Keeping up with clinical terminology standards can be a full-time job. As a clinician, we tend to use colloquial language when documenting diagnoses, procedures and findings and are used to writing (or scribbling) this information in paper charts and now with the EMRs, we want to continue to use our shorthand expressions for searching.
But to document care to support the billing ICD codes, we have to learn a new, more structured vocabulary. That task was tough enough under ICD-9, but the transition to ICD-10 coding significantly increases the degree of difficulty considering that ICD-10 introduces thousands of new codes. The Centers for Medicare and Medicaid Services (CMS) states that ICD-10 uses 68,000 codes compared with the 13,000 codes used in ICD-9.
The increased number of codes involved in the ICD-9 to ICD-10 conversion “provides a significant increase in the specificity of the reporting, allowing more information to be conveyed in a code,” according to CMS.
Angioplasty, for example, which had one code under ICD-9, will have 854 codes under ICD-10, CMS noted. The additional codes will, among other things, convey important information such as laterality -- which side of the patient’s body or which limb is under evaluation. ICD-10 also provides information on the gender of the patient, the nature of the physician encounter (initial, sequel or subsequent visit) and the severity of an injury.
Needless to say, as a clinician, we will need to document the care we provide in more detail. And to complicate matters, we face a deadline for doing so. Covered entities under the Health Insurance Portability and Accountability Act are up against an October 1, 2015 compliance deadline for ICD-10-CM/PCS implementation.
Workflow Enhancing Search Facilitates Conversion
Fortunately, clinicians can leverage content like Provider Friendly Terminology (PFT), as part of a Workflow Enhancing Search (WES) solution, to make the ICD-9 to ICD-10 conversion easier to manage. PFT is a content set containing the essential elements -- synonyms, colloquialisms, abbreviations and common misspellings – utilizing the language clinicians commonly use and automatically mapping those terms to SNOMED, ICD-9 and ICD-10 behind the scenes.
When you combine a solution that maps clinical terms to standard terminologies, clinicians find they can more readily document care. That’s because WES lets clinicians use the terminology they are already familiar with when inputting clinical data in an EHR. Here’s how the process works: A clinician enters a synonym, colloquialism or abbreviation into an EHR to record a diagnosis and the WES solution will automatically translate that information into the most suitable ICD-10 code. This is accomplished through mapping the PFT content set to the ICD-10 codes. When more information such as the laterality or fracture type is required, WES through the EMR workflow can prompt the clinicians to enter these data elements. Soon enough, we will just add the data elements to our initials searches so we don’t have to be reminded by prompts. The PFT content also offers clinically oriented attributes to enable better documentation as to the severity of the illness, or a more detailed (and less ‘unspecified’) version of the ICD-10 codes. For example, WES can prompt for the severity of the asthma, such as mild, moderate, or severe rather than selecting an unspecified version. These more detailed codes could improve reimbursement and also improve data analytics and outcomes research. If I wanted to tell which groups of asthma patients were returning to the ER most often, then documenting the severity will enable me to best tailor their treatment. Thus, the healthcare provider benefits by abstracting the complex terminologies from clinicians, which boosts clinician satisfaction plus they can also minimize lost revenue that can occur from inaccurate or incomplete clinical documentation.
Overall, this approach eases the transition from ICD-9 to ICD-10 by offering a way forward for healthcare institutions that are already engaged in a complex mission -- providing quality care to patients -- and may be juggling other compliance deadlines such as those associated with the federal government’s Meaningful Use initiative. WES operates on the principle that the easiest, and least painful, path to change will spur the best adoption rate. Getting independent-minded physicians on board for any initiative is challenging. Health systems employing hundreds of clinicians will need all the help they can get if they hope to get everyone moving to ICD-10 in a timely fashion.
Ready for the Transition?
WES simplifies ICD-9 to ICD-10 conversion by simplifying problem and diagnosis search by enabling the creation of Meaningful Use and ICD-9/ICD-10 compliant documentation using the language clinicians’ use. Are you prepared for the ICD-10 transition? Would the ability to incorporate clinician-friendly language help?
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