| |||||||||||||
|
Home
|
For other articles and previous issues click here. December 16, 2002 Preparing
for ICD-10-PCS An overview of the fundamental structure
of ICD-10-PCS, including the industry drivers that led to its development
as a replacement for ICD-9-CM procedures, should illustrate the
challenges expected from the new system. There are steps HIM professionals
should take to assess their organizations’ implementation risk
as well as strategies, including budgetary considerations, staff
education, information systems issues, and the creation of a multidepartmental
implementation task force. The CMS funded a three-year project with 3M Health Information Systems to meet the requirements of NCVHS. The ICD-10-PCS system development was completed in 1998. A May 2001 public hearing on ICD-10-PCS as the national standard for inpatient procedure coding resulted in widespread support of its use from organizations such as the American Health Information Management Association (AHIMA) and the American Hospital Association (AHA). Prior to the passage of the Health
Insurance Portability and Accountability Act (HIPAA), the CMS had
planned to implement ICD-10-CM in 2001. This date has been moved
back several times due to the passage of HIPAA. HIPAA coding standards
cannot be changed unless the CMS goes through the official HIPAA
process, which begins with NCVHS hearings and its recommendation
to the secretary of Health and Human Services. It is anticipated
that these hearings will take place in 2003. The estimated date
for implementation of new code sets would then be around 2006. • Completeness • Expandability • Multiaxial • Standardized Terminology Three general guidelines were followed
in the development of ICD-10-PCS: Character 2 refers to the body system where the procedure is performed. Each section (character 1) has its own list of body systems. These are generally accepted anatomical categories. Some of the traditional body systems may be assigned multiple categories to provide more detail and allow more room to add codes. Character 3 refers to the root operation, which is the underlying objective of the procedure. Each root operation is given a precise definition to avoid confusion. In the medical and surgical section, these root operations are alteration, bypass, change, control, creation, destruction, detachment, dilation, division, drainage, excision, extirpation, extraction, fragmentation, fusion, insertion, inspection, map, occlusion, reattachment, release, removal, repair, replacement, reposition, resection, restriction, revision, transfer, and transplantation. Each definition defines a complete procedure. Incision (opening) is not a root term and would be included as part of the procedure. Excision (to cut out or cut off a portion of a body part) would be a root operation. Excision may include the use of a laser or a knife and would define procedures such as a partial nephrectomy, wedge ostectomy, or pulmonary segmentectomy. Character 4 refers to the body part
upon which the procedure is performed. The listed parts will depend
on the section and body system selected. If the physician does not
provide detailed documentation describing the body part, the coder
can select a general body part for this character. Character 6 refers to the use of a device in the procedure. This character specifies only devices that remain after the procedure has been completed. Materials used in the procedure, such as clips or sutures, are not considered devices. This character describes a limited set of root operations, which includes bypasses, fusion, insertion, and replacement. Examples of devices found in the medical and surgical section are drainage device, radioactive element, and autograft. If no device is used in the procedure being coded, the coder will select Z for none. Character 7 is the qualifier. A qualifier
can be used to identify extra information such as the type of transplant
or a second site for a bypass. It is specific to the procedure. The tabular listing is formatted in
Figure 2. In the second phase, 200 medical records
were coded using both ICD-9-CM and ICD-10-PCS. The systems were
compared for ease of use, time needed to identify codes, number
of codes required, and the strengths and weaknesses. CDAC coders
favored ICD-10-PCS over ICD-9-CM because of its greater specificity
in the assigned codes and the increased information available for
research and statistical analysis. ICD-10-PCS is a natural progression
of increased health information requirements. It will expand the
clinical data collected by the individual coder and provide better
information at both the facility and national levels. Proficient
coders have a solid background upon which to build during the period
preceeding implementation. Weaknesses can be identified and addressed
by education. Because the most important issue to address is fear
of change, an optimistic approach to training, auditing, and education
is an important aspect of any implementation plan. Storing both ICD-9-CM, ICD-10-CM, and ICD-10-PCS code sets will be required for hospital reporting, research, and trending of clinical and financial data. A crosswalk exists that converts ICD-10-PCS to ICD-9-CM procedure codes. At this time, there is no crosswalk to convert all ICD-9-CM codes to their ICD-10-PCS counterparts because of major changes in the structure for determining the procedure codes. Without crosswalks for code conversion, systems may need to retain the ability to store ICD-9-CM codes for future case mix analysis and comparative studies. The type of facility and amount of research or clinical reporting that is done on a regular basis will determine how many ICD-9-CM data are archived. Facilities conducting little or no research—and needing to trend only a few years’ worth of data for financial purposes—will complete the implementation period quickly. Research-oriented organizations such as university hospitals, cancer facilities, and children’s hospitals will require more planning and adjustment. The CMS will likely map codes to their
