Many people have been congratulating each other on how well the transition to the ICD-10 coding system has proceeded with little adjustments. From a compliance viewpoint, however, there is concern over the quality of clinical documentation supporting billed ICD-10-CM codes. Questions to ponder are: What is the true realization from post-October 1, 2015, if an external audit is conducted? Are you absolutely comfortable your clinical documentation (key source supporting medical necessity of provided services) supports the ICD-10-CM code you selected? Guess what we discovered? Overall, only 43% of clinical documentation actually supported billed/reported ICD-10 codes.
We conducted a retrospective review of more than 200 providers who select their own ICD-10 codes reported on claims. The review included more than 1,500 claims with more than 3,800 ICD-10-CM diagnoses codes covering a multitude of provider specialties and subspecialties from small to large practices. In our process, clinical documentation details were compared with billed/reported ICD-10 codes.
Initially, we assessed the overview of providers’ ICD-10-CM documentation education, noting all of the providers during the implementation and transition phase had attended or participated in some type of formal and informal ICD-10 documentation and coding education based on general information followed with a specialty-focused education. Education continued through specialty physician champions as well as clinical documentation specialists and/or coding liaisons during medical staff meetings or during patient rounds. The self-learning education methods were tracked to ensure 100% participation for all practices.
As this audit project began, we had some questions about the educational content for coding in general and then specifically related to ICD-10-CM as follows:
- Did the providers receive any overall information regarding Official Guidelines for Coding and Reporting?
- Did the providers understand how to apply the ICD-10- CM Official Guidelines for Coding and Reporting?
- Do the providers understand clinical documentation for ICD-10-CM requires additional details to support accurate code selection?
- Do the providers understand the specificity available with ICD-10-CM codes and how each ICD-10-CM code supports a patient’s level of acuity, intensity of services, and complexity of care for each encounter?
- Why do providers continue to code medical conditions that no longer exist as if the condition is an acute or ongoing condition?
Our answers to each question were more negative than positive. For demonstration purposes only, the chart below notes some of the common specialties we found to have an accuracy rate below 50%. Where does your specialty fall in the accuracy rate? Do you know? Maybe not.
Table.1 General overview of specialties with accuracy rates below 50%
Where Do We Begin To Fix the Mismatching?
CMS has given providers a year from October 1, 2015, as somewhat of a grace period to fine-tune coding skills as noted in their Clarifying Question and Answer Document (Reference 2) on how ICD-10 codes need to be selected.
Careful reading of this document will provide the provider/ coder a resource to understand the necessity to select an ICD-10-CM code using all of the required characters to provide the highest level of specificity for the medical condition.
CMS and the healthcare industry use the accuracy rate of 95% as a guideline for any person performing coding and/or billing activities. Therefore, this is the goal everyone needs to be aiming toward. With accuracy rates below 50%, however, start with the following steps:
- Focus on your specialty’s most common specific ICD-10- CM selected codes.
—Select the top five diagnoses.
—Educate/discuss the specific elements within the five diagnoses that need to be clinically documented.
—Develop documentation hint tools to improve the clinical information allowing for an improved ICD-10- CM code selection.
- Conduct a prebilling review by your coder comparing each provider's clinical documentation with selected ICD-10-CM codes.
—Benchmark with an initial review of 5-10 claims/encounters per provider.
- Use the findings for documentation improvement as starting points.
- Set goal to increase the accuracy of each ICD-10 code selection supported by clinical documentation.
- Continue with internal reviews focusing on clinical documentation and accuracy of ICD-10-CM code selection improvement.
—If the accuracy rate is below 70%:
- Identify the top three issues with coding and/or clinical documentation.
- Provide specific specialty education.
- Develop clinical documentation education for the provider.
—If the determined accuracy goal rates are not improving toward at least 85% then the focus may need to be specific to the group of providers or to a specific provider.
- Collaboration with a physician champion and coder liaison may be necessary to ensure specific documentation/coding weaknesses are addressed in a timely manner and corrected.
—Establishing a timeline for ongoing monitoring with education flexibility is a must to ensure competency of ICD-10-CM code selection is supported by clinical documentation.
- Select diagnoses from the Problem List that often are not the reason for the encounter.
- Ensure all providers authenticate/append a signature including date for every encounter whether through the electronic health record or handwritten.
Challenge to Diminish Compliance Risk
Accurate code selection and clinical documentation compliance is a challenge in all healthcare settings, while inaccuracy can place the organization at risk from all directions, especially with external auditing organizations. No organization wants to suffer regulatory fines or civil and criminal penalties along with a damaging reputation. Therefore, focus on your coding accuracy to achieve documentation and coding compliance and anticipate financial benefits. The benefits really have not changed in years and include the following:
- Overcoding creates a compliance risk with the possibility of fraudulent submission of claims.
