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Comments on Some ICD-10-CM/PCS Meetings

I attended two meetings in 2013 that were focused on ICD-10-CM/PCS. The first was the HIMSS ICD-10 Forum and the second a two-day workshop on ICD-10-CM/PCS presented by ICD-10 gurus Lynn Kuehn RHIA and Gail Smith RHIA. Following are some highlights from what I heard and learned at these programs, with my additions/comments appended in italics.

The HIMSS ICD-10 Forum
  • The October 1, 2014 implementation date for ICD-10-CM/PCS is firm. There will be no delays. There will be no extensions. It will happen. Get ready! This was repeated again and again throughout the meeting, most emphatically by Farzad Mostashari, National Coordinator for Health IT, and Denise Buenning, Deputy Director, Office of E-Health Standards and Services, CMS.
  • Update: Despite the firm CMS announcement above, implementation has indeed been delayed until October 2015. 
  • Start dual coding by January 2014. Yes, Virginia, knowing how to code in both ICD-9 and ICD-10 makes sense – and makes the coder more valuable! A recommendation, repeated time and time again was: Start dual coding early, not for every encounter but for a sampling – and require all coders to participate. And yes, our Coding for Healthcare Professionals program will be adding an ICD-10-CM/PCS module. Watch for the announcement later this summer.
  • Up to 30% of existing coders are expected to leave the field. This spells OPPORTUNITY!
  • CDI (clinical documentation improvement) programs should be expanded. The link between documentation and coding is strong. MTs already know the value of accuracy, completeness, and consistency in documentation. Applying that knowledge to coding makes sense.
  • SNOMED-CT will become increasingly important because it is “constructed the way clinicians think.” CMS is developing a crosswalk between SNOMED-CT and ICD-10. SNOMED-CT can ease the transition to ICD-10. This came across like a sales pitch. My view: Documentation is done in “clinician-speak,” and it would be more accurate to say that SNOMED-CT is “constructed the way ‘they’ want clinicians to think.” The “they” is both SNOMED-CT developers and NLM (National Library of Medicine), each of which has invested tremendous effort and resources (including funds) in this terminology system. They’ve got a long way to go before clinicians are in alignment with this goal, worthy though it is. 
  • Think of ICD-10 as “simplicated” instead of “complicated.” ICD-10 is logical. Unfortunately, the huge number of codes in ICD-10 compared to ICD-9 has led people to think it is more complicated. In reality, as you learn and use it, its logical design becomes evident and appreciated. It makes sense!
  • All data collection should not fall on the doctor. Involve patients, nurses, and non-clinical staff. Here is another area where MTs/coders can play a role, at least through advising and querying. There is a potential for that role to expand as efforts grow to diminish the burden of data collection for physicians. (See last bullet in section below about the MaHIMA meeting for how this goes a step further in ICD-10-PCS.)
  • CMS has developed an approved 1500 (Health Insurance Claim Form) paper version for those providers still using paper! Alas, paper still abounds and so must be accommodated.

