Analyze Your EHR for ICD-10 Readiness
Determine, target, and fix your system’s areas of greatest concern.
by Pam Brooks, CPC, PCS
On Oct. 1, 2013, all diagnosis codes will be reported with a new format: ICD-10. By this time next year, you should be able to demonstrate with confidence that your billing system is capable of transmitting and receiving ICD-10 codes in the newer three to seven character, alpha-numeric format. You may still be worried, however, whether your provider(s) and electronic health records (EHRs) will be able to reproduce the documentation necessary to report ICD-10 with the required specificity. A preliminary detailed analysis can help determine whether your EHR will be ready, functional, and compliant to support this new format when that fateful day comes.
Before you begin your analysis, familiarize yourself with ICD-10, particularly sections pertaining to your specialty. Obtain a draft copy, read the official guidelines, and note its conventions and code structure. There are two new exclusion notes (EXCLUDES 1 and EXCLUDES 2), and there is the new use of the “x” placeholder. You’ll quickly see, more often than not, the guidelines are quite similar to ICD-9.
You should also be familiar with your EHR, and how the templates and software interfaces operate to drop default documentation in progress notes. Analysis of this interface is the key indicator if your EHR has the capability to illustrate the patient’s condition with the specific detail required in ICD-10.
Although payers have not come right out and said so, coding experts suggest payers may limit the use of the “not otherwise specified” (NOS) and “not elsewhere classified” (NEC) codes (yes, they are available in ICD-10) in lieu of the more specific codes. Payer contracts mandate that we code to the highest specificity. This means that providers must document and diagnose in detail using one of the 79,000 codes devised for that purpose. The ubiquitous diabetes NOS code, 250.00 Diabetes mellitus without complication type ii or unspecified type not stated as uncontrolled, which crosswalks to ICD-10 code E11.9 Type 2 diabetes mellitus without complications, may not be acceptable by your payer, considering there are 204 other, more specific codes to report diabetes.
Although your billing software may be ICD-10 and 5010 compliant, if your EHR is not integrated, it may not have the capability to store and generate codes in the new alpha-numeric format. The patient’s past medical history and chronic conditions are all currently linked to ICD-9 codes.
Ask these questions of your vendor to see if your EHR is ready:
- Will my EHR be able to translate ICD-9 codes into the ICD-10 format?
- Will my EHR differentiate whether to report an ICD-9 or ICD-10 code based on the date of service?
- If my provider follows up on a condition that originated during the days of ICD-9, what will that encounter use as a diagnosis code after Oct. 1, 2013?
Work with information technology (IT) staff to examine these features in the EHR test environment.
Conduct the analysis specific to your practice’s coding patterns beginning with your top 20-50 reported diagnosis codes. Use this list to evaluate your EHR’s documentation capabilities for each of these codes when crosswalked to ICD-10 based on the additional codes, code descriptions and “code also” requirements for both ICD-9 and ICD-10.
For example, if one of your top ICD-9 codes is 300.00 Anxiety state unspecified, check the ICD-9 code description to see which other conditions are reportable using 300.00. Then, using a basic crosswalk as a preliminary guide (remember one-to-one crosswalks may be too nonspecific for payers to accept), determine which ICD-10 codes is appropriate for reporting each of those conditions. In this case, 300.00 can be used to report anxiety state, unspecified; anxiety neurosis; anxiety reaction; anxiety state (neurotic); and, atypical anxiety disorder. Then, use each of those descriptions to determine which ICD-10 codes are used to report them. Make a note of what is excluded in the ICD-10 descriptions that were included in ICD-9 because additional codes may have been created to be more precise. In this case, F41.1 Generalized anxiety disorder is used to report neurotic anxiety, F43.0 Acute stress reaction for an (acute) anxiety reaction, F41.8 Other specified anxiety disorders for atypical anxiety (other stated) disorder, and F41.9 Anxiety disorder, unspecified is used to report anxiety NOS. Remember: Payers may not accept NOS codes because we have so many, more specific code choices with ICD-10.
