Thoracic Surgery: New Alliance Under ICD-10

Although implementation of ICD-10 is still over a year away, it’s not too early to prepare. Surgeons in particular will find that accurate coding and billing under ICD-10 may require a higher level of specificity. However, the transition may offer an opportunity for medical records to more closely mirror the surgeon’s understanding of the patient’s condition in an accessible, standardized way.

Originally set to take effect in 2013, the Centers for Medicare & Medicaid Services (CMS) extended the deadline for compliance with ICD-10 until October 2014 to give providers—particularly physicians in private practice—more time to adjust. For facilities that are ready to use the new system, the delay may be inconvenient and costly. But physicians who are unfamiliar with the new system and its requirements will benefit from the extra time, says Francis C. Nichols, III, MD, thoracic surgeon and medical director for the Office of Billing and Revenue Cycle at Mayo Clinic in Rochester, Minn.

Many physicians will need to make adjustments to their documentation and dictation, because ICD-10 drills down to a much deeper level of specificity than under ICD-9. ICD-10 comprises more than 68,000 diagnosis codes, and almost 72,000 procedure codes. Apart from learning to provide new information in their documentation to allow coders to assign the correct diagnosis, physicians will need to work closely with the coders in their offices and at the hospitals.

“Coders help to keep us compliant, but physicians must provide them with sufficient documentation and information about what we do,” says Nichols. Ultimately, the physician must ensure that the coder understands the patient’s diagnosis and the procedure to code it accurately and completely.

New kind of code

The move to ICD-10 is meant to accomplish more than assuring proper reimbursement, says Nichols. Because the information the codes convey is more descriptive and precise, the new system will enable an analysis that distinguishes quality data and patient safety data, and provides more accurate information to anyone who accesses the clinical record. This is important for improving integration and quality of care.

Diagnosis code changes—ICD-10-CM—are the only ones  physicians must adopt, says Kathy DeVault, manager of professional practice resources at the American Health Information Management Association (AHIMA). The new diagnosis codes will require physicians to provide more detail than they are used to giving to coders. For example, the codes can now distinguish between types of coronary artery disease (CAD) and pinpoint the severity of the disease. For a patient who undergoes CABG, the codes distinguish between bypass and native vessels, autologous or nonautologous.

Also, surgeons will have to adjust to ICD-10-PCS, new procedure codes that hospitals use for inpatient coding. The new approach to coding under ICD-10-PCS requires the coder to have a much greater knowledge of anatomy and of the physician’s approach and technique. “The coders will need a lot of knowledge they don’t necessarily have, and that physicians are not necessarily aware that they will need,” DeVault says.

Positive change

Thoracic surgeons should take a proactive stance to engage with the hospital coders, says DeVault, to teach them the appropriate anatomy and mechanics of the procedures. Nichols adds this will be critical for a successful transition to ICD-10.

“Over the years, I’ve become a big proponent of working closely with coders,” Nichols says. “We as physicians don’t need to understand all the bundling rules and code sets, but we do need to understand what they need to code our work properly.”

Nelly Leon-Chisen, director of coding and classification for the American Hospital Association, emphasizes that although the new system will require some changes, they are changes for the better. She points out that ICD-9-CM has been around for approximately 40 years, and cannot accurately reflect all the changes in medical practice and technology that have taken place over that time period. 

In thoracic surgery, open procedures were the norm when ICD-9 was introduced, Nichols explains. Now, there exist minimally invasive approaches such as video-assisted thoracic surgery, endoscopic therapies, catheter-based interventions and hybrid procedures. With its greater capacity for detail and description, “the new system will allow us to follow a patient from first presentation to resolution, and tell the patient’s story through codes,” Leon-Chisen says.

Codes are used for more than billing, she adds. They are the source of data for quality improvement, resource integration and best practices. With the proliferation of public outcomes reporting and data registries, outcomes reporting and quality measurement are likely to become more accurate and nuanced, which is better for patients and for physicians. 

Proactive training

As the time for ICD-10 implementation approaches, DeVault suggests initiating mutual training sessions with coders. “The codes are so detailed now that coders will not be able to ‘fill in the blanks’ because they will require clinical knowledge they don’t have,” she explains. DeVault suggests physicians take the time to explain to the coders what types of patients they see, the range of diagnosis and how they perform procedures—not just the type of procedures, but how they perform them.

“I always try to include videos when I conduct coding trainings,” she says. If possible, thoracic surgeons should consider using videos to help coders understand the mechanics of the procedures they perform.

Hospitals will be expecting their coders to use the full range of codes available to them under ICD-10, and so thoracic surgeons should be proactive in teaching coders about what they do, DeVault says. “Otherwise, they’re going to be overwhelmed with queries once the new system goes live.” 

Another possible issue is that because of the higher levels of specificity in ICD-10, providers will be expected to use specificity in their documentation. “There is the potential to raise a red flag if a physician uses too many unspecified codes, or uses them too often. The question may come up, ‘Does the doctor not know, or is it poor documentation?’ After some level of intervention, the physician should have sufficient information to start using specific codes,” DeVault cautions.