# ICD-10 Frustration



## hsmith67 (Jun 21, 2013)

Getting up on my soapbox, can anyone help me here?

It seems 100% of the "focus" on the ICD-10 transition is all about ... drum roll please..."clinical documentation needs to allow coders to code to the appropriate ICD-10 code." 

It simultaneously seems 100% of the education, seminars, etc. on ICD-10 transition targets billing staff and coders.

Am I the only person that sees the huge disconnect here? Coders and billers don't do clinical documentation, the clinicians do! 

I have a medical billing company with clients in cardiology, urology, Family Medicine, Internal Medicine, and geriatrics. I'm married to an Internal Medicine doc. I just asked her what literature has the AMA sent her about improving her documenation for ICD-10? Answer: None. What literature has the AACP (Americian College of Physicians - the college for Internal Med) sent you for preparing for ICD-10? Answer: None.

When I talk to my billing clients as well as my consulting clients that span the same specialties and also include Ortho, Neurology, and GI, I get glazed over eyes from the clinicians and they basically tell me to go away, it's not their problem. Clinicians have not been educated by their medical organizations and I don't see that changing. Clinicians, in general, are not open to change and especially not open to listening to coders and billers. As I see it, this is setting us all up for failure and next October and the next several months after are going to be very painful. 

Does anyone know of any CLINICIAN CENTERED education opportunities, seminars, etc. that clearly explains ICD-10 transition success is THEIR responsibility and NOT the sole responsibility of coders and billers?

Thanks for any advice anyone can offer. 

Hunter Smith, CPC


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## bridgettemartin (Jun 21, 2013)

The AAPC will be offering on-line training geared towards physicians beginning sometime this summer.  Go to the ICD-10 tab under code set training, and there you'll see a site for physicians.


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## jimbo1231 (Jun 21, 2013)

*See the Same thing*

Hunter,

I'm seeing pretty much the same thing. All kinds of training, webinars, publication aimed either at coding or IT. Coders can be completely trained and both provider and payor systems can be completely ICD-10 compliant(well, probably not) come 10/14; but if the documentation doesn't reflect the granualrity, specificity, laterality etc  etc of ICD-10, there is going to be massive exception processing; charts returned for clarification, or not coded at optimum level of specificty. Add that to the loss of productivity and the probable payor mess, and we could be looking at a perfect storm.
I do think that some billing companies that specialize in certain specialties like Emergency medicine or Radiology, have begun talking to their providers about ICD-10. And many might be intimidated by hitting their overstressed clients with more stress. I'm surprised not to see more professional societies including ICD-10 in the agends of their national and regional meetings. Although there will be more of that. Maybe the provider industry thinks the whole thing won't happen.
I am going to put together a seminar aimed at ED documentation for ICD-10. But I'll keep an eye out for trianing for providers on ICD-10 documentation.

Jim Strafford  CEDC  MCS-P


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## mitchellde (Jun 21, 2013)

What I am suggesting to my classes is that they try to set aside a minimum of an hour each week and look at claims they have coded the previous week, then using the documentation recode them with the ICD-10 codes,  From this they will get a great picture as to where the documentation is insufficient, this feedback then should go back to the providers.
For instance did you know with ICD-10 Cm you can no longer use UTI unspecified for a dx of urosepsis?
Are you aware that most providers never document osteoarthritis as being primary or secondary, and yet most code this as 715.1- and it should be 715.3-; there is no ICD-10 equivalent to 715.3-, there is only primary, secondary, unspecified.  It must be documented as primary to code as primary.
Most providers never communicate how the laceration occurred when the patient come in for suture removal yet we need to know this for ICD-10 CM.
And I can go on and on.  But if the office coders do know the ICD-10 guidelines and codes and how to apply them, how are the providers going to come to understand that the documentation needs to reflect certain things.  Oct of 2014 is too late for the office to start using these codes.  The code books are available and need to be purchased so that practice can begin.


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## hsmith67 (Jun 21, 2013)

Some great ideas, thanks. I really like what you are doing mitchellde, I'd like it even more if the providers themselves were told to code to ICD-10 based on their documentation!

Bottom line is what gets providers attention? Money. My fear is that as Jim alluded to, we will not get the providers on board with better documentation until there is a financial impact (perfect storm) and that will not be until November-December of 2014. Then it will be one heck of a firestorm drill to play catch up when this perfect storm could be avoided by getting their attention to improve documention BEFORE the financial impact of not changing hits. This is probably all rhetorical, but I felt compelled to say it anyway. 

