Embracing ICD-10: Physician documentation in a new era

Physicians’ fears of handling the transition to ICD-10 are likely not rooted in reality, especially in the hospital setting, industry experts say.

“There are just a few things physicians need to learn how to do that they’re not doing already, and they will learn pretty quickly,” said Dr. Anthony Oliva, vice president and chief medical officer of the health division of Nuance Communications, a Boston-based consulting firm, in an interview. Previously, Dr. Oliva was chief medical officer for the Borgess Health in Kalamazoo, Mich.

Dr. Oliva cites as an example a patient with a history of heart failure. In addition to noting that he has a history of cardiomyopathy secondary to ischemia and a history of decreased left ventricular function, a provider also must indicate that the patient has “chronic systolic failure,” according to Dr. Oliva, who says that failing to add these three words could mean not aligning with the diagnostic group logic being used in the ICD-10 code set, and thus not being reimbursed accordingly.

Although physicians might roll their eyes at this, Dr. Oliva, himself a family practice physician, says it’s better than having to memorize “a zillion” code combinations. “The majority of what we see is hypertension, diabetes, some kidney disease, and some GI disease, so you can just pare down what you have to know, and what you have to document. It becomes manageable. It’s more about documenting than it is about coding,” says Dr. Oliva. For specialists, it’s even easier he says, since they need only know a narrow swathe of the more than 70,000 ICD-10 codes. Dr. Oliva says that in time, health system coders likely will reveal to physicians the codes they must know for the documentation they are doing most often.

Dr. Daniel Ari Mendelson

“In bigger practices with coding support, it will be the coders working with their providers to get the precision,” says Dr. Daniel Ari Mendelson, an associate chief of medicine at Highland Hospital in Rochester, N.Y. “In small and solo practices, the provider usually has all of the burden.”

Dr. Mendelson is not of the opinion that extra documentation will add value to the patient.

“It’s possible that this precision will better capture acuity and therefore risk of morbidity and mortality, so the provider gets a better expected to observed morbidity and mortality ratio, and thus better ratings on quality metrics” he concedes, but he has his doubts. “This has some potential for better reimbursement and thus an improved reputation, but can also backfire.”

The reason for this, Dr. Mendelson says, comes down to how motivated to excel physicians are at using the new codes.

“Most of us focus on adequate documentation to communicate with each other and provide good, safe, thoughtful care and not on compliance or reimbursement issues that don’t seem to provide better safety, quality, cost, or value to patients or us,” he noted.

Coding and physician reputation

The connection between precise coding and improved physician reimbursement cannot be the sole justification for a clinical documentation initiative, both Dr. Oliva and Dr. Mendelson agree.

“I really believe that with physicians, reputation matters more,”says Dr. Oliva. Or put another way, even if you hate ICD-10, administrators are banking that your ego will triumph over your disdain for the new codes.

Because billing is determined by how well coded – and documented – each patient visit is, if the costs associated with your patients don’t add up to what the codes on them indicate they should, your reputation could suffer – and not just with hospital bean counters, but with the public at large.

Online physician rating sites are powered by data on every patient treated by every physician in the Centers for Medicare & Medicaid Services system, purchased from CMS each November, says Dr. Oliva. The more disconnects between physician documentation and coding, the lower a physician’s ratings in the data shared with the public.

“We come from a culture of being very competitive our entire lives, and never having failed, and all of a sudden we’re talking about objective performance and score cards,” Dr. Oliva said. “Physicians don’t know where this is all coming from because it’s not something that’s been done before, and they don’t know how to impact it.” The solution, he says, is to just do what you were trained to do: Note something with specificity. “Take a breath. Relax. It’s manageable for you as a physician.”

Dr. Mendelson, also his institution’s palliative care director and geriatric fracture center codirector, is not quite as optimistic. “Coding the above scenario correctly does not change anything clinically,” he says. “The way the note is written and the care executed tells the story way more than the coding.”