For all the negative press ICD-10 has gotten over the past few years, it has the potential to have a tremendously positive impact on the quality of patient care. The new system will require more accurate clinical documentation, increase the amount of data collected, improve quality measurements, streamline claims processing, and ultimately improve the quality of care provided to patients.
The new implementation date of ICD-10 October 1, 2015 will be important because it will provide updated terminology and increased specificity in a variety of areas, which ICD-9 does not currently provide. Most critical is the need to replace the ICD-9 procedure classification, which is outdated, can no longer be expanded, and is unable to keep pace with advances in medicine or medical technology, as well as demands for increasingly detailed healthcare data.
In addition, the enhanced specificity of ICD-10 provides assistance with delineating clinical populations. The expanded codes more effectively capture data about signs, symptoms, risk factors, time frames, laterality (left vs. right), complications, and comorbidities. The system also differentiates body types, procedure types, surgical approaches, and devices used in treatments.
The implementation of ICD-10 offers many quality benefits. The additional granularity of data collection and detail will require improved clinical documentation and care decisions, facilitate ongoing performance improvement, enhance evaluations of population health, and enable comparisons across the continuum of care.
The transition to ICD-10 in 2015 presents a perfect opportunity to establish a clinical documentation improvement (CDI) process at your facility, if you do not have one underway already. Following are some areas on which to focus your CDI:
Laterality: A renewed emphasis on laterality within documentation under ICD-10 is intended to enhance communication between providers as they formulate each patient’s story; all of the complexities and factors affecting the care of the patient are expected to be recorded. The goal is to improve the quality of care provided to the patient.
Disease pathophysiology: Disease pathophysiology, or the study of ongoing changes in the disease state, is much more detailed in the ICD-10 disease descriptions. Documentation must reflect the highest level of known pathophysiology for diseases so that CDI specialists can identify the most accurate level of severity.
Combination codes: Combination codes have been created to merge two diagnoses that typically are related to one another. In ICD-10, this means some codes now have six options, whereas they had one or two options previously under ICD-9.
Encounter timing: ICD-10-CM requires documentation of the type of treatment that is rendered for specific conditions, such as injuries, signs and symptoms, and external causes of morbidity. Stage of care is also a critical element of this documentation.
Identification of trimester in ICD-10: For obstetrics clinicians, new definitions of trimesters have been introduced. In addition, each episode of care must be reported along with the patient’s trimester.
Increased disease specificity: ICD-10-CM has expanded many code descriptions to connect complications and manifestations with conditions.
Alcohol and drug abuse: ICD-10 has clarified the way alcohol and drug abuse and dependence should be documented to mitigate confusion when attempting to accurately represent the patient’s condition. This will include effects, aspects, and manifestations of substance abuse.
Expansion of injury codes: Documentation of the sites and types of injuries will be required in ICD-10.
Post-procedural disorders: ICD-10-CM requires documentation to indicate if a condition or disorder is caused by or follows a procedure. Every physician needs to clearly state if a procedure caused a negative impact to a patient’s condition.
Documentation practices will be the primary driver for success in ICD-10. There will be significant changes required in clinical documentation, specifically in the areas of disease specificity, anatomical site and laterality, complication and manifestations, obstetrics, and correct use of medical terminology and naming. Providers must adhere to these changes to increase the specificity of the codes as well as decrease the potential for coding errors and unpaid claims that could impact reimbursement or quality of care.
Training is the key to preparedness for ICD-10 in 2015. Training your clinicians and providers on the code specificity is the first critical step in preparing for this transition. Your education programs should be well underway to ensure that your staff members are educated on the appropriate anatomy, physiology, and level of ICD-10-CM/PCS training required for each member’s role and work setting. October 2015 will be here before you know it!