I just feel that the AAPC is to support us and I feel the AAPC should drive the bus to get the message home to all the clinical organizations, specilist societies, etc.  that the success or lack of success lies with the clinicians documenting to a level that allows us to do our jobs. I feel I'll be "ready" but I will not have providers changing how they document to justify my readiness.

Please feel free to keep the ideas and suggestions coming. 

Thanks again!

Hunter Smith, CPC
p.s. Thanks for the tip bridgettemartin about AAPC education geared toward the clinicians.


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## bridgettemartin (Jun 21, 2013)

We have started doing what Debra has suggested.  Our coding team has a weekly ICD-10 meeting.  During that time we take operative notes that have already been processed and  code them using the 2012 draft version of ICD-10.  We've only been doing it for 3 weeks now, but have already come across some potential issues in our documentation.  I am using these "discoveries" to educate our physicians.  I developed a monthly newsletter, and each month I highlight a disease process that effects our Practice and am asking our providers to change the way they document now.  
I also just remembered...there is a really good AAPC webinar from October 2012, entitled "ICD-10 Clarity on what will happen-not horror stories".  it's given by a physician and in it he talks about how to approach physicians about the change, and what not to do as well.  I thought it was a very good webinar.


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## camillecoder@hotmail.com (Jun 21, 2013)

check out your state's medical society.  Washington State Medical Association has offered material directed at the providers.


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## shaundra38 (Nov 23, 2013)

Sadly the physician will not pay attention until money slows down. But I would encourage any biller/ coders to do what I learned years ago at a Nephrology seminar on how to get a raise!. Doctors only talk in dollars, someone in each practice has to take the time to compare, crosswalk and indicate coding differences from ICD-9 to ICD -10. If you would take lets say 10 patients a day for a week, crosswalk the codes, show the indications of change ie...title, name change, Laterality , etc, then take it another step further pull up payers for each person, what claims originally paid for ICD-9.....STOP!....with same patients, with new indications show the physician that if this new documentation is not indicated the chance of these claims being paid after Implementation is unsure. Show the physician the loss of money!...that will get them on board!


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## MarcusM (Nov 23, 2013)

I was at a Texas Medical Assoc. Meeting on ICD 10 and they are proactive.  However, we need to educate the doctors.  UHC offers their opinion of a 30-40% decrease in revenue during a 4-6 month period after this kicks in, and there is already too much money invested to delay any further.  Damn the torpedoes, full speed ahead, just like Obamacare.  So the doctors need to get anal and use lots of adjectives, new vs old, controlled and stable, right, left....like they are explaining their work to a fourth grader.  When you go from a system with TWO dx codes for broken patella to a new system with over 300 dx codes for a broken patella, you can see the effect this will have.  Those who adapt, adjust and make these critical changes sooner rather than later will not only survive, but will prosper.  Throw out the old archaic and soon to be obsolete stuff, and embrace the insanity.


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## pandorarose3 (Dec 7, 2013)

I agree here, most physician's blow stuff off till it starts hitting them where it hurts. their check books.  A lot of physician's are still under the impression of 'it won't affect me' attitude and there is no waking some of them up till the pots on the burner cooking and their checks start to slow down.  Then it will be WHAT THE....  

The funny thing about what someone said about the AMA I tried contacting them a few months back for a speaker to come to my chapter.  They told me their ICD 10 reps were all out in the field talking to physician's about ICD 10.  

The associations have probably tried to reach out to many physician's but they may just be blowing it off as someone elses responsibilities, or worse yet still a pipe dream.



shaundra38 said:


> Sadly the physician will not pay attention until money slows down. But I would encourage any biller/ coders to do what I learned years ago at a Nephrology seminar on how to get a raise!. Doctors only talk in dollars, someone in each practice has to take the time to compare, crosswalk and indicate coding differences from ICD-9 to ICD -10. If you would take lets say 10 patients a day for a week, crosswalk the codes, show the indications of change ie...title, name change, Laterality , etc, then take it another step further pull up payers for each person, what claims originally paid for ICD-9.....STOP!....with same patients, with new indications show the physician that if this new documentation is not indicated the chance of these claims being paid after Implementation is unsure. Show the physician the loss of money!...that will get them on board!


