Freezing both the current ICD-9-CM and the new ICD-10-CM/PCS code sets will save organizations further cost and complexity by enabling them to focus on the system change without simultaneously managing code updates. The Centers for Medicare and Medicaid Services has been receiving recommendations on whether to freeze the code sets and, if so, for how long.

In a recently released statement, AHIMA recommends that:

• The final ICD-9-CM update should be FY 2012 (beginning October 2011, in conjunction with the federal government’s fiscal year).
• No updates should be made to ICD-10-CM/PCS for FY 2013 or FY 2014 (i.e., beginning October 2012).
• Updates to ICD-10-CM/PCS should resume in FY 2015 (October 2014).

Freezing code sets presents its own challenges, given that the practice of medicine will keep evolving. AHIMA recommends that exceptions should be allowed for urgently needed codes. Organizations requesting updates would be required to make a “clear and convincing” case to the Coordination and Maintenance Committee as to why the codes can’t wait for the next regularly scheduled update (such as the emergence of a new disease).

AHIMA recommends that the Coordination and Maintenance Committee, which maintains the code sets in the US, should continue to meet during the freeze in order to consider code proposals and avoid a backlog in 2014. “Working draft addenda” could keep the industry appraised of code changes slated to go into effect for FY 2015.

In addition, AHIMA recommends that flexibility be retained during the freeze to correct errors identified in the ICD-10-CM/PCS code sets, such as incorrect index entries or incorrect code references in instructional notes.

AHIMA offers ICD-10 information and resources at www.ahima.org/icd10.

• Sample project communication plan
• Sample project plan
• Sample project progress report
• Sample issues log

The online version also includes a list of communication aids that organizations may use in the transition to ICD-10-CM/PCS and a contact form for the major stakeholders leading the ICD-10-CM/PCS implementation.

As the practice brief notes, planning for the transition to ICD-10-CM/PCS is a multifaceted effort. Defining the organization’s data management plan will facilitate a smooth transition to ICD-10-CM/PCS and optimize its greater specificity.

The conversion project offered an early test of the General Equivalence Mappings and provides organizations with a process for converting their own applications to ICD-10-CM/PCS.

Rhonda Butler and Janice Bonazelli, senior clinical analysts at 3M Health Information Systems, offer an overview of the conversion in this early look into the upcoming November/December issue of the Journal.

The upgrade to the HIPAA transaction 5010 standard was announced in tandem with the January 2009 final rule mandating the upgrade to ICD-10-CM and -PCS. The 5010 standard is necessary to support ICD-10.

According to a timeline published in the final rule, by the end of 2010 covered entities should have completed internal testing and can send and receive compliant transactions (”level 1″ testing). In January 2011 they begin testing with trading partners and move into production (level 2). The compliance date for all covered entities is January 2012, one year in advance of the ICD-10 deadline.

Read more in the current issue of AHIMA ICD-TEN newsletter.

Revisions to both code sets go into effect October 1. The 2009 addenda with all the changes to the ICD-9-CM tabular and alphabetic index (volumes 1 and 2) are located on the National Center for Health Statistics Web site. The 2009 addenda with all changes to the ICD-9-CM procedure tabular and alphabetic index (volume 3) are located on the Centers for Medicare and Medicaid Services Web site.

That is the motto of the clinical documentation improvement specialists (CDSs) at Shands Hospital, based in Jacksonville, FL. They routinely “shadow” physicians as part of their clinical documentation improvement program (CDIP), seeking clarification in real-time and making recommendations for how physicians can fine-tune documentation to enable more accurate coding.

CDIPs are popular in healthcare facilities looking to capture better documentation. Physicians know the documentation they need for treatment and continuity of care, but CDSs are anticipating additional detail that will later produce more complete and accurate coding. A more thorough description can enhance reimbursement and more correctly reflect the facility’s quality of care indicators.

Officials at Shands and other facilities using this technique say they get more out of their CDIPs when documentation specialists are present with physicians in real-time, not querying later via e-mail or paper forms left in the chart. But some challenges, like time management and physician buy-in, also come with the successes.

How It Works

In many CDIPs, documentation specialists resolve queries after physicians have taken part in the patient encounter and recorded their documentation. Typically CDSs pick up the chart from a nurses’ station and review for documentation clarification. If a question arises or chance for clarification is spotted, the CDSs may leave a paper query form in the chart for the physician to answer next time, e-mail the physician, or seek a face-to-face discussion.

