D'Arcy Gue

ICD-10 Revenue Neutrality — Is Your Current Documentation Sufficient?

November 19, 2013

ICD-10 3 Minute Read

This post is the second installment in our “ICD-10 and Your Bottom Line” series.  

Payers tell us that their ICD-10 efforts focus on ensuring revenue neutrality – that the same services provided before and after the ICD-10 transition date will provide the same reimbursement. However, their calculations assume that provider documentation is sufficient to justify an equivalent mix of ICD-10 codes. That may not be the case.

I’ve discussed ICD-10 coding requirements with several physicians recently, and invariably they say that their documentation is better than average, and that they expect no challenge in meeting the increased specificity requirements for ICD-10.   Based on the number of hospitals I’ve worked in with successful Clinical Documentation Improvement (CDI) programs, it seems unlikely.

CDI programs look at patient charts during the patient visit, identify areas where provider documentation may be missing from the chart, and query the provider for the information.   Frequently, the items addressed are refinements of diagnoses and addition of secondary diagnoses that would lead to higher levels of acuity and revenue.   The fact that significant opportunities are being identified at the ICD-9 level of specificity is a sign that many providers’ documentation is not “better than average” and that the greater level of specificity required for ICD-10 is almost certainly going to be an issue that needs addressed.

To assess your level of risk from documentation that doesn’t meet the specificity requirements of ICD-10 requires an audit of existing charts.   We recommend that providers perform an evaluation of charts from (at least) their top 25 DRGs and their top outpatient diagnosis codes. It’s important that this audit focuses not just on coding, but on areas where documentation would make a difference in the final diagnosis. If you don’t have the ICD-10 and trained CDI expertise in house to analyze these charts, there are many firms available to assist you.

To be cost effective, this chart analysis must be focused on your top diagnoses.  The following examples represent three very different areas where coding requirements have changed substantially and will significantly affect documentation.

  1. Angioplasty, which changes from one procedure code in ICD-9 to 1,170 codes in ICD-10, provides detail about location of the procedure and any device involved for each patient.
  2. Trauma and injury codes expand across the board to provide more detail about anatomic location, specific injury, and when the physician interacts with the patient.  For example, the common emergency department diagnosis, sprained ankle increases from 5 codes in ICD-9 to 45 codes in ICD-10.
  3. Obstetrics codes receive a major overhaul.   Unlike the ICD-9 codes, obstetrical codes are not divided by antepartum, delivery, and postpartum status.  Most ICD-10 codes, however, indicate the trimester of pregnancy in the last character.  There are also significantly more codes to describe complications in pregnancy.

Results from this analysis will indicate areas where documentation is lacking, and where coders would be forced to use non-specific codes that would impact reimbursement.   By comparing the same charts coded (and the impatient charts grouping into MS-DRGs) in ICD-9 and ICD-10 you can assess the overall financial impact of your current documentation.

Just as importantly, you can use the areas where documentation is lacking as specific teaching points for your physician education program, and therefore eliminate the deficiencies before they can cause an impact in October 2014.

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