Maxine Lewis, CMM, CPC, CPC-I, CCS-P

	So you’ve decided to get your practice ready to use ICD-10-CM coding. Where do you begin? Our experts recommend the following steps:

	“Appoint one person, be it the officer manager, the coder, or the biller, to drive the process and oversee all the details,” says Maxine Lewis, presidentof Medical Coding and Reimbursement.   

	“I think it’s important to put goals in front of yourself to achieve this planning,” she says. 

Identify your codes and assess coder knowledge:

	One of the most important elements in preparing will be identifying the codes your practice uses the most, so that you can begin learning what they will be in ICD-10-CM, Lewis says. The easiest way to do this is to review your superbills. Also, you must make sure your coding staff has knowledge in the areas of basic anatomy, physiology, and medical terminology. This will be necessary for them to better understand the provider’s documentation.

Analyze your contracts with third-party payers:

	“Chances are, you have a lot of services that are carved out, or services that are automatically provided because of a certain diagnosis. So you have to find those in your contracts and make sure you’re using ICD-10-CM for the services you are performing, because if you don’t know what the new code is, you won’t get paid,” Lewis says.

	Better documentation is absolutely critical for ICD-10-CM coding. Start evaluating provider documentation today, says Renee Stantz, CPC, billing and coding consultant for VEI Consulting Services.  Learn where deficiencies lie and where education is needed to fulfill the ICD-10-CM code requirements. Although some have said that electronic health record (EHR) systems will handle this, many are skeptical. Through regular reviews, most auditors and consultants will tell you that that physicians and NPPs are currently not documenting the necessary information for ICD-10-CM coding. 

	For providers, an assessment will entail reviewing current documentation to evaluate if the required ICD-10-CM detail is included.  The assessment should also incorporate mapping of ICD-9-CM to ICD-10-CM codes for the practice’s frequently-billed codes, and identifying any deficiencies that exist. This exercise will clearly pinpoint specific information that is lacking for accurate coding in the ICD-10-CM world, and allow for parallel provider training and payer testing.  Keep in mind that temporary workflow change-and additional staff-might be needed to conduct this assessment.

	The Centers for Medicare and Medicaid Services (CMS) has estimated that ICD-10-CM training for clinical staff and providers will require 8 to 16 hours, 24 to 40 hours for coders, and 4 to 8 hours for IT staff members. Some form of in-office and classroom training will be necessary for your entire staff, and fostering good communications between providers and coders is essential, Stantz says. All staff involved with dagnosis coding will need to know their training goals and clinical staff will need to understand how their documentation will impact the ability to code.   

	Talk with your software vendor, clearinghouse, billing service, and payers to make sure they are prepared for ICD-10-CM claim testing, Stantz says. Ask your vendor if your practice management and EHR systems will need to be upgraded in order to handle the new diagnostic codes. If so, find out when that upgrade will be finished. Ask your clearinghouse, billing service and each payer if their software can accomodate the new codes and when you can start testing.

	Schedule times to send test transactions, and review results when testing is complete, Stantz says. Some payers are already equipped to accept test claims, so don’t wait to test. If a payer is not ready to test, find out when testing can start. Work out a process in advance to address any glitches. Do not allow your revenue to be delayed because you didn’t test the right way.

Articles

So you’ve decided to get your practice ready to use ICD-10-CM coding. Where do you begin? Our experts recommend these steps.

Preparing your practice for ICD-10

 able to document a patient's visit with the assistance of an EHR, all documentation must be medically indicated for a patient's presenting problem.  

For an established patient, only two of the three key components (history, examination, and medical decision-making) must be used to select a level of service. With a simple click, you can upload the history portion-consisting of the review of systems and the past, social, and/or family history. You still must note and update the chief complaint and history of present illness if a disease is chronic. 

In addition, auditors have seen cases in which the physical examination has been brought forward to the new encounter, sometimes without changes. EHR templates are standard for all patients, so you may not be able to distinguish one patient's physical examination from another.  

Also, the question arises from having so much documentation available: Is the documentation medically indicated for the patient's presenting problem? The federal government also sees this can be a problem. 

Let's assess the extent to which the Centers for Medicare and Medicaid Services (CMS) made potentially inappropriate payments for evaluation and management (E/M) services and the consistency of E/M medical review determinations.  

Medicare contractors are noting an increased frequency of medical records with identical documentation across services. Medicare requires you to select the code for the service you provide based on the content of the service and that you have documentation to support the level of service you report. 

Medical decision-making should drive what should be and is appropriate for the patient. The documented work not only should include the key components, but also must be reasonable and necessary. Many of the EHRs currently available include in the medical decision-making portion helpful templates for specific diseases and treatment plans.  

A significant problem occurs, however, when an EHR automatically posts a code to a patient's bill when no provider has been selected and the level of service is taken from the encounter. 

You are responsible for ensuring that the codes you submit accurately reflect the services you provide. E/M codes represent the type, setting, and complexity of services provided, as well as the patient's status (new or established). 

CMS analyzes the E/M codes by specialty and uses data-mining to determine the names of outliers (doctors who report codes more frequently or at a higher level than their specialty peers). Recovery audit contractors use this method in their searches for overpayment. 

The physician whose name appears on the claim for the third-party payer, not the EHR software, ultimately is responsible for the code reported. 

The author is president of Medical Coding & Reimbursement in Cincinnati, Ohio.

This month's question asks how to document and code in an EHR. Find out the answer to this pressing coding question.

Document and code in an EHR with care

 When a patient stays in the hospital for more than 48 hours and is discharged, even if a transfer to another facility is involved, your note should recapitulate the reason for the hospitalization and include significant findings; the procedures or treatments given; and the principal, secondary, and final diagnosis(es). Do not use symptoms unless specified as undiagnosed, but include the patient's discharge status as well as specific instructions to the patient and/or family. 

When a patient is readmitted after a procedure in another facility 2 days later, document this in an admission note in the patient's medical record within 12 hours, if possible. The admission note should contain the reason for admission; provisional diagnosis(es); and a statement regarding the initial assessments of the patient that includes candidacy for a surgical procedure, where appropriate, or any other procedure that involves a degree of risk. The admission note also should have a relevant H&P. 

A complete H&P for inpatient admissions and procedures performed in an operat-ing room should include identification data; chief complaint; details of present illness, including an assessment of the patient's relevant medical/social/family history; a review of the inventory of body systems; physical examination; mental status; current medications; allergies; vital signs; and a diagnosis or problem list with a plan of care.  

An H&P for children and adolescents should include an evaluation of developmental age; consideration of educational needs and daily activities as appropriate; a parent's report or other documentation of immunization status; family/guardian expectations for and involvement in the assessment, treatment, and care of the patient; and the psychosocial needs as appropriate to the patient's age. This may be part of the H&P or the initial nursing assessment. 

Some hospital bylaws state that if you performed an H&P within 30 days before the patient's admission, you may include a copy of the report in the patient's medical record provided you add a note stating that no changes occurred or detailing any changes that occurred. If your hospital's bylaws do not include this information, seek clarification at the hospital's medical staff office.  

Coding for a visit after a patient's recent hospital stay poses a unique challenge. Find out the answer to this pressing coding question.

Author | Maxine Lewis, CMM, CPC, CPC-I, CCS-P

Articles

Preparing your practice for ICD-10

Document and code in an EHR with care

Documenting a visit after a hospital stay