CDIPs that use physician shadowing get more out of their program through direct, real-time documentation improvement efforts, says Michelle Dragut, MD, CCS, physician advisor for clinical documentation improvement at Shands Hospital. Dragut also helps implement CDIPs as a physician advisor for the Florida Hospital Association.

“This is real-time interaction with the physician pen. When the ink is still fresh,” Dragut says—“on-the-spot interaction with the physician, when the case is fresh in their mind and they are in the process of making decisions.”

The shadowing program pairs CDSs with physicians as they make their rounds and evaluate each patient’s status for the day. After each patient encounter, the CDS and physician discuss the recently added documentation in the chart regarding the patient’s diagnoses and treatment and potential DRG assignment.

At Shands, four CDSs—including Dragut—accompany physicians several times a week. The shadowing isn’t random. The CDIP staff identify physicians who have a history of under-documenting in the chart. New hospitalists or residents are also good candidates. CDSs additionally review current patient charts for cases and conditions that are historically under-documented.

Once these cases and physicians are identified, the CDSs familiarize themselves with the physicians’ cases and current documentation, then shadow the physicians during rounds, discussing their documentation immediately after it is written in the chart.

“You read the chart right after it is written and engage in a discussion right then,” Dragut explains.

In the Room or in the Hall?

Most CDSs do not enter the patient’s room with the physician. Instead they wait until the patient encounter is over and review the physician’s documentation outside of the patient’s room. This gives physicians space to practice medicine, and it offers patients additional privacy that could be compromised if a nonclinical CDS was in the room, Dragut says.

However, some facilities do encourage CDSs to be present in the patient room, according to Paula Frost, RN, CTR, clinical documentation improvement specialist at the Reading Hospital and Medical Center, in Reading, PA. Reading Hospital’s newly launched “Concurrent Educational Rounding Initiative” has CDSs enter the patient’s room with hospitalists in order to fully understand the encounter and pick up on missed documentation opportunities.

“Opportunities for increased severity documentation might be available at this level,” Frost says. “It is possible the physician might not document something that was discussed or reviewed for one reason or another, but the CDI specialist would recognize the information as an opportunity for clarification, degree of severity of illness, or accuracy of documentation.”

CDSs at Shands, an academic hospital, participate in case discussions between residents and attending physicians. They attend these meetings, review documentation, and evaluate the opportunities for a better way to express the severity of a illness in a case or other factors.

Hospitalists, attending physicians, and residents are the physicians usually shadowed by CDSs, though community physicians can also take part in the shadowing program.

Shadowing is only part of the CDS role at Shands. CDSs also do the more traditional CDIP work of querying through paper notes left in the chart. However, since the CDSs at Shands are on the floor—or “battlefield of documentation”—90 percent of their day, Dragut notes, they can always approach a physician with a paper query to have it answered on the spot.

Training and Orientation

For those facilities with limited CDIP resources, physician shadowing does not have to be an everyday aspect of the program. Shadowing may be used during CDIP orientation as a way to directly educate physicians on what is expected from the program.

At Catholic Healthcare West, a 40-hospital system based in San Francisco, physician shadowing was used when CDIP were introduced in the system’s hospitals. Gloryanne Bryant, RHIA, CCS, CCDS, conducted the shadowing several times between 2003 to 2006 while working as the senior director of coding and HIM compliance at Catholic Healthcare.

After giving her CDIP orientation presentation to a facility’s hospitalists, Bryant asked for CDIP shadowing volunteers who would like suggestions on improving their documentation.

This shadowing program was only done at the implementation level. Each individual hospital in the Catholic Healthcare West network did implement a CDIP throughout 2008, but used the traditional methods of paper, e-mail, and face-to-face querying.

During her shadowing experiences, Bryant would bring along her ICD-9 book and a laptop in order to reference specific DRGs and classification codes that could be linked to the physician documentation.

“The physicians actually were very enlightened, very positive, and said they would like to do this again,” she says.

Now as the regional managing director of HIM at Kaiser Foundation Health Plan Inc and Hospitals, based in Oakland, CA, Bryant is getting ready to implement CDIPs in 20 of Kaiser’s northern California region hospitals. Both the implementation and actual daily CDIP work in the hospital will contain documentation improvement physician shadowing, she says. The program is referred to as Clinical Documentation Integrity, or CDI. The shadowing will be done by CDI staff and physicians who have a strong knowledge of coding and quality measures. The CDI educating physicians will work in tandem with CDI staff who are both RNs and HIM coding professionals.

