January 17, 2011
Game Changer: How ICD-10 Will Reshape Documentation Processes
By Selena Chavis
For The Record
Vol. 23 No. 1 P. 14
Come 2013, the playing field will change significantly for coders, CDI specialists, and physicians.
Set to go into effect October 1, 2013, the countdown to
ICD-10 has been under way for some time. During the ramp-up, healthcare
organizations are being confronted by the harsh realities they will
have to overcome in order to be compliant.
It’s no secret that documentation practices that have defined
the industry for the past 30 years will no longer be sufficient. The
new order of the day is specificity, and it will take a solid team of
well-trained professionals from HIM and clinical staff to ensure that
physician documentation contains the details needed to code accurately.
It’s also no secret that healthcare organizations that have
not formally embraced clinical documentation improvement (CDI) practices
will have a much higher mountain to climb in the race to meet the
deadline looming in the not-so-distant future.
“Facilities that haven’t jumped on the [CDI] bandwagon yet
are going to be way behind,” says Eric Riebel, RHIA, CCS, HIM manager at
Lafayette General Medical Center in Louisiana. “It’s going to be a
very big uphill battle all the way around. … Documentation has always
been a challenge, and with ICD-10, it’s even more so.”
Going forward, industry professionals agree that the
relationship between coding and CDI professionals who interface with
physicians will be a “make-or-break” ingredient when it comes to a
facility’s chances of meeting ICD-10 demands.
According to Jim Kennedy, MD, CCS, a managing director of
Atlanta-based FTI Healthcare, these relationships are important going
forward because “CDI is a process, not a person.” The process, he
notes, includes concurrent documentation and retrospective physician
queries that will lead HIM professionals to the most specific ICD code
that can be reported. With experience as a physician as well as a
coding professional (since 2001), Kennedy has experience on both sides
of the aisle and knows the challenges facing doctors as well as the
problems associated with inconsistent documentation that prohibits the
appropriate specificity of a diagnosis.
“I don’t see the process of CDI changing [with ICD-10], but
there will be increased requirement of physicians to be more precise,”
Kennedy explains, adding that clear understanding by CDI staff of what
the coder needs will be paramount to make sure such precision happens
with concurrent review.
The end result, according to many professionals, is that the
United States will finally catch up with the rest of the industrialized
world by adopting ICD-10. Riebel notes that other countries have been
successfully using ICD-10 for nearly 20 years, and that ICD-11 is
already undergoing beta testing.
“From a national perspective, we should not be this far
behind in the world,” Riebel says, adding that newer classification
systems do a much better job of addressing advances in medical
knowledge and issues associated with morbidity and mortality reporting.
“It does help to verify severity better than ICD-9. … That’s huge
improvement. From a WHO [World Health Organization] perspective, it’s
about time we get there.”
Relationships That Work
Healthcare teams that work toward a common goal are the ones
that will transition better to ICD-10, says Robert Gold, MD, CEO of
DCBA, an Atlanta-based CDI firm. “In some organizations, there is an
antagonistic relationship between coders and documentation specialists
that exists,” he says, pointing out from his own experience that many
documentation specialists have been trained to expect coders to be
Because the two contingents must be in agreement, Gold
believes ICD-10 training should be a joint effort between CDI
professionals and coders. He goes as far as to say that without an
established baseline consensus of what is required, the coder will not
receive the necessary information. “If physicians have been trained
right by the documentation specialist, they will be able to easily do
what is necessary,” he says, emphasizing that the key word is “right.”
Kennedy also recognizes the importance of physicians being
properly trained because no matter how knowledgeable coders and
documentation specialists may be, the clinician has the last word.
Therefore, from a philosophical standpoint, the primary relationship
exists between the coder and the physician, with everyone else—nurses,
documentation specialists, and other clinicians—becoming “servants” to
“The doctor is the ultimate authority in saying a patient
has a certain condition,” Kennedy explains. “The nurse [or another CDI
professional] doing the concurrent review has to know the needs of the
Riebel concurs, noting that physicians do not currently
provide the level of specificity needed for ICD-10.
“You see it
documented well by nurses, but that doesn’t do a coder any good,” he
says. “It’s going to require a level of specificity that we have always
been able to get around.”
For example, Riebel cites the coding for the suture of an
artery. Under ICD-9, there was one code; however, under ICD-10, there
are more than 180 ways to code the procedure. Communication skills become paramount for documentation
specialists, who need to solidify the relationship between the other
parties, Kennedy says, adding that the question often becomes what type
of professional can most effectively establish the link between coders
Although he is an advocate of coding or nonnursing
professionals performing concurrent reviews, Kennedy acknowledges that
not all coders have the ability to establish effective rapport with
physicians to achieve the desired outcome. “Many coders have some
trepidation with physicians,” he notes, pointing out that nurses tend
to have more camaraderie with physicians and are better able to develop
“They have to be able to have those communication skills. …
Some coders are very good at it. Well-functioning [CDI] programs have
seamless communication, but there’s no perfection.”