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## Denise0728 (Dec 24, 2013)

*Icd-10*

I enjoyed reading the comments and opinions on ICD-10.  One link I use a lot for myself to stay informed and educated (beyond AMA and CMS) is ICD-10 Monitor.  Here is a link for a decent article in speaking with the clinician.

http://icd10monitor.com/enews/item/...ocumentation-for-icd-10-clearing-up-the-chaos

A couple of points I try to make (and I am not always heard the first time it is stated) is the documentation guidelines are NOT changing - the coding of the documentation is.  However, many, many clinicians have become lax, abbreviated or have flat moved away from the  documentation guidelines.  95/97 DG?  These are NOT new guidelines.

Sometimes this reminder will hit home.

Good medical decision making IS happening;  ICD-10 will require the documentation to be expanded.  None of us will be experts at the 48,000+ ICD-10 codes.  But for efficiency, accuracy, specificity sake... we will need to be experts at our own practice's top 10, top 25, top 100 (and we will keep increasing) for ICD-10.

HTN, DM, CAD - benign?  Controlled? Coronary Artery Disease or Carotid Artery Disease?  These are some examples of what is NOT going to be passable documentation with ICD-10.  

Finance neutrality and procrastination can be hugely detrimental.

All that being said; to the coders I say to be a value you must be a resource.  We are as much educators as coders.  Now, is the time to have a process, a form of feed back to share and direct your clinicians to the expanded and consistent documentation.

In truth; I believe it will be equally our (the coding profession) responsibility to educate ourselves as well as our clinicians in the expansion of ICD-10.  

Now, dont get me started on Level ll CPTs and PQRS - that is a whole other soapbox -   financial impact is TODAY/right now!


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## Pam Brooks (Dec 24, 2013)

Although this board tends to be aimed at Pro-fee coders, there are some of us who code at the facility.  And we have noticed (as we begin training on I-10) that there are some coding conventions and changes that we didn't anticipate.  For example, when coding outpatient rehab services, we used to code V57.9 (encounter for rehabilitative services).  Now, we'll be coding the injury (according to the seventh digit) or the late effect.  That's entirely new, so as we've been doing our dual-coding for each hospital service, we're identifying changes to our coding process to supplement our staff training.  What we learned, is that we can't always use the ICD-9 to ICD-10 crosswalks, since V57.9 crosswalks to an aftercare code.  The convention for coding rehab services now tells us to code the injury with a subsequent (or sequelae) indication in the 7th digit.  Interesting stuff and a reminder to us that those crosswalks are not foolproof.  I'm spending some significant time with the AHA's ICD-10 coding clinic updates (in my free time!) as a result.


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## lorrpb (Jan 5, 2014)

Please remember that the intended use of GEMS is for data tracking and conversion of large databases. GEMS are NOT to used to code patient cases, and the situation you describe regarding rehab is an excellent example of the reason why.


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## FractalMind (Dec 3, 2014)

*ICD-10 index default to primary type OA*



mitchellde said:


> What I am suggesting to my classes is that they try to set aside a minimum of an hour each week and look at claims they have coded the previous week, then using the documentation recode them with the ICD-10 codes,  From this they will get a great picture as to where the documentation is insufficient, this feedback then should go back to the providers.
> For instance did you know with ICD-10 Cm you can no longer use UTI unspecified for a dx of urosepsis?
> Are you aware that most providers never document osteoarthritis as being primary or secondary, and yet most code this as 715.1- and it should be 715.3-; there is no ICD-10 equivalent to 715.3-, there is only primary, secondary, unspecified.  It must be documented as primary to code as primary.
> Most providers never communicate how the laceration occurred when the patient come in for suture removal yet we need to know this for ICD-10 CM.
> And I can go on and on.  But if the office coders do know the ICD-10 guidelines and codes and how to apply them, how are the providers going to come to understand that the documentation needs to reflect certain things.  Oct of 2014 is too late for the office to start using these codes.  The code books are available and need to be purchased so that practice can begin.



Hi Debra,

We have a debater whether to assign the default primary OA codes for certain sites: (Knee, hip, etc.). For example, when the provider only documents "Bilateral Knee OA" you get the primary OA code M17.0 by default in the index. 

Also, what ICD-10 should be assigned for "Bilateral shoulder OA"? There's no specific code in ICD-10, should we assign M19.011+M19.012 since it is specified that OA is present in both shoulders...?


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## mitchellde (Dec 3, 2014)

You should not default to primary OA, the provider needs to document it as primary or degenerative in order to code it specifically.  In ICD-9 there is a choice 715.3- for not stated as primary or secondary, this choice does not exist in ICD10-CM.  The coder cannot assume it is primary.  If there is no bilateral code choice for the area you have, then yes you will select two codes, one for the right side and one for the left side.


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