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The Coding Circuit: ICD-10 CM/PCS From a Trainer's Viewpoint

By Shelley L. Oglesby, RHIT, M. Ed, RHIT, CCS-P, CPMA

Manager, Coding/Reimbursement

Loyola University Medical Center

Recently, I spent three days training in a face to face interactive ICD-10 classroom. I learned a lot,

but left wondering how to accomplish all that needs to be completed and ready for the 10-01-2013 implementation date. Once I realized that retirement is not an option, the reality that there is a lot to be accomplished over the next 700 or so days.

Based on what I learned, my first recommendation is that coders need to invest personal time in reading, learning and comprehending as much as they can about ICD-10. This can be done through professional journal articles such as AHIMA, AAPC and the Internet. After working through the "root operations" for procedural coding, make a note, an anatomy and physiology refresher course should be high on the priority list.

The process for the assignment of procedure codes is more challenging in ICD-10 than in ICD-9. Individual coder investment in ICD-10 is necessary for both professional and personal growth. Coders should not view ICD-10 preparation and readiness as the sole responsibility of their employer. ICD-10 could serve as a pathway to job growth and retention.

ICD-10 education for physicians and other allied health professionals shall be geared toward documentation, documentation and more documentation. The ICD-10 coding system does not lend itself to the same coding quandaries in ICD-9-CM. For example, there is limited use of NOS (not otherwise specified). Documentation such as laterality and manifestation specification will be key to code assignment.

If someone would ask me what I believe should be the key focus of physicians’ education, my response would be to focus on documentation, such as laterality, disease manifestation, injury occurrence and surgery methods. It is essential that the message provided to physicians and other allied health professionals responsible for documentation is not a "new coding system" but that the need for documentation continues to grow.

As the onset of RAC, PSI among many others has pushed the need for the highest level of specific documentation to the forefront. While ICD-10 is about two years away, the aforementioned entities are here now and are setting ground rules for better documentation. Their primary focus is patient treatment which must be documented to the most specific diagnosis (es) and how the diagnosis (es) was/were treated. It is recommended not to monopolize physicians’ time with how to assign a code but what documentation is required. Use the time you have to educate physicians about documentation not about how to assign a code. You do not want to waste their time with the minutia of a code assignment but instead documentation requirement. The goal shall be to gain their attention so that they understand what documentation is required so that the coders have the necessary information to accurately assign diagnoses and procedure codes.

Remember, the physicians are not responsible for the code assignment.

It is important to know that while coding education is high on the list, there are many system process check and balances occurring simultaneously in the background which will impact ICD-10 readiness and compliance with the 10/01/2013 implementation date.

The greatest take away should be that a team approach to awareness, preparation and implementation is essential for a successful ICD-10 implementation.

Ask yourself the question, will everyone on your team be ready?

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