Medical Coding in the ICD-10-CM World; Computer Assisted?

It has been suggested by some that the ICD-10- CM Medical coding changeover will cause chaos because of the significant changes in the number of Medical Diagnostic codes added to create specificity to a degree no one could have imagined.

Wellington, FL November 14, 2012 – It has been suggested by some that the ICD-10- CM Medical coding changeover will cause chaos because of the significant changes in the number of Medical Diagnostic codes added to create specificity to a degree no one could have imagined. The number of Medical diagnoses codes will increase from 14,567 to 69,833 and inpatient procedure codes will increase from 4,000 to 71,918.

Some have suggested that automated systems will help but some organizations with their Medical Coding; others disagree because the systems work best when there are fewer source documents to review. ICD-10 entirely changes the view of clinical documentation to something that may be beyond the grasp of many Medical coders and physicians. According to clinical leaders, “Physicians do not typically document to the highest level of specificity required by ICD-9-CM” and so it can be inferred that ICD-10-CM medical coding and clinical documentation will be a far greater challenge.

For ICD-10-PCS (Procedure Coding), coders must have intense training, advanced clinical understanding of what physicians do and and expanded medical terminology vocabulary. Not to mention of course, anatomy, physiology, pathophysiology and a working knowledge of pharmacology.
Hospitals and clinics are faced with a grave problem. As Medical/Hospital coders and physicians prepare for the upcoming changes, KLAS, a highly regarded research firm, has found that almost half of all hospitals will purchase a computer assisted coding product in the next several years in hopes of avoiding a slowdown in cash flow and an increase in Denial of Claims. Vendors will be pitching their coder-assisted products to hospitals as the new paradigm for success in this new environment. While such systems can be helpful, the truth is that hospitals and physician practices management need to work with the medical staff and Medical coders on the basics. The first thing to determine is how well they are doing with ICD-9 coding and clinical documentation now. A review of the quality of the clinical documentation as it relates to the coding outcome is essential to understand the current state. The results of a Clinical documentation audit using a Deconstruction methodology, will establish current state conditions, and help set the stage for introducing ICD-10 Medical/hospital coding and the very stringent clinical documentation requirements.

Most professionals agree that no matter what tool or system is used to assist in Medical/Hospital coding, the outcome is only as good as the documentation in the patient records and the coders’ understanding of what has taken place in the patient encounters. Without a clinical documentation improvement program in place, not only will cash flow slow down but denials will increase and chaos will ensue.

The best practices and the best minds in the industry are incorporating specific steps for a successful program improvement transition. These organizations are conducting thorough reviews of the current quality of clinical documentation across all disciplines in the current coding requirements of ICD-9-CM. Then they are relating such findings to the core group of physicians in each discipline to get their input on the best way of achieving improvements to meet the ICD-10-CM challenge.

They are taking current cases and applying the ICD-10-CM requirements and testing the quality of the Clinical documentation and Medical coding. These findings begin the process of using “live” cases to create the substance of the training process. Physicians don’t like lectures but they enjoy the challenge of diagnosing and recommending treatments in the context of actual patient encounters. Medical/Hospital Coders and physicians should work closely to advance their mutual understanding of each other’s knowledge of what is critical to that discipline to realize the best reimbursement based upon the actual resources used.

In subsequent stages, most senior Medical/Hospital coders who have excellent critical thinking skills, will round with physicians in each discipline so they can learn what the physicians do and the physicians in turn can begin to learn the new language/descriptions that drive the ICD-10 System. Lastly, efforts should be made to identify the champions on the medical staff who will pair up with colleagues to help teach and become models for the rest of the staff.
The introduction of automated systems will only confuse everyone unless the program outlined above is working throughout the organization and the physician practices.

Call us 866-908-4226 or email to with any questions…

Medical Coding in the ICD-10-CM World; Computer Assisted?