Demonstrating the “Common Goal”

Documentation improvement shadowing is a way to bring the clinical and coding sides together, Bryant says.

“[Shadowing] shows the real life, real-time impact of the pen, or keystroke, to capturing patient’s severity, acuity, and risk of mortality,” she says. “It gives insight into the link between the documentation and the coding classification system, details that are in a separate world from the clinical world. It pulls the two sides or efforts together to see the common goal.”

Physicians and CDSs see many benefits from the direct interaction. Physicians learn firsthand the type of documentation necessary for their treatment and diagnoses to be clearly recognized and coded. CDSs get to participate in the patient care experience and can better understand the gap between doctors’ day-to-day clinical language and the ICD-9-CM code-able lingo, Dragut says.

Shadowing also gives physicians and CDSs a chance to answer each other’s questions immediately. Written queries can be misunderstood or set aside for a future time. Paper forms and e-mail limit back-and-forth discussion. But a face-to-face conversation can clearly sort out what both parties need or do not understand.

Just the fact that CDSs are visible and active on the floor serves as a reminder to all physicians that specific documentation is necessary, Frost says.

During shadowing, CDSs can educate physicians on the rationale behind a request to document in a particular way. A CDS can better provide the specific reason for a request for clarification—such as a particular documentation affects severity, accuracy, or DRG. This cuts down on the physician impression that they should answer the documentation question “because we asked you to,” Frost says.

Time and Buy-in among the Challenges

There are several challenges that come with CDIP physician shadowing. Shadowing is time-consuming, and it lowers the number of chart CDSs can review each day.

The biggest challenge is getting physician buy-in. Physicians may see shadowing as a nuisance, while others may take offense. If the program’s intent is poorly communicated, physicians may feel CDSs are questioning their clinical judgment.

Many CDIP shadowing programs start with physician volunteers who serve the “liaison or champion” role. These are usually hospitalists and residents, who have a stronger connection to the hospital and its financial performance, Bryant says.

When physicians are resistant at Shands, Dragut and the other CDSs stress how the program is in the doctors’ best interest. Documentation is used for more than just the bill, they explain. It is turned into codes which are then abstracted into data used to judge physician performance and the overall quality of care at a hospital, including case-mix index, severity of illness, and even physician report cards.

“You can do the best patient care in the world, but if you don’t do the best documentation, there is no way for the outside world to know that you did your best,” Dragut often tells reluctant physicians.

Clinical, Coding, and Communication Skills a Must

Academic hospitals provide a great environment for shadowing. New residents can learn good documentation skills up front through the program. But community hospitals can also implement CDIP shadowing with equal success. Buy-in from C-suite staff and numerous physician champions is necessary for any shadowing program to survive, Dragut says.

In order to effectively shadow physicians in a CDIP, CDSs have to have both a strong clinical and coding background. Of the three CDSs at Shands, two have physician backgrounds and one is an RHIA with 35 years of coding and HIM practice. Reading Hospital employs two RNs as CDI specialists.

HIM professionals with good clinical and coding knowledge are ideal candidates for CDIP shadowing, Bryant says. Strong communication skills are also vital.

“I think that we need to make sure when we are looking at clinical documentation improvement programs that we design them to look for professionals, whether they be nurses, physicians, or HIM professionals that do the CDI work, who have a good, strong communication skill set,” Bryant says.

The possible intimidation of working with physicians can be minimal if a CDS has confident knowledge of how codes translate into data and what the data means from a quality perspective. Bryant advises CDSs to study MS-DRGs and HHCs, learn how documentation affects hospital and physician finances, and understand quality reports on sites such as healthgrades.com.

Physician shadowing can be a great experience for a CDS with an HIM background, Bryant says. “Personally, I found it very rewarding to share knowledge and see lightbulbs go on,” she says. “It is quite exciting to see people get it, understand the value in their day-to-day interaction, and then later see it appear in the documentation and see the coded data is actually improving.”

The long-standing coding shortages weren’t magically solved in the past year. Only 60 percent of respondents to this year’s poll reported that their departments are completely staffed for all approved positions. About a quarter (23 percent) have coding positions that have been open for more than 3 months. The balance reported positions that have been open 3 months or less.