original DRGs during the transition to give hospitals a period of
adjustment. ICD-10-PCS and ICD-10-CM codes will map to more appropriate
DRGs with different reimbursement levels in subsequent years. HIM is the most obvious point of impact because it is the source of coding. Assessing the gap between what is to occur upon ICD-10-PCS implementation and processes currently in place is a critical first step. To begin a gap analysis, coders and coding managers can prepare individually and as a department by selecting a population of medical records and recoding them with the new system. ICD-10-PCS training manuals are available
from the CMS and 3M Web sites. These will help coders determine
areas of weakness associated with anatomy or specific surgical processes
that will require additional education. Coders will also be alerted
to problems with physician documentation. Correct coding with ICD-10-PCS
will require more extensive documentation from surgeons, and education
may be needed in some facilities to provide information for accurate
coding. The number of procedures generating DRG-driven reimbursement should be factored into the departmental picture. If the facility has a 60:40 ratio, where 40% of its DRGs are driven by procedure codes, the rule of thumb is that more than one-half of the facility’s reimbursement is tied to procedural coding. The question to be answered is: If 40% of the coding is slowed by X amount of time, how many additional coders will be needed to maintain an acceptable accounts receivable during and after implementation? PFS needs to be completely aware of potential slowdowns in HIM. These slowdowns may affect monthly summaries, operational reports, and accounts receivable. Many HIM departments use the “first in, first out” method of determining coding priority. This, however, may not be the most cost-effective way for the facility to continue to bill. With the help of PFS, the HIM department can prioritize its charts by categories such as payor filing date, high-dollar stay, and chart availability. Hospital finance departments use an assortment of reports and summaries featuring DRGs for contract negotiation, resource utilization, cost management, strategic planning, and other functions. These reports are the lifeblood of the facility, and potential slowdowns in their generation could be problematic. While PFS is concerned with the speed of DRG submission, finance is concerned with the content. An inventory of all reports going to finance and containing DRG information should be compiled and examined to determine areas of risk during the implementation period. The hospital information systems department
is responsible for maintaining an inventory of all systems that
will carry the ICD-10-PCS codes, interfaces that will pass them,
databases that will hold them, and an assessment of the level of
technical risk within each. IS will interact with all vendors to
assure each provides an update to the current system. In very large
facilities, additional employees might be required for this task.
IS will coordinate the actual implementation and decide on additional
system storage needs. Reports generated for individual departments are used in many facilities for Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reporting, research, clinical pathway development, and resource utilization. All reports containing procedure codes and related DRG information that go to department heads should be inventoried and analyzed for areas that will change with ICD-10-PCS. Individuals running these reports should be updated on changes that would result with the code-set transition. They should be aware of a report’s use and how the change might affect the information and the clinical picture that is being presented. Physician documentation touches all
areas of the facility—from the clinical picture being portrayed
to the reimbursement received for services. Physician documentation
has been an ongoing problem since the beginning of the 1900s when
the medical record profession was given responsibility for patient
records and the information within. The situation has not improved
much over the years, despite all the programs designed to address
the issue. With ICD-10-PCS, documentation problems will increase
because of the expanded requirements for code assignment. Incorrect
code assignment, especially in the second year, can significantly
change the clinical picture of a department, the reimbursement to
the facility, and the professional profiles of the physicians. HIM
directors and quality management directors should be prepared to
aggressively address this issue with administration. Each area will approach education from
a different perspective. Coders need to increase their medical knowledge,
physicians need to understand the requirements for documentation,
and the medical staff needs to be aware of the challenges to the
physicians and be supportive of processes that allow greater interaction
between the coding staff and the physicians. Quality management
needs to understand ICD-10-PCS and how it relates to its data collection,
reporting, and JCAHO requirements. While the leadership position should
belong to HIM, all areas play a vital role in a successful transition.
ICD-10-PCS can also be viewed as an opportunity to break down the
silos that exist within hospitals and produce a smoother workflow
that generates better, more useful health information. |
 |
3801 Schuylkill Rd • Spring City, PA 19475 Publishers of For the Record All rights reserved. |