How to decipher confusing ICD-10 codes

Question 1: I was told that the ‘Episode of Care’ 7^th character in ICD-10 doesn’t mean what it appears to mean. That ‘initial’ encounter doesn’t always mean the first encounter. Is that correct?

Answer: Yes, that’s about the size of it. The three values usually assigned to the 7^th character for episode of care are ‘A’ – Initial Encounter, ‘D’ – Subsequent Encounter for injury with routine healing, and ‘S’ – Sequela.

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A commonplace and non-coding meaning of the word ‘initial’ is first. And most folks would think there can only be one ‘first’ of something. But that is not what it means here.

The ICD-10 guidelines for coding and reporting of fractures directs you to use the ‘Initial Encounter’ character ‘while the patient is receiving active treatment for the fracture. Examples of active treatment are surgical treatment, emergency department encounter and evaluation and treatment by a new physician.’

So a couple of versions of ‘initial’ are found here. ‘While receiving active treatment’ can include the entire hospitalization, not just the first day. That is the longitudinal version. ‘Initial’ can also include the first encounter (or maybe more as above) with a provider other than the first provider to treat the problem. So yes, ICD-10 ‘initial’ means more than one thing, and not necessarily what it may appear to mean.

‘Subsequent’ is a bit more consistent with traditional meanings: “encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.”

ICD-10 seamless for some, a puzzle for others

If in doubt, look to your guidelines. Don’t rely on guesses.

Question 2: I am increasingly told that I need to spell out my thought process, differentials and concerns in the assessment and plan (A/P) portion of my notes. At the same time, my electronic health record (EHR) exports the comments from this part of the chart into the patient summary – a printed copy of which is given to the patient.

Next: Where do we go with this?

Some of my impressions are not things I really want to share with the patient. Where do you go with this?

Answer: Excellent question one that points towards changes in the overall manner in which medical records are used-and to some degree a case of unintended consequences.

Per the Federal Documentation Guidelines “Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes.

The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates:

• the ability of the physician and other health care professionals to evaluate and plan the patient's immediate treatment, and to monitor his/her healthcare over time.

• communication and continuity of care among physicians and other health care professionals involved in the patient's care;

• accurate and timely claims review and payment;

• appropriate utilization review and quality of care evaluations; and

• collection of data that may be useful for research and education.

The government was careful to broaden the description of medical record use to include not just the original and principal purpose of communicating among healthcare providers, but to include claims, utilization and research users as well. Those guidelines came from 1997 and are still in effect today.

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But now we also have the requirements of meaningful use and the Health Insurance Portability and Accountability Act , whereby patients and others have access to the record. The same information that was once meant to drive care and was written primarily for other healthcare professionals now belongs to a variety of users – with different levels of education, understanding and very different interests.

Your question focuses on two elements of the Stage I meaningful use requirements;

• Provide patients with an electronic copy of their health information, upon request.

• Provide clinical summaries for patients for each office visit

As you point out, some EHR’s have been set up to facilitate easier patient summaries by copying data from various parts of the chart. But what information do you want to share, and with whom?

Next: 'There is another kind of risk'

Chart auditors and coding educators have long heard providers comment that the auditors desire to see the overall risk and morbidity mortality spelled out, or the likelihood or discussion of differentials, could run contrary to medical legal advice. There seems to be some sense that it is better not to state these things explicitly, so that if there is an adverse or unexpected outcome you don’t look wrong, or worse, liable. That said, in order to give you credit for your medical decision-making, you have to tell them how sick someone is. The tools that reviewers use depend on their ability to recognize risk, rule-outs and the language that characterizes the patient’s problems.

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There is another kind of risk in speaking too clearly about a prognosis or diagnosis that could have a negative impact on a patient when the patient sees the words in the summary. One view is that if the patient is surprised by what you have written, then perhaps the truth of the situation was not adequately communicated to begin with. More likely the patient did not really hear, or choose to hear, what the provider said.

In the world of paper charts many providers made their own cryptic notes in the margins, or their own little glyphs somewhere in the history area that told them things they needed to remember, or impressions about the patient: long-winded, drug seeking, morbid obesity, poor hygiene or social-type commentaries. This allowed the record to function as it was originally intended: as a note to self.

In the somewhat over-mechanized, over-shared universe of EHR’s, perhaps the answer is to find a lace in the chart to make those observations that is not intended for sharing or data-mining. Half sentences and your own shorthand should suffice to say what you need or want to remember without having it broadcasted and potentially misunderstood.