A lack of qualified candidates appears to remain the root cause. The vast majority of respondents (46 percent) said their departments are short on coders due to a lack of qualified candidates in the market. Many respondents commented that candidates lack on-the-job experience.

A minimal number of respondents said their staffing shortages are the result of hiring freezes or layoffs. Layoffs were the cause of coder shortages in only 1 department.

Thirty-eight percent said they were under no restrictions on hiring for approved positions. Nearly half (48 percent) reported that their departments are able to recruit for open positions, though no others. The final 14 percent reported a complete freeze on hiring.

The lack of experienced candidates in the market is requiring organizations to be flexible, creative, and committed when filling positions. Respondents commented that their departments commit to training hires that lack experience, grow coders from within, and work with community colleges to boost the local pool of candidates.

The survey was conducted online June 29–July 12, with 95 responses.

* * *

The World Health Organization maintains the Family of International Classifications, a suite of classification products that may be used in an integrated fashion to compare health information internationally and nationally. The International Classification of Diseases is published and maintained by WHO-FIC. ICD-10 is the current edition, and ICD-11 is in development.

Internationally endorsed classifications such as those in WHO-FIC facilitate the storage, retrieval, analysis, and interpretation of data; they enable the comparison of data within populations over time and between populations at the same point in time. Their use results in the compilation of internationally consistent data.

Accordingly, WHO-FIC seeks to

• improve health through provision of sound health information to support decision making at all levels;
• provide a conceptual framework of information domains for which classifications are, or are likely to be, required for purposes related to health and health management;
• provide a suite of endorsed classifications for particular purposes defined within the framework;
• promote the appropriate selection of classifications in a wide range of settings in the health field across the world;
• establish a common language to improve communication;
• permit comparisons of data within and between member states, health care disciplines, services and time; and
• stimulate research on health and the health system.

WHO has designated a number of collaborating centers to work with it in the development, dissemination, maintenance, and use of WHO-FIC. The WHO Collaborating Center for the Classification of Diseases for North America was established in 1976 to represent the US and Canada in international activities related to study and revision of ICD.

Now known as the WHO Collaborating Center for the Family of International Classifications for North America (abbreviated as NACC), it is located at the National Center for Health Statistics, a part of the US Centers for Disease Control and Prevention.

NACC works in close collaboration with two Canadian agencies: the Canadian Institute for Health Information and Statistics Canada. It maintains liaison with WHO on use, implementation, and maintenance of the FIC by the US and Canadian governments.

Nine WHO committees and reference groups contribute to maintaining the FIC:

• Update and Revision Committee
• Education Committee
• Implementation Committee
• Family Development Committee
• Electronic Tools Committee
• Mortality Reference Group
• Morbidity Reference Group
• Functioning and Disability Reference Group
• Terminology Reference Group

In addition to representatives from the collaborating centers who are members of the WHO-FIC network, other classification, health information, and clinical experts can be appointed by respective collaborating centers to represent their respective countries.

Representatives from AHIMA currently serve on three committees and reference groups: the Morbidity Reference Group, the Terminology Reference Group, and the Education Committee.

Morbidity Reference Group

The Morbidity Reference Group seeks to improve international comparability of morbidity data and the application of ICD in morbidity by analyzing and integrating needs deriving from statistics (e.g., hospital data), case mix (e.g., DRG systems), and clinical documentation (e.g., clinical terminology and electronic health records).

AHIMA’s participation helps provide the US health information management perspective to the process of developing and maintaining current and future versions of ICD and developing associated international usage rules.

While differences in national regulatory requirements and reimbursement systems inevitably lead to differences in clinical modifications of ICD and reporting rules, the goal is to minimize these differences and achieve international data consistency and comparability, to the extent possible, through international collaboration.

Sue Bowman, RHIA, CCS, AHIMA director of coding policy and compliance, currently serves on the Morbidity Reference Group and shares a US vote with Donna Pickett, MPH, RHIA, medical systems administrator at the National Center for Health Statistics.

The group:

• Identifies, discusses, and solves problems related to the interpretation and application of ICD to coding and classification of morbidity, including the establishment of standardised interpretation of the categories and the development of agreed definitions, coding rules and guidelines
• Develops recommendations for ICD-10 updates for forwarding to the Update and Revision Committee annually, through a democratic process that attempts to achieve consensus
• Supports the revision process for ICD by providing advice on morbidity-related issues and possible terminology linkage for morbidity coding
• Reviews possible morbidity applications of WHO-derived and related classifications, to inform recommendations for change to ICD
• Considers and supports statistical, epidemiological, reimbursement (including casemix), and clinical applications of ICD for morbidity purposes
• Constructs a database summarizing national applications of ICD for morbidity purposes
• Provides documentation of discussions and decisions in a database that can be used online and offline

The Morbidity Reference Group participates in the development of ICD-11, as do all of the committees and reference groups.