The ICD-10-CM/PCS workshops at the MaHIMA Convention (MaHIMA is the Massachusetts State Association of AHIMA).
  • The 2014 ICD-10-PCS Code set and guidelines have been released by CMS and can be downloaded from their website. They’re free, in PDF format, and easy to access. You’ll probably want to use them electronically rather than printing their numerous pages. 
  • The Merck Manual is the presenters’ recommended resource for pathophysiology questions, and it’s free on the Internet. The Mayo Clinic and Cleveland Clinic sites are also valuable resources. Many .org and .edu sites can provide good information as well, but be wary of .com and .net sites. Make Merck Manual your go-to site for such questions as, “Is this symptom integral or not to this disease process?” 
  • While ICD-10-CM will be used for both inpatient and outpatient coding, ICD-10-PCS will be used only in inpatient settings. In other words, CPT will continue to be used for procedures in physician practices and other outpatient settings. Exception: At least 7 states are requiring ICD-10-PCS in outpatient settings. I don’t know which states are among these 7 but will try to find out and report back. Also, it’s not clear whether these 7 states will require ICD-10-PCS in addition to or instead of CPT for procedures, so I’ll try to find that out as well. One wonders if this is the beginning of the recognition that PCS is better constructed, more logical, easier to use, and provides more valuable data than CPT and that it makes sense to use both ICD-10-CM and PCS in both inpatient and outpatient settings because doing so will provide more complete and accurate data about population health. The two systems are dramatically different and have different purposes. CPT is a reimbursement system (developed, owned, and licensed for a fee by AMA), whereas ICD-10-PCS (as well as -CM) is a classification system in the public domain that will provide valuable data regarding population health and healthcare delivery. Yes, it is also used for reimbursement, but that is not its primary purpose or value. Further, there is a logic to ICD-10-PCS (and -CM) that is absent in CPT. All that said, the likelihood that ICD-10-PCS will replace CPT is slim to nil, at least at this juncture. It’s just not politically feasible.
  • The real value and purpose of ICD-10-CM/PCS are not related to reimbursement but rather to population health, quality of care and clinical knowledge. Yes, I realize I said this in the above bullet, but it is worth emphasizing. This point has been lost in much of the discussion and brouhaha related to ICD-10-CM/PCS adoption.  
  • The examples presented by those who would like to halt the adoption of ICD-10 often emphasize the “absurdities” of data that ICD-10 will generate. Examples: Fell into bucket causing drowning; bitten by a rodent in a single family dwelling; pecked by a hen in a farmyard; poked eye with a knitting needle. These examples relate to external cause codes. There is no national requirement for mandatory ICD-10-CM external cause code reporting. These are codes that must be recorded only when a particular state, provider institution, or payer requires doing so. Repeat: CMS does not require external cause code reporting!
  • “Many of the terms used to construct PCS codes are defined within the system. It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear. Example: When the physician documents “partial resection” the coder can independently correlate “partial resection” to the root operation Excision without querying the physician for clarification.” I saved the best for last. The above is guideline A11 from the 2014 CMS Guidelines for ICD-10-PCS, and for emphasis, I bolded the sentence regarding the coder’s responsibility. This guideline recognizes both the role and the (expected) expertise of the coder, who is charged with determining whether physician documentation that doesn’t use the terminology expressed in PCS is, nevertheless, equal to it, thus avoiding unnecessary delays that would result from querying the physician to confirm same. So simple, so sensible. Applause! Applause! Regarding the example given, you may be wondering how “partial resection” equates to “Excision.” In PCS, the definition of the root operation Excision is “Cutting out or off, without replacement, a portion of a body part,” and the definition of the root operation Resection is “cutting out or off, without replacement, all of a body part.” Thus, physician documentation that uses the phrase “partial resection” is correctly correlated to the root operation Excision.

Finally, some general comments about the meetings

The HIMSS ICD-10 Forum was disappointing: Presentations varied greatly in content, delivery, and value; too much basic information; only a handful of exhibits, etc. I would give high scores to only three or four presentations. I couldn’t help but compare it to AHIMA’s ICD-10 Summit that I attended in April. That program was much better designed, had better speakers offering greater depth and breadth, and included a larger, more diverse and valuable range of exhibitors.

The MaHIMA two-day workshop addressed ICD-10-PCS the first day and ICD-10-CM the second day. It was delivered by Lynn Kuehn MS, RHIA, CCS-P, FAHIMA, and Gail I. Smith MA, RHIA, CCS-P, both well-known authors, HIM consultants, and AHIMA-approved ICD-10 experts, who have immersed themselves in ICD-10-CM/PCS for the past several years. They packed each day with tremendously valuable learning points laced with humor, and they dispelled the view that ICD-10 is difficult and cumbersome. Their expertise in, commitment to, and enjoyment of ICD-10-CM/PCS were evident, and they made this a valuable learning experience. Further, the registration fee was less than half that for the HIMSS ICD-10 Forum. Much more bang for the buck.