Focusing queries in ICD-10
Wondering how planning to approach the anticipated number of queries related to ICD-10 specificity (I estimate that if we query for all ICD-10 specificity the volume will jump 300-400%).
Most CDS I know are working at full capacity just to keep up with their current caseloads, and although they (and their coders) are being trained in ICD-10, I'm not hearing that administration/senior leadership is really defining what reporting expectations are in the future.
For example, does leadership assume that the CDS will be able to identify and clarify EVERY non-specific diagnosis? Knowing that the CDS cannot possible query everything on the front end, are Coders expected to pick up the difference?
My perception is that facilities (and leadership) are focusing on the broader issues associated with I-10 (technical support, mapping codes in the chargemaster, etc.) but that no one is developing a plan on how to get those codes in the first place. Senior leadership does not even have an understanding of what the implications will be when unspecified codes are reported after ICD-10.
I recently spoke with a leader of a large payer organization who stated that they have definite plans in place to revise their guidelines and rules associated with payment of claims. For example, pre-authorization for inpatient admission may be denied if the condition is not reported as "acute" or "exacerbation" (hello ICD-10). They plan on leveraging the availability of the greater detail of ICD-10 codes to determine the medical necessity of the claim, and whether payment (partial or full) will be made to the provider.
Many CDI programs (believe it or not), due to staffing, or the expectation to meet certain productivity standards prioritize queries and reviews based on maximizing the MS-DRG rather than specificity. I'm wondering what will happen in 2015 when suddenly the providers start receiving lower payments due to the non-specific codes on the bill. Leadership does not seem to understand that ICD-10 impacts every case, not just Medicare or other DRG cases.
Has anyone addressed these concerns with leadership, and what was the response you received?
Most CDS I know are working at full capacity just to keep up with their current caseloads, and although they (and their coders) are being trained in ICD-10, I'm not hearing that administration/senior leadership is really defining what reporting expectations are in the future.
For example, does leadership assume that the CDS will be able to identify and clarify EVERY non-specific diagnosis? Knowing that the CDS cannot possible query everything on the front end, are Coders expected to pick up the difference?
My perception is that facilities (and leadership) are focusing on the broader issues associated with I-10 (technical support, mapping codes in the chargemaster, etc.) but that no one is developing a plan on how to get those codes in the first place. Senior leadership does not even have an understanding of what the implications will be when unspecified codes are reported after ICD-10.
I recently spoke with a leader of a large payer organization who stated that they have definite plans in place to revise their guidelines and rules associated with payment of claims. For example, pre-authorization for inpatient admission may be denied if the condition is not reported as "acute" or "exacerbation" (hello ICD-10). They plan on leveraging the availability of the greater detail of ICD-10 codes to determine the medical necessity of the claim, and whether payment (partial or full) will be made to the provider.
Many CDI programs (believe it or not), due to staffing, or the expectation to meet certain productivity standards prioritize queries and reviews based on maximizing the MS-DRG rather than specificity. I'm wondering what will happen in 2015 when suddenly the providers start receiving lower payments due to the non-specific codes on the bill. Leadership does not seem to understand that ICD-10 impacts every case, not just Medicare or other DRG cases.
Has anyone addressed these concerns with leadership, and what was the response you received?
Comments
Currently we review all inpatient records, regardless of payer. However, I don’t see how we could identify/fix all I-10 Specificity issues. I don’t think most programs (if any) truly query for all I-9 specificity currently, and I do not see that changing in I-10. I also doubt it is needed. Even if this did happen where insurers would not pay (or paid less) for NOS dx, I am assuming this would only pertain to the Pdx? It seems we could make this a priority. That being said, I find it hard to believe that they could make a blanket rule that they will not pay for NOS claims. In plenty of cases NOS is appropriate. Not just from a coding perspective but also a clinical one. We don’t always know more than what the MD is saying even if there are more specific codes available. Pneumonia, sepsis, or patients who expire prior to diagnostic testing would be perfect examples (on a side note, this is also an issue with querying for all I-10 specificity available -there is the potential to be sending a lot of queries that the MD is 'unable to determine').It seems like if insurers do make this change, it would likely be for specific diagnoses. CHF may be a good one in most instances?
There are a lot of unknowns right now with all the new healthcare initiatives being implemented currently. I don’t pretend to know what the impact of all of them will be. But I do emphasize with Senior Management that a big benefit of having a robust CDI program is that we are a team of concurrent reviewers who can quickly adapt to those changes and help the hospital meet new needs as they are identified.
Whenever I hear it suggested that CDI should be querying for all coding specificity, I wonder if those facilities would be better off initiating a concurrent coding program. My team does not consist of coders but if we are expected to query for all specificity, we would need to be basically coding out the records and looking for any holes. I am not sure CDIs are the right people to do this? I think it might be more effective to have a concurrent coding program in that case and then have CDI do targeted reviews for specific types of cases (certain Pdx, PPx, etc). Just a thought....
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
evanspx@sutterhealth.org