Terminology Reference Group

The Terminology Reference Group follows terminology and terminology systems developments and promotes awareness of the need to ensure and verify congruence between concepts underlying clinical terminologies and the WHO classifications.

The group first convened at the 2006 WHO-FIC meeting in Tunisia. Its establishment reflects the importance placed on the relationship between the classifications of WHO-FIC and the emerging clinical terminology initiatives around the world. Subsequent meetings were held in 2007 and 2008.

AHIMA director of practice leadership Rita Scichilone, MSHA, RHIA, CCS, CCS-P, F-CHC, serves as a US representative to the group. The group:

• Promotes awareness of the need to ensure and verify congruence between concepts in clinical terminologies and the categories available within the WHO-FIC products such as ICD and ICF
• Collaborates with the research community, healthcare providers, software developers, and health authorities
• Monitors and provides guidance for mapping between classification and clinical terminologies
• Guides the evolution of WHO-FIC products (e.g., ICD-11) so new work takes account of the content and formalisms used to construct and maintain clinical terminologies

Discussions between the International Healthcare Terminology Standards Development Organisation (IHTSDO) and WHO-FIC began in 2007 for harmonization of classification systems with the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT).

Education Committee

The Education Committee assists and advises WHO and the WHO-FIC Network in improving the level and quality of use of WHO-FIC in member states by developing an education, training, and certification strategy; identifying best training practices; and providing a network for sharing training expertise and experience. Its current work plans prioritize ICD and the International Classification of Disability, Functioning, and Health.

The Education Committee entered into a joint collaboration with the International Federation of Health Records Organizations (IFHRO) in 2001. IFHRO is a nongovernmental organization in official relations with WHO; AHIMA is its US representative. Together the Education Committee and IFHRO have developed an international training and certification program for ICD-10 coders and trainers. In cooperation with the WHO, they have been developing Web-based training tools for ICD-10 and the International Classification of Disability, Functioning, and Health.

AHIMA director of practice leadership Rita Scichilone serves as a US representative to the Education Committee. Its functions include:

• Assessment of the needs of users of the classifications, including those who provide source information, apply codes, conduct research or use the resulting data
• Identification of the learning objectives for educational approaches
• Inventory of existing educational materials and capacity
• Recommendations for learning content including development of core curricula
• Recommendations for best practices for promotion and delivery of educational material
• Harmonization, review, development, and maintenance of self learning tools.

References

Berg, Lars, and James R. Campbell. “Mapping SNOMED CT to ICD-10—A Joint Task of IHTSDO and WHO-FIC.” 2008.

National Center for Health Statistics. “WHO Collaborating Center for the Family of International Classifications for North America.”

World Health Organization. “Terms of Reference of the WHO-FIC Committees.”

World Health Organization. “The WHO Family of International Classifications.”

“The automated reviews are less burdensome on the provider, because there’s no request for medical records,” said Marie Casey, deputy director of the Division of Recovery Audit Operations at CMS, in the news item. “They’re also easier for the RACs to manage.”

The delay for medical necessity auditing is due to the complexity of the reviews. “We’re delaying because it’s more difficult,” Casey said. “We are really trying to ensure that when there is a difference of opinion [on the medical necessity determination of the case], the RAC clearly documents their rationale.”

The delay will also help CMS roll out an issue review team, a group comprised of members from various agency divisions that will look at policy questions, such as whether the RACs have been correct in the interpretation of coding guidelines. These teams will look comprehensively at the questions before approving new issues for RAC review, according to Kathleen Wallace, a CMS representative who spoke at a May 28 Region D RAC training session held in Helena, MT.

When record requests do come, they will start sporadically but eventually fall into a pattern, at least in Region D, said HealthDataInsights president and CEO Andrea Denko, during the Helena training session.

Jane Cook, Cheryl D’Amato, Gail Garrett, Becky Ruhnau-Gee, Linda Hyde, and Natalie Novak sort out the relationship of POA, HACs, SREs, and “wrong” surgical site policies in “Understanding National Coverage Policies.”