ICD-9 is 30 years old, has outdated and obsolete terminology, uses outdated codes that produce inaccurate and limited data, and is inconsistent with current medical practice. The code set cannot accurately describe the diagnoses and inpatient procedures of care delivered in the 21st century. For example, in the fracture coding with ICD-9-CM there is no laterality notated in the codes. If a patient happens to be treated for successive ankle sprain, for example, there is no way in ICD-9- CM to indicate right from left. There are also no current codes to show the episode of care for injuries (initial active treatment or subsequent treatment after initial care, etc.) in ICD-9-CM.ICD-10 will provide benefits such as increased specificity in clinical information that can lead to more accurate and timely reimbursements, better quality of patient care and improved disease and care management. Critics are more skeptical about what benefits will actually be gained by health care providers in the near and maybe distant future. Regardless of perceived value, the implementation of this new code set will be a major challenge and will impact the vast majority of people working in the health care field. Because ICD-10 will permeate all aspects of our health delivery system, a sound understanding of the new coding standards, coupled with effective education, will be necessary for a successful ICD-10 transition.
The ICD-9-CM and ICD-10-CM Official Guidelines for Coding and Reporting state, “The importance of consistent, complete documentation in the medical record cannot be overemphasized.” Poor documentation can lead to errors and inefficiencies which can directly impact patient care and revenue.Understanding the new documentation requirements for ICD-10-CM is vital to a successful transition to ICD-10. ICD-10-CM requires more detailed documentation for assignment of the most specific diagnosis code(s). Clinical documentation is a vital component that represents the medical condition of the patient and, therefore, has always played a vital role in medical coding. With the implementation of ICD-10, documentation must include a level of detail that can support the increased specificity required withthe ICD-10 code set. The ICD-10 transition will require a behavioral change for many physicians who are not used to documenting with this level of specificity and could be as much of a challenge as learning the new code sets. See chart for an example from AAPC of an outpatient clinical note that highlights thespecifics needed for proper ICD-10 coding.
Clinical documentation has always proven to be a challenge. From the example one can conclude, the new coding version is not a simple substitution of one code set for another, the learning curve is expected to be quite steep for clinicians, coders, and administrative staff, particularly for small – and medium-sized organizations that do not employ certified coders. Physicians will face the need to make documentationimprovements to meet hospital and medical necessity requirements. Being prepared is paramount for ICD-10 implementation! There are significant consequences of poor preparation for the transition. Educate the physicians on how documentation impacts the success of the organization (and them!)under ICD-10. Tailor education to physicians to ensure that when coders are ready to assign ICD-10-CM/PCS codes, the documentation won’t be a barrier to their success.