With those realities in mind, Kennedy suggests the process
of choosing the best person for concurrent review should focus more on
the person than the function.
Time Is of the Essence
Experts agree that education and training for ICD-10 should begin now.
“You need to start training all coding staff now and start
rolling out programs for physician champions through 2012,” Riebel says,
adding that in 2012, education programs should be planned and running.
Then by 2013, organizations will have 10 months to be fully compliant.
“I’m finding that most hospitals are not even looking at this yet,” he
Riebel recommends that the program be presented under the
guise of CDI rather than as a big push for ICD-10. This will avoid
pushback that is likely to come from those professionals who have been
entrenched with ICD-9. “Those who have been doing ICD-9 five or more
years will fight it tooth and nail,” he says.
Gold says education and training will help minimize some of
the panic that currently exists in the industry. “The general impression
is that folks are approaching ICD-10 like they did Y2K—total panic
without really understanding what it’s going to be,” he says, pointing
out that training will need to occur on two levels: diagnostic and
procedural. “The concepts governing diagnostic are no different than
ICD-9,” but the procedural level will be foreign to coders.
At the Tennessee Health Information Management Association
(THIMA), the goal is to create a unified front for education so
healthcare organizations are well prepared to meet the demands of the
transition. The association is taking a proactive approach by providing
training to all healthcare professionals so best practices are
implemented across the state from the outset.
“We’re rolling this out to all healthcare professionals in
the state of Tennessee,” says Kathy Hallock, RHIA, medical coding
quality consultant with Vanderbilt University Medical Center (VUMC) and
a member of THIMA’s ICD-10 committee. “Our goal is to be the educators
Kennedy , who, like Hallock, is a THIMA ICD-10 committee
member, says training sessions aim to clear up the differences in
primary clinical issues between ICD-9 and ICD-10. “My hope is that we
can communicate to [coding and CDI professionals] what areas are going
to affect code assignment,” he says.
This month’s THIMA symposium featured two tracks, one for
CDI programs in general that included a session on ICD-10 and a track
geared specifically for coding professionals. Hallock says healthcare
organizations should already have a CDI program in place, and those
that do not are way behind the curve. “Your CDI program is a place you
need to be doing stuff right now,” she says.
VUMC’s CDI program has matured well beyond its initial
reimbursement focus. “It’s really grown into a much bigger process than
just documentation and coding,” Hallock says, pointing out that the
program now delves into areas such as quality and risk management.
A More Clinically Focused Skill Set
In the past, some hospitals would take individuals with no
coding background and train them to become coders. “That’s going to go
away,” says Riebel. The complexities of ICD-10 will require coders as
well as CDI specialists to have a more expansive medical knowledge
In the near future, coders and CDI specialists involved with
concurrent review will need to become anatomy experts. “These
professionals will need to know anatomy,” he says. “It’s critical. You
just won’t be able to get around it.”
Those who perform concurrent review will have to indicate
specificity on all organs and body systems, even down to defining
lateral location, Riebel says. As a result, he believes facilities
using nurses for concurrent review will have greater success meeting
Gold agrees with the new focus on anatomy, pointing out that
documentation specialists will need to go through the body systems to
determine where specificity must be added. Kennedy says coders may need
to supplement their education to get up to speed. “This is going to be
a big emphasis—the need to learn anatomy,” he says.
In a nutshell, physicians will have to be more precise in
their operating notes and coders will need to understand what they are
reading and what they are looking for in operative notes.
Those coders who have been trained to do a specific task in
the HIM department—such as diagnosis-related group optimizers—will
likely struggle with the complexity of ICD-10, Gold says. On the flip
side, coders who have worked in the outpatient arena will likely have a
much easier time with the transition than their inpatient counterparts
because ICD-10 appears to be structured in much the same way CPT codes
have been in the past.
“Those who have done outpatient coding will probably have
little difficulty transitioning to outpatient ICD-10,” he says. “There
are a lot of folks who have done both inpatient and outpatient. They
will find it a lot easier.”
The good news for coders, according to Riebel, is that
ICD-10 will be harder to memorize than ICD-9, ultimately slowing down
productivity and increasing the demand for coders. “We’re going to need
more,” he notes.
— Selena Chavis is a Florida-based freelance journalist
whose writing appears regularly in various trade and consumer