See if Your EHR Supports Documentation Requirements
When you’ve determined which ICD-10 codes could be used to report your common ICD-9 diagnoses, you will need to verify your EHR’s ability to document the signs, symptoms, and etiology of each disease. A robust EHR with the ability to document a great deal of the history of present illness (HPI) information might not be a blessing because the mention of certain symptoms can entirely change the code that should be reported. With anxiety, for example, if the patient also reports panic attacks or social phobias, the final diagnosis may be more appropriately reported as F41.0 Panic disorder [episodic paroxysmal anxiety] without agoraphobia or F40.10 Social phobia, unspecified.
Take a look at your frequently reported ICD-9 NOS codes. As noted in the earlier example of the diabetes codes (250.xx), there are many ICD-10 codes that are extremely specific. Each has a very detailed code description, such as E11.00 Type II diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC).
To evaluate your EHR’s abilities, ask yourself:
- Does it have the capability to illustrate this specificity?
- Is it a signs/symptom choice in the HPI template?
- Can you notate in the review of systems (ROS)?
- Is there an automated method (radio button or popup menu) to document this specificity?
- Will associated lab work provide supporting documentation?
- Where is the documentation stored in the EHR?
- Will your provider have to type in the details?
- Your provider could easily select this diagnosis from a drop-down ICD-10 list, but does his documentation support such a specific code?
This is why it’s important to take a close look at your most common diagnosis codes, so you can determine whether your EHR needs updating or your providers require additional education.
Another new feature of ICD-10 is the concept of laterality. In the example of shoulder pain (ICD-9 code 719.41 Pain in joint involving shoulder region), ICD-10 asks us to report whether the pain is on the left or right (M25.511 Pain in right shoulder or M25.512 Pain in left shoulder). Interestingly enough, ICD-10 continues to allow providers to report shoulder pain without specifity (M25.519 Pain in unspecified shoulder). If you were to use this code, you would run the risk of not supporting medical necessity if your provider did not report in which shoulder the patient was experiencing pain. For this reason, claim edits can be helpful in substituting unspecified codes with more specific diagnosis codes prior to claim drop.
EHR Must Accommodate Specific Secondary Codes
Even with the multitude of extremely specific ICD-10 codes, there are still situations where secondary codes are required to be reported. This is a current ICD-9 expectation, but the secondary ICD-10 codes are just as detailed as the primary codes.
For example, with S04.011 Injury of optic nerve, right eye, ICD-10 asks you to use an additional code to identify any visual field defects or blindness (H53.4-H54). It’s no longer sufficient simply to code the injury if other symptoms exist. Make sure your providers are aware that the secondary code is expected, and determine if your ICD-10 code library suggests it. If your billing system allows you to identify diagnosis codes when a secondary code is appropriate through a claim edit, you may wish to implement this.
You also should report the additional codes used to identify long-term medication use. Determine whether your EHR can be configured with a hyperlink to drop the additional code if the provider reviews that particular medication on the patient’s electronic medication list. Savvy IT technicians and reasonably robust software can take the sting out of ICD-10 implementation if you can harness the software’s abilities to work to your advantage.
Watch Out for Placeholders
The newest ICD-10 feature that has many coders (and IT professionals) worried is the concept of the placeholder. This is a dummy digit; an “x” placed typically in the fifth and/or sixth position to allow the additional placement of a seventh digit. This scenario is found when using injury and poisoning codes, and is used to report the timing of the patient encounter. For example, poisoning by antitussives, accidental, initial encounter is reported with T48.3x1A Poisoning by antitussives, accidental (unintentional), initial encounter. It will be important to make sure your EHR can document whether the visit represents the initial encounter, subsequent encounter, or sequela.
In the obstetrics world, the seventh digit is used to report multiple gestations. To report maternal care for breech presentation, fetus two, you would code O32.0xx2 Maternal care for unstable lie, fetus 2. Note that both the fifth and sixth digits require placeholders. Not only will your provider and EHR need to identify and report that the placeholders are required, but the documentation must be able to support which fetus is affected. Note also the use of the letter “O” and the number “0” (zero). Make sure your EHR can clearly identify these, and transfer them accurately into the 5010 format.
