There is much talk about ICD-10 implementation, which is set to begin on October 1, 2014. However, many home health agencies are behind on their implementation plans and training according to the timelines set up by Medicare[1]. Not only are a majority of them behind on planning their ICD-10 implementation, they are also behind on training their staff.

Clinicians who are hearing bits and pieces of information may be left to wonder how the implementation of ICD-10 will affect them. In addition to all the tasks that home health field staff clinicians juggle on a daily basis, the added stress of being left in the dark regarding ICD-10 can cause uneasiness.

When it comes to coding, whether ICD-9 or ICD-10, the Outcome and Assessment Information Set (OASIS) guidance manual states that the clinician is responsible for assessing the patient and determining the primary and secondary reasons for home health care need and assigning these diagnoses.  In most agencies, a supervisor or coder then assigns the correct diagnosis code to the assessment. This facilitates accuracy and compliance to Medicare regulations as well as Coding Clinic rules.  CMS is makes it clear in OASIS –C that diagnoses should not be sequenced by degree of symptom control or by “payer” codes designation[2].

Most clinicians are not trained in ICD Coding for Home Health. Therefore, they should report to the person in their office who does the coding and together, the two can code appropriately using the clinician’s assessment and the documentation from the referral source and the physician’s office. Clinicians may need to query the physician for more information if there is no clear documentation of diagnoses. Clinicians should not rely on caregiver report or assume diagnoses based on medications alone.

The primary responsibility of field staff with ICD-10 is providing INFORMATION accurate assessment and documentation. Because ICD-10-CM has an expanded and more descriptive set of diagnoses, assessing clinicians will need to document specifics about diagnoses and locations of diseases or problems. Clinicians may need to brush up on their anatomy and physiology in order to properly document for assignment of ICD-10-CM codes.  For example: In ICD-9-CM, assessing clinicians would do well to document that their patient has cancer of the lower lip. However, in ICD-10, the coder will need to know specifics of the location as ICD-10 further categorizes this disease such as “external lower lip” or “lower lip, inner aspect”, which includes the buccal aspect of lower lip; the frenulum of the lower lip; the mucosa of the lower lip; and the oral aspect of the lower lip[3]. Needless to say, clinicians will need to assess and document more specifically so that the coder can assign the correct code. In cases where the referral documentation and assessment cannot provide such information, the physician will need to be queried for this information.

As agencies learn more about implementation of ICD-10-CM, referral sources may require education regarding what is needed on referral. Agencies will need accurate documentation of diagnoses and needs from the physician office or hospital in order to code properly. These Referral Sources may need education as to why this information is required; marketers may look at assisting in gathering this information to ease the burden of facilities’ case managers or discharge planners.

Clear agency policies regarding whom will be responsible for physician query, in cases where further information is needed, is also a good idea. Staff members who are tasked with this call should document the reason for the query, as well as the information that is received, in the clinical chart. This can be documented on a communication note, coordination of care note , or the OASIS depending on the timeline in which the information is received.

As always, clinician documentation is a necessary part of compliance with regulations. As we have all learned in our respective Schools of Nursing, Schools of Physical Therapy, Schools of Occupational Therapy and Schools of Speech Therapy-“If it is not documented, it is not DONE”. With Implementation of ICD-10, this is especially true.

A study by AHIMA (American Health Information Management Association) showed that coder productivity dropped to almost half of usual when ICD-10-CM was implemented in Canada. This translates into decreased amount of claims that will be ready for billing than usual. Many agencies will want to look into hiring additional certified coders or outsource their coding for this reason. However, it is important not to wait until the last minute to secure contracts with certified coders as there will be numerous agencies seeking their expertise[4].

With an implementation plan, education of all of the agency’s employees, and compliant documentation by staff, ICD-10-CM implementation will be much less daunting a task. It is never too early to start working on your implementation plan. Check with your software vendor regarding their readiness, check out the CMS readiness timeline, and attend as much training as possible to ensure a smooth transition. Most of all, plan ahead for the known drop in productivity that will occur with the transition.

[2] http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIOASISUserManual.html

[3] Complete Home Health ICD-10-CM Diagnosis Coding Manual, Preliminary Edition; copyright 2012, Decision Health

[4] http://ehrintelligence.com/2012/10/29/providers-look-to-canada-for-lessons-in-icd-10-implementation/