—Per the OIG: Civil Monetary Penalties (CMP) consist of treble damage per claim amount plus from $5,000 up to $10,000 per claim to begin.
- Undercoding creates a financial risk of losing money when documentation supports a more accurate code for the provided service.
- Decrease the amount of time and effort of reworking rejected claims or having to write-off costs of service.
Mismatching Coding and Documentation
It is our recommendation to conduct proactive activities to possibly mitigate high-compliance risk liabilities:
- Validate that each encounter has been authenticated by the provider.
—Handwritten clinical documentation must include a legible signature and credentials and be dated.
- If the signature is not legible, a sample of the provider’s signature needs to be entered into a logbook with the provider’s printed name, credentials, and date of entry.
- Refer to the CMS issued Transmittal 327 on March 16, 2010, titled “Signature Guidelines for Medical Review Reporting.” This transmittal reference is located in the Resources section at the end of this article with the specific website.
- Establish policies and procedures for routine audits to ensure ICD-10-CM codes are supported with detailed clinical documentation.
—Review the correct use of the Problem List.
- Add new problems.
- Update problem list at each visit as necessary, and move to the inactive/past medical history resolved problems such as:
—Medical problems resolved but have clinical importance
- Signs and symptoms are only temporary and should be replaced with a refined diagnosis when workups are completed.
- Minor complaints do not belong on the problem list.
- Nonproblems do not belong on the problem list.
- Develop a process to evaluate and identify the accuracy rate for overall clinic, office, and department and accuracy rate for overall clinic, office, and department and accuracy rate per provider.
- Develop clinical documentation education to be given to providers based on findings from each review period as designated by the reviewer. The goal is to ensure that the accuracy rate of selecting ICD-10-CM coding improves toward the goal of 95%.
- Maintain reports documenting compliance with the Policies and Procedures.
The following are examples from a few provider specialty services with mismatching ICD-10 codes and clinical documentation.
Radiotherapy side effects/complication code selection
Radiotherapy ICD-10-CM code selection involves a convoluted path through the ICD-10-CM coding manual, beginning with a “must” understanding of each code’s description and directions for selecting the most accurate code. Understanding Official Guidelines for Coding and Reporting is imperative to selecting the most accurate ICD-10-CM code.
At issue is the crosswalk of ICD-9-CM 990: effects of radiation, unspecified, which takes the coder to ICD-10- CM code T66.XXXA — radiation sickness, unspecified, initial encounter. Since this in an inappropriate ICD-10-CM code selection, there is no need to provide detail to the 7th character. Below is how ICD-10-CM code T66 (requiring a 7th character) appears in the coding manual:
T66 Radiation sickness, unspecified (7th character required)1
Excludes 1 specific adverse effects of radiation, such as:
Burns — go to category T20-T31
Leukemia — go to category C91-C95
Radiation gastroenteritis and colitis — go to category K52.0
Radiation pneumonitis — go to category J70.0
Radiation-related disorders of the skin and subcutaneous tissue — go to the category L55-L59 [L59 will be the family code to select]
Radiation sunburn — go to category L55.7
The appropriate 7th character is to be added to code T66:
A Initial encounter
D Subsequent encounter
According to the excerpt from 2016 Official Guidelines for Coding and Reporting2
Section 1 — Conventions, General Coding Guidelines and Chapter Specific Guidelines, Subsection: 12.a. notes the below directions for a coder to follow and understand:
12. Excludes Notes
The ICD-10-CM has two types of excludes notes. Each type of note has a different definition for use, but they are all similar in that they indicate that codes excluded from each other are independent of each other.
a. Excludes1: A type 1 Excludes note is a pure excludes note. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
Therefore, the coder interpreting this directional needs to reference the ICD-10-CM code family of L55-L59. The correct ICD-10-CM family would be L59. Other disorders of skin and subcutaneous tissue related to radiation with two choices to select from are:
L59.8: Other specified disorders of the skin and subcutaneous tissue related to radiation or
L59.9: Disorder of the skin and subcutaneous tissue related to radiation, unspecified (this may be the only option based on a third-party payer’s unique policies and procedures for billing).
Surgical Care of various specialties was audited as noted in the above chart. The following is a sample of clinical documentation and code selection weaknesses:
- Plastic Surgery —Scenario: Female patient has right breast cancer and is requesting a consultation premastectomy regarding a right breast mastectomy with reconstruction. The provider ICD-10-CM billed the following codes without supporting clinical documentation evidence:
—N64.89: Other specified disorders of breast
—Z85.3: Personal history of malignant neoplasm of breast
—Z90.11: Acquired absence of the right breast and nipple
—Not Coded: C50.911: Malignant neoplasm of unspecified site of the right female breast is supported by clinical documentation
- Pediatric Surgery —Scenario: History of cervical lymphadenitis, resolved with treatment using antibiotic and steroid regime. Presents for follow-up noted ”without any evidence of lymphadenitis.” Return to office as needed.
