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At this point in the implementation process, your practice should begin documentation assessments. Documentation will have the largest impact in ICD-10-CM implementation. Since ICD-10-CM has more specificity embedded in the code description and up to seven characters to include this specificity, you must verify that current documentation in the medical record can support ICD-10-CM code assignment.
Whether your practice uses an internal staff member or an outside consultant, auditors should be experienced in both auditing and ICD-10-CM coding and guidelines. Records should be selected at random and should be based on your practice's commonly used diagnosis codes. These records should incorporate E/M services, surgical procedures, and diagnostic services performed in the office.
Using an clinical documentation assessment tool, take an in-depth look at the current level of documentation in the medical record. Review any lack of specificity in the documentation and analyze how to begin the improvement process. This can be done by assessing two intrinsic questions for each piece of documentation. Does the documentation support the current diagnosis reported? Will the documentation support ICD-10-CM coding? View a good representation of what your audits can look like.
Once the audit has been conducted and analyzed, the practice will have a good assessment of documentation deficiencies and can develop a priority list of diagnoses requiring more detail. The audit also helps identify providers who will benefit from focused training using ICD-10-CM. By conducting an ICD-10-CM documentation readiness audit now, you can help the practice assess risk, allow time for any required training, and perform re-assessments prior to implementation.
IN THE NEWS
Provider Manual Resource
CMS just announced new resources they now offer providers to minimize the cost of the ICD-10 transition. These resources include tips and advice on how to plan and execute your transition to ICD-10, including timelines, checklists, and fact sheets. The provider manual on implementation is a great starting point.
PREOPERATIVE DIAGNOSIS: Right colon and left colon cancers with carcinomatosis and hepatic metastasis
POSTOPERATIVE DIAGNOSIS: Right colon and left colon cancers with carcinomatosis and hepatic metastasis
OPERATIVE PROCEDURE: 1. Resection of distal ileum and ascending colon with ileocolonic anastomosis, 2. Resection of the descending and sigmoid colon with low anterior anastomosis, 3. Needle biopsy of the liver
ANESTHESIA: General endotracheal
DETAILS OF OPERATION: After satisfactory general endotracheal anesthesia was obtained, the patient's abdomen was prepped and draped in the usual fashion. Midline incision was made and carried down to the intra-abdominal cavity. The patient's abdomen was evaluated. She was found to have a large right colon tumor that was metastatic to the distal ileum, approximately 10 cm proximal to the ileocecal valve. Patient also had a tumor in the descending colon and in the sigmoid colon. Decision was made to resect both the distal ileum, the ascending colon, save the transverse colon, and connect the transverse colon to the rectum. The patient is also noted to have a liver largely replaced with tumor. At this point, a cone biopsy of the liver tumor was obtained and hemostasis was obtained with electrocautery. Incision is made along the white line of Toldt on the right colon. The right colon was rotated anteriorly. The retroperitoneum was markedly inflamed, and the patient's right colon tumor had metastatic nodules that attached approximately 30-40 cm proximal to the ileocecal valve. The ileum was divided, mesentery to the distal ileum and right colon was divided between hemostats, and vessels were ligated with 2-0 Chromic. The transverse colon was divided at its junction with the ascending colon, and then the ileum was anastomosed to the transverse colon with an inner row of 3-0 Chromic and outer row of 3-0 silk sutures. Mesenteric defect was closed with 2-0 Chromic. Attention was then turned to the left colon where the patient had tumor just distal to the splenic flexure and tumor in the sigmoid colon. Incision was made along the white line of Toldt on the left colon. The left colon was rotated anteriorly, and the mesentery to the left colon was divided between hemostats after mobilizing the splenic flexure. The rectum was mobilized, and the transverse colon was anastomosed with a low anterior anastomosis to the rectum. Wound was copiously irrigated with saline. Fascia was closed with #1 Prolene. On-Q PainBuster pump was inserted in the fascia. Fascia was closed with #1 Prolene. Skin was closed with staples after inserting a Hemovac. Patient tolerated the procedure well. PATHOLOGY: Malignancies of the right and left colon with hepatic metastasis
C18.2 Malignant neoplasm of ascending colon
C18.8 Malignant neoplasm of overlapping sites of colon
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct
Rationale: In ICD-10-CM, A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to the subcategory/code .8 ("overlapping lesion"), unless the combination is specifically indexed elsewhere. In this case, this patient has an overlapping tumor in the descending and sigmoid cancer which is why this code was selected. But, the patient also had another malignant lesion in the ascending colon; therefore a separate code needs to be assigned. For multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the same breast, codes for each site should also be assigned in this case for the neoplasm in the ascending colon. We also need to report the hepatic metastasis from the procedure.
ICD-10 IMPLEMENTATION STRATEGIES
We will be sharing a number of strategies to help your practice successfully implement ICD-10-CM. Please remember to track your progress in your ICD-10 Implementation Tracker on AAPC's website.
A gap analysis is an effective tool that can be used to assess where you are on the road to transition, what obstacles are in your way, and what you need to do to overcome them to achieve your goal of successful ICD-10 implementation. You will use the gap analysis to assess your strengths (staff, education, software, etc.), your weaknesses (skill sets, new code sets, etc.), the opportunities available (boot camps, online training, chapter meetings, etc.), and the obstacles that may slow down your progress.
A gap analysis is a process that allows you to take a look at your "as is" state and outlines the plan to get to your desired "to be" state. With each step that is taken on the road to implementation, the gap analysis may be repeated to assess how the "gap" has been reduced. This can be used as a good marker on keeping track of your ICD-10 implementation.
Get a head start on ICD-10 and learn how it will impact your practice's top 50 most frequently used codes with these quick-reference cards. AAPC has crosswalked the top 50 ICD-9-CM codes to the latest ICD-10-CM codes for your specialty so you know where to begin in preparation for your documentation assessments and superbill changes, and so you can get a jump on the 2014 implementation.