Coding Quandary

Overcoming the ICD-10 clinical documentation problem is a tall order. Here are some tips to help you tackle the task. 

By Lena Kauffman

With the October 1, 2015, implementation date for the International Classification of Diseases and Related Health Problems 10th edition (ICD-10) fast approaching, one growing area of concern is the current quality of physician clinical documentation, say Radiology Business Management Association (RBMA) instructors and billing experts.

Kathleen G. Bailey, CPA, MBA, CPC, CPMA, CPC-I, CCS-P, an RBMA U faculty member who teaches traditional and online coding, health IT and administration subjects, has asked hundreds of coders and medical office managers if they currently have enough clinical information to code in ICD-9 and nearly all say “no.”

“Because ICD-10 is more specific, this problem is only going to get worse,” she warns.

In theory, ICD-10 should give physicians a strong incentive to improve their clinical documentation because it impacts their ability to get claims paid just as much as it does a radiology business. However, past experience has shown that when it comes to clinical documentation, there are some things even money can’t buy.

“Anybody that provides poor data now is not going to automatically be wonderful when we get to ICD-10,” says Jenny Studdard, a member of the RBMA’s Coding Subcommittee as well as a senior consultant with Coding Strategies, Powder Springs, Ga.

So what can radiology businesses, or any medical practice for that matter, realistically do to avoid problems with poor clinical documentation that will prevent proper claim coding once the more specific ICD-10 codes go into effect?

Starting the Conversation

Kathleen G. Bailey, RBMA U Faculty Member

Before you begin reaching out to referring physicians and your own radiologists about the need for better clinical documentation, you need to make sure you are embarking upon a conversation and not a lecture, say Bailey, Studdard and other RBMA coding experts.

“You can’t scare people and then ask them to be participatory,” Bailey explains.

Instead, she advocates listening to the physicians, asking for their feedback and most of all giving them specific information that is directly relevant to the work they do.

“They need to understand that quality and proper patient care is something that requires thorough clinical documentation,” she said. “If we are not communicating that ICD-10 supports patient care, we are doing physicians a huge disservice. Is it more specific? Yes, it is much more specific. Are there things in ICD-10 that need to be improved on? Yes, absolutely. But I think we’ve scared physicians about all of these crazy accident codes that you hear about, and those are rare occurrences. On a day-to-day basis, what you get with ICD-10 is better documentation of pressure ulcers, better documentation for fractures and the healing of fractures, better documentation for diabetes, and so on.”

Understand the Physician Perspective

Jenny Studdard, Coding Strategies

It also helps to appreciate the challenges physicians face in improving documentation in today’s already rapidly changing healthcare marketplace. For example, a lot of hospital physicians must use electronic medical record (EMR) systems that complicate documenting details on signs and symptoms, both Studdard and Bailey note. The numerous pull-down menus in these EMR systems push physicians toward doing part of the work of diagnosis coding. Consequently, these physicians may be understandably reluctant to learn about ICD-10 coding documentation requirements because they fear that this is yet another way to get them to do more of the coding work in an already cumbersome EMR.

“Throw ‘diagnosis code’ as a term out the window when talking to physicians and instead focus on the clinical terminology that needs to be documented,” Studdard advised.

In other words, don’t talk about codes, talk about quality. Connecting the dots between better clinical documentation, more specific diagnosis coding and higher quality care should get physicians’ attention because they know that future payment is being linked to quality of care, Bailey says.

“We need to explain that what we are doing here is going to give them ways to make sure they are providing better care, and they can document that care and make sure that their reimbursement will be there as everything moves to quality,” she said.

If your practice has a marketing staff, enlist them in carrying the ICD-10 documentation requirements message to top referring physicians, Studdard advises. “It gives them something to go out and talk to the doctors about and become that value added,” she said. “Make the message relevant and specialty-specific, so there is one message for oncology and one for orthopedists, for example.”

Target Your Efforts

Debbie Mann, Advocate Radiology Billing and Reimbursement Specialists

What overwhelms many about ICD-10 is how many more codes there are compared to ICD-9. However, the typical radiology practice will only use a small fraction of all of those codes.

Debbie Mann, CPC, RCC, ROCC, an RBMA Radiology Summit faculty member and coding documentation and education manager with Advocate Radiology Billing and Reimbursement Specialists, in Powell, Ohio, advises practices to start by determining the top 10, 20 or even 50 diagnoses they most commonly bill and then examining what the clinical documentation requirements are for these diagnoses and whether the practice currently has the information it needs to code for those claims, or if they are at risk of denial for insufficient clinical documentation once ICD-10 is implemented.

