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CDI: Just Tell Me What to Say

CDI Still the RX for Accurate Reimbursement

Published March 23, 2012 3:24 PM by Alice Zentner

The accuracy of your reimbursement under ICD-10 is a direct result of the accuracy of your clinical documentation. As with ICD-9, the goal is to get the dollars that you are entitled to get. No more. No less. Manipulating codes to maximize reimbursement is still considered fraud.

The assignment and order of primary and secondary diagnoses must accurately reflect the patient’s condition and resources consumed by that patient as documented in the medical record. Physician documentation must reflect the situation in detail. This has also been a challenge for HIM and CDI professionals. However, the proliferation of codes under ICD-10 makes this task even more daunting.

So how do we all cope?

The first step is to fully understand the list of CCs (complication and co-morbidity) and MCCs (major complication or co-morbidity) in ICD-10 and how these codes are extrapolated over a larger expanse of principal diagnosis. A good example for CDI and HIM professionals to reference is a diagnosis of cerebral-vascular accident (CVA).

In ICD-9 coding, the diagnosis of hemiparesis following a CVA has three choices of codes. In ICD-10, the number of possible codes for the same diagnosis explodes. You now have options for right dominant, right non-dominant, left dominant, left non-dominant, unspecified, intracranial, subdural, hemorrhagic, embolic or any combination of the above. What were three choices in ICD-9 are now 28 choices in ICD-10. So physicians must say what type of CVA, which side of the brain is impacted and to what extent.

Another case is angina. If you document only angina with spasm you will get a CC. However, if you document angina with spasm with atherosclerotic heart disease (ASHD) of native coronary artery, then it is not a CC. It is just a manifestation of the underlying disease. If the angina is documented as unstable, then it goes back to being a CC. Confusing is an understatement!

For HIM and CDI professionals, the end goal is to know and understand the needs for ICD-10 and its CCs/MCCs. Once you understand the need, you can convey to the physician community the documentation protocol to accurately code the condition. Start with your high volume, high revenue diagnoses. But please get started!

posted by Alice Zentner

2 comments

Alice/Marc,

The need for specificity in itself does not complicate reimbursement. In actuality it may speed up the reimbursement process and negate certain claim denials because information that is requested multiple times from providers by claims processors, will now be readily available due to the beauty (granularity) of ICD 10. I personally think that it is time for coders, coding auditors and coding educators to stop presenting ICD 10 as more complex than it truly is. Anyone who is a true born and bred coder who has experienced this beautiful classification system is in awe at its sheer clinical simplicity. I submit to you that - A CVA needs a location. Identifying the location allows for greater specificity in the patient care continuum. Isn't the care of the patient the ultimate goal?

Tunde , Coding - Manager, KP April 5, 2012 3:45 PM
Pasadena CA

Sounds like arguments making tax code more fair.  The increased number of codes further complicate reimbursement.  The cost to implement is excessive, the change in workflow is unnecessary.  The US is the last to make this conversion. AS we look at the other countries that have implemented this there is a common theme: No benefit for ambulatory medicine.  So it obscenely expensive, unnecessary and  burdensome. APMA should be joining the AMA in stopping ICD 10 altogether.

Marc Garfield, Podiatry - DPM, Self Emp March 27, 2012 12:24 PM
Williamsburg VA

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