Four CDI challenges Emerge in ICD-10

By James P. Fee, MD, CCS, CCDS, vice president at Enjoin

Editor’s Note: Read this article’s companion piece “Fighting CDI Fires in ICD-10: Three Burning Questions Every Organization Must Answer” in the December 2015 edition of ICD-TEN, available here.

For most clinical documentation improvement (CDI) specialists, bridging the gap between clinical terminology used by physicians and diagnostic coding terminology used for reimbursement is an arduous task. Crossing this divide was a challenge in ICD-9. It’s an even greater hurdle with ICD-10.

This is evidenced by the fact that most documentation problems in ICD-10 are the same ones coders faced in ICD-9—for example, identifying sepsis, defining encephalopathy, and specifying heart failure.

CDI specialists must continue to motivate providers to document the specificity necessary for ICD-10 while looking ahead to HCCs, value-based purchasing, readmission reduction, and quality measures reporting. The following list provides a glimpse into the most recent CDI challenges facing coders and CDI specialists.

1. Even despite a less than one percent observed shift in MS-DRGs from ICD-9 to ICD-10, changes are not always intuitive. The small percentage of change means that CDI teams continue to use the MS-DRG in ICD-9 to validate the MS-DRG in ICD-10. However, unexpected shifts will occur, given the changes in PCS code assignment (i.e., the assignment of root operations). For example, coding a spinal refusion using the root operation “fusion” will drive a MS-DRG shift in some cases in which anterior and posterior fusions are performed.

2. Coding and sequencing secondary diagnoses requires careful consideration. In many cases, CDI specialists must refer to Coding Clinic or cross-reference instructional and exclusion notes for additional information. This creates workflow bottlenecks with concurrent CDI. For example, a patient presents with acute COPD exacerbation and pneumonia. The instructional note under COPD with acute lower respiratory tract infection isn’t clear regarding when it’s appropriate to assign the pneumonia as a co-equal principal diagnosis. However, based on confirmation within the tabular index, it becomes clear that this note references acute bronchitis and acute bronchiolitis code range only.

3. ICD-10-PCS often requires physician clarification. This has been particularly true for character six (device) and character four (body part).

4. ICD-10-PCS has slowed CDI specialist productivity. It has become evident that PCS is the primary source of productivity loss, ranging from 20 percent to 40 percent. Understanding the rationale and pathophysiology behind the PCS code assignment is critical, and it continues to challenge both coders and CDI specialists. For example, when a surgeon clips a bleeding vessel within a peptic ulcer, coders should report a repair of the stomach. If a surgeon clips a bleeding angiodysplasia within the stomach, coders should report an occlusion of the vessel.

Keep Identifying Documentation Gaps

Dual coding helped organizations identify documentation gaps prior to ICD-10. However, now that ICD-10 has entered a live production environment, organizations must find new ways to continually monitor documentation deficiencies. Here are three best practice steps:

• Perform ongoing chart reviews linked to the individual coder, CDI specialist, and physician
• Identify trends and patterns of insufficient documentation, missed query opportunities, and incorrect coding
• Target education and CDI efforts accordingly

For more on ICD-10’s impact on CDI efforts, read the December ICD-TEN article “Fighting CDI Fires in ICD-10: Three Burning Questions Every Organization Must Answer” here.

About the author

James P. Fee, MD, CCS, CCDS, is vice president of Enjoin. He is board certified in Internal Medicine and Pediatrics and maintains a clinical practice in hospital medicine. Dr. Fee is an AHIMA-approved ICD-10-CM/PCS trainer and serves in a consultative role regarding clinical documentation integrity and its impact on financial accuracy, physician and hospital profiling, and quality metrics.