Enabling physician support of ICD-10 documentation requirements is one of the most important milestones in NYP’s ICD-10 project.  In order for NYP to be compliant with ICD-10, our physicians need to incorporate additional details into the documentation that they enter into their patients’ charts.  For example, proper ICD-10 coding requires information about the cause of a patient’s condition, the severity of that condition, and how long the patient has experienced it – details that are not necessary for ICD-9 coding.

NYP is supporting physicians in providing this additional documentation through several avenues.  The Documentation Improvement team has been training physicians on the additional ICD-10 documentation requirements for their specialty.  Documentation Nurses are also beginning to incorporate ICD-10 documentation requirements into their chart reviews, sending queries to physicians whose documentation is missing details that are needed for ICD-10 coding.

Additionally, the ICD-10 Provider Education and Adoption workgroup has collaborated with the IT department to develop a tool that is embedded in the Allscripts Sunrise Clinical Manager (SCM)Electronic Medical Record that helps guide physicians to provide ICD-10 required documentation while they are in the patient’s chart.  Called ICDx, this tool will launch automatically when a provider opens certain types of notes.  The tool helps providers maintain an accurate ICD-10 problem list which drives documentation that can be readily coded in ICD-10.  By guiding physicians to include ICD-10-compliant documentation while they are in the patient’s chart, the tool should reduce the need for subsequent queries from Documentation Improvement nurses.

The ICDx tool is currently being piloted with twelve physicians, who have provided mainly positive feedback.  The team is incorporating some requested changes into the tool, and plans to launch the tool institution-wide for the ten most frequently used notes on each campus later in the spring.  The tool will be incorporated into additional notes over time in order to ensure that our physicians can easily provide the required documentation for ICD-10 coding.

In preparation for the expected transition from ICD-9 to ICD-10 on October 1, 2015, evaluation of the impact that this change will have on NYP’s quality measures data (e.g. – AHRQ Patient Safety Indicators, Value Based Purchasing) used for public reporting, is a critically important undertaking.

ICD-10 has greater specificity and detail for both diagnoses and procedures.   This enhancement provides better data for use in assessing patient severity, outcomes, and quality of care. Understanding the differences in the ICD-9 and ICD-10 definitions is important in assessing changes or shifts in volumes or outcomes observed. Increases or decreases in case volume and case compliance could impact publicly reported data, affect reimbursement, and change how NYP compares to and ranks among other peer organizations. Some measures, because of ICD-10’s impact on the qualifying patient populations could lead agencies to question the original intent of the measure, refinement of the measure, or even lead to some measures becoming obsolete.

Everyone is in a learning phase. NYP is in the process of thoroughly reviewing ICD-10 code set conversions and estimating changes in patient populations and the metric results for approximately 23 different safety and quality indicators. To date, four of those measures appear to be potentially affected by the transition. An example of one those measures, accidental puncture and laceration is included here.

To conceptualize the increase in number of codes, predominately due to specificity, that will occur in moving from ICD-9 to ICD-10 that are utilized in various inpatient quality measures reporting see TJC specification manual reference documents and website.

In the context of healthcare, “coding” refers to the process of converting words or phrases from the medical record into standardized codes that capture the conditions of a patient (diagnosis codes) and what we did to treat those conditions (procedure codes). In the inpatient world, these codes are analyzed to yield a single Diagnosis Related Group (DRG), which is the basis of reimbursement for Medicare, Medicaid, and many other payers. The codes are also used for various types of research, e.g. on outcomes and other measures of quality. The current code set is ICD-9 (ICD stands for International Classification of Diseases), and the next version will be ICD-10.

A tool called an encoder helps the coder to arrive at each diagnosis or procedure code by asking them a series of questions about the case. Next, another tool called a grouper analyzes the codes to yield a DRG for that inpatient discharge. Because the DRG is the basis for how we get paid, getting the ICD codes correct is vital to ensure appropriate reimbursement.

Dual coding refers to the assignment of both ICD-9 and ICD-10 codes to a given patient visit during a single coding session. Because ICD-10 is almost always more complex than ICD-9, the encoder provides additional prompts to the coder in order to gain the additional information that is required to produce ICD-10 codes.

Dual coding is a transition-period function that will help us prepare for ICD-10. Some motivating factors for dual coding are listed below. As part of the ICD-10 project, NYP has coded more than 5,000 inpatient cases and hundreds more outpatient cases in ICD-10 to satisfy these goals.

1. Coder practice and proficiency. NYP employs dozens of coding professionals to translate the care documented in patients’ medical records into billable and reimbursable diagnosis and procedure codes. This group is as affected by the transition to ICD-10 as any in the organization. The more time they are provided to practice and master coding actual claims in ICD-10, the greater chance for NYP success.
2. System and interface testing. Dual coding allows us to determine whether our systems and interfaces are capable of handling ICD-10 codes, and to take corrective action if there are issues. This applies to both our internal systems and to external systems used by payers, clearinghouses, registries, etc.
3. Financial impact analysis. Dual coding a case generates two DRGs – one for ICD-9 and one for ICD-10.   If the DRGs (or other metrics such as Severity of Illness, or SOI) don’t match, further investigation is warranted. Sometimes a DRG shift is due to human error, and so highlights an educational opportunity. Other times, correctly coding the chart in ICD-9 and ICD-10 results in two different DRGs, which means our reimbursement could change. In these cases, we may comment to Medicare to request that they alter their methodology.
4. Claims testing. We want to be sure that our payers are ready to process ICD-10 coded claims, and that they get the same DRGs that we do. If our DRGs don’t match, we need to explore why.
5. Quality metrics drift. Dual coding cases that fall within the metric population for various quality metrics, e.g. core measures and patient safety indicators, allows us to see whether the metric population may shift under ICD-10, which could result in changes to our performance on those metrics.
6. Medical Necessity testing. Dual coding can help to identify cases that met medical necessity in ICD-9 but do not in ICD-10, or vice versa.
7. Clinical documentation improvement. The best way to prepare providers for the additional document requirements of ICD-10 is with actual examples. When the coder is responding to the encoder’s prompts during a dual coding session, if they are not able to respond to a question because of inadequate documentation, this indicates an opportunity to provide education to providers.

At NewYork-Presbyterian Hospital, employees across the organization use reports for a wide variety of purposes.  Whether we’re looking at operational metrics like length of stay and discharges, quality indicators like readmissions and infection rates, or financial measures related to billing and payment, it’s important that our reports be accurate and up to date so that we can make informed decisions.  Because many of the reports we rely on to run our departments, practices, and units contain ICD-9 codes, the upcoming transition to ICD-10 means that we need to update our reports to reflect the new code set.

The ICD-10 IT workgroup, headed by Ken Thibault, has been leading the effort to ensure that all necessary reports are converted to ICD-10.  The group has already created an inventory of about 150 reports that use ICD-9 codes, and has begun the process of determining which ones need to be updated, collecting the relevant ICD-9 codes, and converting those ICD-9 codes to ICD-10 codes.  Once the ICD-9 codes are mapped to ICD-10 codes, the mapping is sent to the report’s business owner for approval, at which point IT will make the necessary updates so that the report will populate properly once we transition to ICD-10.

If you are a business owner of reports, you should be hearing from the ICD-10 team in the next month or two so that we can work with you on converting your reports.  If there are reports that you use that you want to make sure are on the inventory, please reach out to the IT team that manages the system in questions.  We look forward to partnering with you to ensure that your reporting needs continue to be met post October 1^st, 2015.