“We try to identify the top codes and then identify which need physician improvement and which need facility improvement based on the three categories of (1) location, (2) context and severity, and (3) associated signs and symptoms,” she said.

Studdard agrees. “If you can tackle the things you see the most, you will get the biggest bang for your buck and then you can deal with the little things that happen once or twice per quarter,” she said. “If everybody looked at their diagnosis codes and looked at where their highest volume is they would probably see that 80% of those services is less than 20% of the codes. By looking at high volume and high dollar (i.e., what is it that most impacts your MRI, your CT, your PET study?) you will be able to target your efforts.”

In addition, break your analysis down by referral source and enlist your coders, technologists and radiologists in identifying the referring facilities and physicians that consistently provide adequate clinical documentation as well as the ones that do not provide adequate documentation.

“The coders know who the biggest offenders are, so ask the coders for feedback on who has the worst clinical data coming in from the referring physician side,” Studdard said. “That way, the marketing team can take those specific examples to that provider and say ‘We see a lot of orders from you on this condition and do you know that in ICD-10 you are going to need to document this for your records as well?’ That way it is something that is specific to what that provider sends.”

This approach has the advantage of recognizing the individuality of each group or facility your radiology practice works with. There may be a problem at one that you can fix and not a problem at another.

In addition, you can help physicians by showing them that some of the ICD-10 coding documentation requirements are really not as difficult as they may have been led to believe. For example, many of the new codes simply indicate if the condition affects the left or the right side of the body. “An easy practice change that we’ve gotten our doctors into is just having laterality,” explains Jennifer Bash, who like Mann is an RBMA Radiology Summit faculty member and coding documentation and education manager with Advocate Radiology Billing and Reimbursement Specialists. “That will cut down on a lot of the unspecified codes.”

Finally, having champions within facilities or referring physician groups is important in getting your message across because physicians will listen to colleagues more readily than they will listen to a radiology practice manager or billing coder. “You need somebody on board with your effort,” Bailey said.

Look at Your Other Existing Resources

Jennifer Bash, Advocate Radiology Billing and Reimbursement Specialists

Having ongoing conversations with providers is of course very important, but it is not the only thing that can be done. Studdard encourages a three-pronged approach where the other two prongs are using internal resources for collecting additional clinical data and technology solutions.

“[Radiology practices] should look at the clinician workflow processes in their facilities and see if there are areas where they can utilize their clinicians to collect additional information before the radiologist gets the imaging study so that the information can be presented in that reading workflow,” she said. “If they look at that and they see they have CTs that come from a certain provider with very little information, they can then identify a person in the CT department that can reach out to that provider to get additional information. They can also look at the history and screening forms to see if there are areas where they can add questions to collect some chronic diseases or additional information that is relevant to the exam being performed.”

Remember to count your technologists as clinicians. “I think the techs are often forgotten,” Bash said. “Make sure the techs are identifying when they are not getting a good signs and symptoms and the order doesn’t make sense. Then they need to have this conversation with the radiologist so that this habit can change and they are not continuing to get patients without indications.”

Schedulers can also help pull in important information when on the phone or speaking in person with the patient, Bash notes. In addition, technology solutions may include exploring greater sharing of clinical information in the EMR with coders, if interoperability and patient privacy concerns can be overcome. That way, providing the necessary clinical information to coders is not solely up to physicians.

“For example, I don’t know an oncologist out there who is going to start chemotherapy or plan radiation on a patient that doesn’t know exactly where the cancer is,” Studdard said. “They have that documented in the chart, it is just usually not communicated because they don’t realize that coders now need that same level of detail.”

Analyze Your Risk

Finally, it is important to recognize that while you can reach out to physicians and facilities to try to improve clinical documentation for coding, you can only ask and not demand. Mann and Bash see hospitals at all stages from those who are well prepared and have taken a department-by-department approach to physician documentation ahead of ICD-10 to those who have not done much at all to prepare. “We can do our best to train our coders, but at the end of the day we are still reliant on providers and payors to do their piece, which we have no control over,” Bash said.

Since inadequate clinical documentation can hold up claims, it is important to have a sense of how many of your claims may be impacted ahead of ICD-10. If enough claims will be held up, you may need to prepare a cash reserve and negotiate with vendors in case your cash flow is impacted.

“It goes back to identifying where the outliers are and what affects your individual practice,” Mann said. “With the physicians, you’d like to think that everyone is dealing with ICD-10, so really the data should be better across the board, but we really don’t know.”

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Lena Kauffman is a contributing writer for the Radiology Business Management Association, a national not-for-profit association providing its approximately 2,300 members with applied business information and intelligence applicable in radiology private practices, academic radiology groups, imaging centers and hospitals.