The transparency and access of the data in a record seems to be at odds with the privacy and security of this information. Our technology has, to some degree, outpaced our ability to use it. There are more variables to consider now. But in the end you need to balance the needs of the patient, the payer, the regulator, the researcher and your own good judgment.

Question 3: My doctor is not following the standard SOAP (subjective, objective, assessment and plan) note format in her hospital notes any more. Is this allowed? I also see problems ahead with some of the copying from day to day.

Next: 'Enter today's EHR...'

Answer: As mentioned in the question above, the answer here relates in part to the background of Federal Guidance for physician documentation and in part to the evolution of the EHR environment.

The first part of your question deals with format, and the SOAP note. Recognize that the rules that govern the documentation requirements for evaluation and management (E/M) coding and the auditing that follows are essentially unchanged from the 1995-1997 timeframe. Moreover, portions of these guidelines, the decision-making table or tables, have been around since the late 1980s. So the tool used to measure today’s note is a minimum of 18 years old, with portions dating back more than 25 years.

Enter today’s EHR, designed to meet today’s demands as well as the older documentation requirements. What you are seeing is a shift not in what providers do but in the way they record it. In the linear version of the SOAP note--history, exam and decision-making – the note ‘looks’ like the guidelines, they are in the same sequence. This has held true for decades, the information gathering comes first, then the assessment or decision-making arising from that work.

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And today’s EHR hospital admissions still follow that format, with the answer at the end. But I suspect what you are seeing is that in the follow-up notes, and maybe inpatient consults, the assessment and plan (A/P) portion comes first, at the top of the note, and then some of the supporting data follows.

Physicians and other chart users have long gone straight to the A/P section when reading, reviewing, or auditing a note. That’s where you find the summary data‑the answer, if you will--and depending on who you are, (why does it depend on who you are?) you’ll likely get the latest disposition or status of the patient.

The history and exam have always been more supportive in nature in a note – the under-pinnings of information that supports the A/P. Now with the EHR,some providers have broken with tradition and put this information below. It’s likely more of a time-saving device than anything, because you don’t have to scroll through two or three pages of data to get to the answer.

Is this allowed from a regulatory perspective? Well, there is no guidance saying that the components of a given note must be in a particular place. And there is Medicare commentary suggesting that if the information is in the record and easily found and attributed then it is acceptable. So for this component of your question the answer is that as long as all the components of the note are included, accurate, attributable, and meet all the other note requirements, then a change in sequence of the type described above is fine.

Next: 'What happens when the notes don’t change with the successive days?'

But your other comment, about copying from note to note, is likely much more concerning. A portion of Medicare’s definition of medical record documentation is especially relevant here:

The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates:

• the ability of the physician and other health care professionals to evaluate and plan the patient's immediate treatment, and to monitor his/her healthcare over time.

Set aside for the moment the obvious issues with copy and paste or cloning in the EHR.  The definition above includes two references to time: “chronologically documents” and “monitor his/her health over time.” There is an aspect of copying or cloning that transcends EHR misuse and goes to quality and care and potential danger to the patient.

Often the newer version of hospital follow-up notes have the A/P, or running problem list, copied from day to day, and updated with new and relevant information. This makes sense. It’s a good use of technology–the list for the most part doesn’t change, and sometimes the status of the problems and even the treatment doesn’t change.

But what happens when the notes don’t change with the successive days? When it’s no longer truly ‘chronological’ or monitors care ‘over time’? We see a note on day three that has for problem # 2, ‘start medication X’. Then we see the same entry on day four, and day five and maybe even day six. The patient was not started on that med each of those  days, so now we don’t really know when the patient started. Could another provider read the day five note, see this, and not realize that the patient has been receiving this drug for three days already?

Copying excessively without updating each element of the note or removing earlier entries can indeed lead to quality of care issues that go far beyond a documentation method or convention. Often we see several days of notes with compounded entries per problem that make it difficult to determine where a patient is in relation to a specific disease or problem.

Recently two providers on the same service disagreed whether the first entry after a problem or the last was the most current! So each individual his or her own assumptions to what are increasingly becoming shared services.

Inpatient follow up notes are prone to cloning in every component of the chart – the interval history, the exam and the A/P as described above. Every practice or group needs to develop an internal standard of documentation as to what constitutes an acceptable degree of copying. This is likely a regulatory hot spot of the near future – cloning is too easy to do, and to do wrong.