders asking to clarify diagnoses, and physicians know they can help by answering those queries quickly to avoid billing delays.

Although not every code has to be specific, more specificity means a better description of a clinical condition and less likelihood of receiving a query from hospital coders and clinical documentation specialists. And some specificity has been critical for helping hospitals avoid payment denials.

Since the ICD-10 go-live, for instance, the highest number of denials has been due to laterality specificity (left or right). In most clinical scenarios, you can easily determine laterality and readily figure out what documentation is required.

But there are certain situations in which requiring laterality may not seem obvious. Lung cancer is a good example: There are left- or right-sided lung, or bronchial cancers. If the malignancy involves both lungs, you need to clarify that. Crohn’s disease— particularly the involvement of small or large bowels, or both—is another condition in which coders and clinical documentation specialists keep coming back to us, asking us to be more specific.

More specificity also seems to be required for certain conditions that hospitalists deal with frequently. Ones that come to mind include heart failure, complications of diabetes (retinopathy, nephropathy and neuropathy) and malnutrition. As we treat these conditions, we can help by providing as complete documentation as possible.

Certain procedure codes
Here’s one unanticipated surprise: Since the ICD-10 conversion, payment for some procedures (catheter thrombectomy of carotid arteries, for example) has been denied due to errors in the way payment policies were set in electronic payment systems. The CMS has tried to move quickly to fix the errors. But in the meantime, hospitals are waiting for large bills to be paid.

Why is payment for procedures a big deal for hospitalists? After all, survey data indicate that the number of hospitalists still doing procedures has dropped quite a bit in the past 10 years.

In our system, that varies from doctor to doctor and from one hospitalist group to another. Some of us still do bedside procedures; I personally still do paracentesis, and I have seen other hospitalists perform lumbar punctures. And in academic hospitalist groups, procedures are still being done because residents need to be trained to do them.

There has also been an interesting “twist” in terms of certain surgical DRGs. During the ICD-9 era, we were able to code a diagnostic paracentesis without causing the DRG to become a surgical DRG, which pays a lot more. But since ICD-10 took effect, using such codes is causing the DRG to become a surgical procedure, which could each cost the CMS thousands of dollars more. Examples include bronchoalveloar lavage procedures, arterial line insertion procedures and paracentesis, among others.

Was this intentional? Did the CMS truly intend to pay more for the same procedures that had been done for years and billed for with ICD-9 codes? Or is this a fluke and an error in the way ICD-10 was built? I’m not sure what the answer is, but I do expect this to be addressed in the new ICD-10 version that will debut this fall.

More to come
In March, the CMS’ ICD-10 coordination and maintenance committee announced that health care providers should expect thousands of revisions and new procedure codes beginning Oct. 1 of this year.

The CMS has released those proposed changes, and they are substantial: more than 3,600 ICD-10 hospital inpatient procedure codes and around 1,900 ICD-10 diagnosis codes. Medicare will release its final changes later this year.

These should fix some of the problems that have surfaced, but they will mean more education for coders and physicians. In the meantime, hospitalists who perform certain procedures need to be as clear as possible in their documentation. When performing paracentesis, for example, is it therapeutic, diagnostic or both? Those options represent significant coding (and payment) differences.

Documentation is a core function of our daily work, and it has a great impact on communication and reimbursement in terms of accurately reflecting illness severity. That in turn has a major effect on risk-adjustment for value-based purchasing programs and other risk-based payment arrangements. Hospitalists can differentiate themselves by being the experts.

coding-AntoniosSam Antonios, MD, is vice chair of the department of medicine and medical director of information systems at Via Christi Hospital St. Francis in Wichita, Kan.

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