The provider billed the following ICD-10-CM code without supporting clinical documentation evidence the lymph nodes were still enlarged:
—R59.0: Localized enlarged lymph nodes
—Missed Code Z09: Encounter for FU examination after completed treatment for conditions other than malignant neoplasm
Orthopedics clinical documentation in ICD-10-CM requires several elements to be documented. The majority of code selections identified were for unspecific ICD-10-CM codes, thus missing these specific elements. The following ICD-10- CM elements for selection of follows were missing on the majority of claims reviewed:
- Acuity (Acute, Chronic)
- Anatomical specific location
- Laterality— Right, Left, Bilateral
- Episode of care is the same as the type of encounter (initial, subsequent, sequela)
Examples Coding Selection:
- M41.9: Scoliosis, unspecified (missing type, age related and anatomical location)
—Correct code M41.124: Adolescent idiopathic scoliosis, thoracic region is based on detailed documentation
- M25.519: Pain in unspecified shoulder (laterality)
—Correct code M25.511: Pain in right shoulder based on documentation
Radiation Oncology ICD-10-CM clinical documentation needs to include specific details related to the neoplasm under treatment or post-treatment monitoring. The following ICD-10 example may provide you with the level of clinical documentation that is necessary to support ICD-10 codes.
- A female had invasive lobular carcinoma of the upper- outer quadrant of the right breast, which was removed with a right mastectomy. Also, the patient had completed the chemotherapy regime and was now ready to begin radiotherapy. The condition is still under active treatment and requires an active condition code.
—The billed ICD-10 code was C50.919: Malignant neoplasm of unspecified site of unspecified female breast
—Missed ICD-10-CM code C50.411: Malignant neoplasm of upper-outer quadrant of right female breast
—Missed ICD-10-CM code Z92.21: Personal history of antineoplastic chemotherapy
—Missed ICD-10-CM code Z90.11: Acquired absence of right breast and nipple
Proactiveness Begins Now
Be proactive now, and get out of the mismatching process by recognizing and understanding the nuances of ICD- 10CM diagnosis code selection. Augment in detail your clinical documentation to support your selected ICD-10- CM diagnosis code to its highest level of specificity. Your coding data will then accurately support your patient’s level of acuity and intensity of services with complexity of care reported on claims to your insurers, accurately reflect patient care, professional profiles, etc.
NOTE: It is imperative to understand clinical documentation and ICD-10-CM code selections are under the microscope from many different levels. CMS and some third-party payers have already identified ICD-10 coding and documentation risks at this early stage after the transition. Although claims are being paid, the challenge is to ensure each provider’s clinical documentation is accurate and complete, thus supporting each ICD-10-CM code selected for reporting (billing and data use).
- Take action by performing oversight prebilling review of ICD-10-CM codes selected by providers, and determine if their clinical documentation supports the ICD-10-CM code selection.
- Understanding the clinical documentation details required for the top 10 diagnoses to obtain the highest level of specificity for each ICD-10-CM code.
- Engage ICD-10-CM subject matter experts (coders, CDIS, ICD-10 trainers) for support of coding questions.
- Institute an incremental goal toward reaching the industry’s coding accuracy of 95% consistently.
¹Optum 360, ICD-10-CM Professional for Hospitals 2016 Coding Manual, pg. 1129 ICD-10 code T66
²Optum 360, ICD-10-CM Professional for Hospitals 2016 Coding Manual, Official Guidelines for Coding and Reporting pg. 3 Subsection 12.a.
Department of Health and Services. CM/PCS The Next Generation of Coding; 2015 at:https://www.cms.gov/Medicare/Coding/ ICD10/downloads/ICD-10Overview.pdf
CMS Questions and Answers Related to the 6, 2015 CMS/AMA Announcement and Guidance Regarding ICD-10 Flexibilities. Refer to the specific questions 3, 4, 6, 7. at:https://www.cms.gov/ Medicare/Coding/ICD10/Clarifying-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint- Announcement.pdf
CMS 327. Signature Guidelines for Medical Review Purposes; 2010 16. at: https:// www.cms.gov/Regulations-and-Guidance/Guidance/ Trandmittals/downloads/r327pi.pdf
Optum 2016 ICD-10-CM Professional Coding Manual
CMS ICD-10-CM 2016 Official Guidelines for Coding and Reporting website at: https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-ICD-10-CM- Guidelines.pdf
OIG–A Road for New Physicians: Fraud and Abuse Laws. Available at: http://oig.hhs.gov/compliance/physician- education/01laws.asp