Use a Spreadsheet to Track EHR Capability
A good way to get a snapshot of this kind of analysis is to set up a worksheet template in either a database or spreadsheet format. For each of your frequently reported diagnosis codes, use a designated template. Headings can include the ICD-9 code, related ICD-10 codes, documentation criteria, EHR ability, and a comments field. Also include information in regards to secondary codes that might be required. The table below shows a partial example from a template set up to analyze diseases of lipoid metabolism. The comments will identify the specifics that need to be addressed within the EHR you’re evaluating.
EHR Capability Analysis
|Includes familial hypercholesterolemia||Must be documented in family history, and noted that it is related.||State whether familial or acquired (radio button?). Mention associated causes such as diabetes, or use of diuretics, beta blockers or estrogens (via text box).|
|Includes Fredrickson’s hyperlipoproteinemia, type IIA||Add hyperlipidemia in family history.|
|Hyperbetalipoproteinemia||State any relation to hypothyroidism, renal failure, nephrotic syndrome, ETOH use or endocrine/metabolic disorder.||Use hyperlipidemia template: Indicate risk factors, comorbidity, and DM management (available). For ETOH, or other conditions, text into “other.”|
|Hyperlipidemia, group A|
|Low-density-lipoprotein-type-LDL hyperlipoproteinemia||Indicate lab values: LDL and triglycerides.|
Verify your documentation requirements directly from the code descriptions, but don’t be afraid to look further to make sure you have the capability to report the most important elements of each diagnosis. If you are unfamiliar with the terminology or disease process, reference pathophysiology textbooks or query your providers to determine any related symptoms that support medical necessity. By using the existing EHR templates in your test environment, evaluate your EHR’s ability to meet documentation requirements. Note any issues or work-arounds that might affect the integrity of the patient’s note. You will use this information to outline your action plan.
Make Use of Your Data
After you’ve evaluated your EHR for quality documentation, what do you do with that information?
First, determine whether the issues you uncovered in your EHR software will be addressed in upcoming releases. Most EHR vendors are aware of the ICD-10 conversion, but are tackling it from a 5010 perspective, not necessarily the documentation/compliance perspective. You can work with your IT staff to determine whether template development or interface modification will improve your documentation capability. Having your analysis done in advance will allow you to target your areas of greatest concern, and will provide your IT staff with specifics regarding the modifications needed. You may decide that to expect physicians to assign their own ICD-10 codes is far too risky, and that pre-billing audits are necessary. By having this information in advance, you can prepare for, and support the use of, additional coding staff.
Working with providers on documentation training for ICD-10 will keep coders very busy for most of 2012 and 2013. Your analysis of the known issues in your EHR will help you devise a training plan specific to each diagnosis, so providers are aware of the pitfalls in terms of supplying incomplete documentation.
Besides obtaining an overview of the basics of ICD-10, providers will also need to understand how their code selections will have to be supported by the electronic notes they generate. Most providers who use an EHR are able to work through the templates and capture the data sufficient to support the patient’s chief complaint, but might not be prompted to type additional information to support a very detailed diagnosis if it’s not part of the EHR’s default template. If it’s not documented, a diagnosis—no matter how specific—is unsupported by the note. Start now by auditing a number of your providers’ notes to see if they meet the highly-specific standards of ICD-10 coding. By using a team approach, you can present your results as an early opportunity for training, and at the same time get their clinical input as to the specific documentation they would expect to see for the various conditions they treat.
Your ICD-10 conversion will be significantly smoother, and your transition time shorter, if you take the time now to evaluate your EHR’s readiness. If you are looking to buy an EHR in the near future, this can give you an idea of the right questions to ask. By getting a head start on the issues you might encounter on Oct. 1, 2013 you’ll be that much more prepared to lead your practice into a successful conversion.
Pam Brooks, CPC, PCS, is the physician services coding supervisor at Wentworth-Douglass Hospital in Dover, N.H. She holds her bachelor’s degree in Adult Education and Workplace Training from Granite State College, and is working on her master’s in health administration at St. Joseph’s College of Maine. She is the secretary of AAPC’s Seacoast-Dover, N.H. local chapter.