If The Documentation Doesn’t Fit, The OIG Will NOT Acquit – Key Points for ICD 10 Success


I-Ten Tuesdays with TMI:  Free ICD 10 Resources for 2014

By Holly Cassano, CPC, Director of Coding Compliance and Education for Tactical Management Inc., (TMI)

ICD-10 Countdown – October 1, 2014 –  242 DAYS Remain

So in case you have been living in a bubble, everyone in the Healthcare community, is well aware of the impending ICD 10 compliance date, of October 1, 2014.  What this means to providers and healthcare entities and Plans, is that all services provided, on or after October 1, 2014, are mandatory to be coded utilizing ICD-10CM for Professional Fees Charges and ICD-10PCS for Inpatient Facility Charges.

Providers, Entities and Plans that submit claims with ICD-9 codes after October 1st, 2014 will be faced with mass rejections.

There is only one set of “exceptions” – Auto liability insurance (No-Fault), Worker’s Compensation and Disability claims, but the rest are required to submit with ICD 10 CM/PCS codes.

To assist with a smooth transition to ICD 10, it is important to have an understanding of the Key Points of the new code set.  Here is a quick breakdown of the basics:

ICD-10 Basics & Benefits:

Two code sets in ICD-10

• ICD-10-CM: Diagnosis codes (all providers)

• ICD-10-PCS: Procedure codes (Facility Inpatient only)

 Both code sets – ICD-10CM/ICD-10PCS have a higher level of detail compared to ICD-9

• Diagnosis codes go from 13,000 to 69,000 codes

• Procedure codes go from 3,000 to 87,000 codes

• Remember – ICD-10-PCS does not replace CPT

ICD 10CM/ICD 10PCS Requires increased specificity in documentation to report a diagnosis:

• Will increase accuracy for reporting metrics for risk adjustment quality measurements

• Allows for superior Encounter Data reporting for Chronic Disease management

• Overall improved data collection for research, and public health concerns

• Clearer and current medical terminology

Ramp Up Provider Documentation NOW!

If you are part of a practice or entity that is prepared in every aspect except documentation, for ICD 10 implementation, than I strongly suggest you put documentation efforts with providers into high gear in order to meet the requirements for higher specificity to support the codes.  I say this in order to avoid potential lags in claims reimbursement due to rejections or queries from payers.  The AAPC conducted a study in the first two quarters of 2013 and the results were a bit chilling.  The study, included over 20,000 audits of physicians’ and how their current documentation faired against ICD 10 documentation specificity.  The AAPC’s findings reflected that only 63 percent of providers in the study, had sufficient documentation that supported diagnosis codes for ICD-10’s required specificity levels.

To view the results of the AAPC’s study, please click on the following link:


Why Your Documentation is Key to ICD 10 Compliance:

• Improves compliance

• Improves patient care

• Improves clinical data for research and education

• Protects the legal interest of the patient, facility and physician

• Enables proper reimbursement for services performed

On occasion, providers will indicate a diagnosis code in the medical record, in lieu of a narrative diagnosis, that is not supported with documentation.  This is unacceptable per AHA Coding Clinic Guidelines, as ALL coding must be initiated from a narrative diagnosis in order to ensure coding accuracy.

Supporting documentation starts with a basic understanding of what must be recorded in an office or surgical note. ICD 10 means increased specificity in code descriptors, which means that providers must be more specific with their notes.  It is no longer enough for a provider to note briefly that a patient has uncontrolled diabetes.

ICD-10 codes require the following:




• MANIFESTATION – if appropropriate

TIP:  A Little M.E.A.T. – Goes a Long Way

Documentation MUST support the 4 components of M.E.A.T.!






The M.E.A.T. of the Matter

You know the saying ‘Let’s get to the heart of the matter?” Well, providers and coders should remember “ Let’s get to the M.E.A.T. of the matter.”  MEAT, is the best way to remember the higher levels of specificity required to report ICD 10 codes.  It is not the “volume” of documentation, that payers and auditors will be looking for in a chart to support an ICD 10 code, it is the “Key Phrases and words, which will support the reported codes, hence the “M.E.A.T.   ICD 10 is not about volumes of documentation in a medical record, it is about reporting key indicators – linking statements and words, which speak to the specificity of a code.  In order for providers to be able to comply, it is mission critical that they have a thorough understanding of what M.E.A.T. is and how it correlates to ICD 10 and the medical record. For example:  “The difference between diabetes mellitus due to an underlying condition and diabetes induced by drugs or chemicals”.

Oncologists must remember that in order to report a Neoplasm code in ICD 10, the key points of their documentation must include the following:

• Type: Malignant (Primary, Secondary, Ca in situ),Benign, Uncertain, Unspecified behavior

• Location(s): (site specific)

• If malignant, secondary sites should also be indicated

• Laterality, if applicable

The  I-Ten Takeaway:

ICD-10-CM will allow for greater clinical specificity than what is currently conveyed in ICD-9-CM.  Updates to Terminology and Disease classification will now be a consistent process and in line with current clinical practices. By utilizing ICD 10, the US Healthcare system will have access to more accurate data to enhance and improve overall clinical outcomes and research in the following areas: ™

• Measuring for quality, safety, efficacy of care

• Minimizing attachments to payer claims that explain a patient’s condition

• Streamlined payment systems for faster and more accurate claims processing

• Allow for the ability to conduct research and clinical trials in numerous areas

• Implementing improved health policies

• More efficient operational/ strategic planning

• Design better health care delivery systems

• Monitor resource use to address over and under utilization

• Allow for better processes that improve clinical, financial, and administrative performance

• Tracking and Enforcement of identified fraudsters/abusers in the healthcare system, as well as aid  with preventing future occurances, with early detection measures

• Early identification of public health risks by allowing accurate tracking measures

I-Ten Free Zone: Feature Special – AAPC Free ICD 10 Coding Tools

AAPC  ICD-10 Documentation Example Tool:

This tool provides actual case highlights reflecting the increased specificity required to code for ICD-10-CM. To review this example, please click on the following link: http://www.aapc.com/ICD-10/icd-10-documentation-example.aspx

AAPC  ICD-10 Code Translator Tool:

The ICD-10 code online translator tool allows you to compare ICD-9 to ICD-10 codes. This online tool also helps with mapping. (Note: this tool only converts ICD-10-CM codes, not ICD-10-PCS.) http://www.aapc.com/ICD-10/codes/index.aspx

AAPC  ICD-9 to ICD-10 Mapping Tool:

This one-page reference sheet will help coding professionals and clinicians ease transition between the ICD-9 code set and ICD-10. It shows how the code sets are organized, with easy color coding and mnemonic tips that assist with locating the correct code.


Additional ICD-10 Resources:

• AMA Web site: www.ama-assn.org/go/icd-10

• MGMA Web site: www.mgma.com

• Centers for Medicare & Medicaid Services (CMS): www.cms.gov/Medicare/Coding/ICD10/index.htm

• For up to the minute I-Ten information, follow on Twitter: @CMSGov, #CMSNPC

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