Friday, December 19, 2014

I don't want to live in a world where Ebola is sold out at the Giant Microbe store - and there's no code for it

There is a super cute little toy shop in Coeur d'Alene, ID called Shenanigan's Toy Emporium that sells vintage toys and other unique items.  When traveling there on business, we usually make a stop in to shop from their wall of amazing salt water taffy and check out their selection of toys that don't come with a power button.  You know, the kind of toys we had prior to the Atari and Game Boy era!

Shenanigan's also has a great display of giant microbes - small plush renderings of everything from the common cold to diarrhea.  I am still marveling at how they could create a plush toy out of liquid stool!  I'm sure it's just the geeky coder in me (and my colleagues), but we decided to buy a few and put them out during our training sessions along with our baskets of Play Dough, pipe cleaners, and candy (we like to have FUN in our training sessions!).  Needless to say, they were a big hit with our clients and we noticed on one of the tags that there was a website where we could order more.  By now your interest is surely piqued, so be sure to check out the online Giant Microbes store.

You're probably thinking what I'm thinking right about now, which is, wouldn't these giant microbes make great white elephant gifts for Christmas?  My thoughts immediately went to what would be appropriate for my family's white elephant gift exchange.  Don't worry, my family has a great sense of humor - there's still a copy of Pamela Anderson's novel (yes, she wrote one) complete with the "naughty" pages clipped together courtesy of my grandmother who was sheltering her daughter from the filthy parts.  And what better gift for someone in 2014 than the Ebola virus?  There's just one problem.

Sold out.

Apparently I am not the only person who thinks that Ebola would make a great Christmas gift.  It's a sign of recent headlines that this virus, which is actually kind of cute in plush form, is unavailable.  What's even more worrisome given that this was the year Ebola came to the US, is that we don't have an ICD-9-CM code to report it.  Here's the best we can do in ICD-9:

  • 065.8, Other specified arthropod-borne hemorrhagic fever
  • 078.89, Other specified diseases due to virus

What about ICD-10-CM?  How about this?

  • A98.4, Ebola virus disease

YESSSSSS!  Way more specific!

In previous years as we've prepped for ICD-10 implementation, the opponents have given a laundry list of extensive and admittedly ridiculous (yet fun!) ICD-10 codes that begged the question, why do we really need this?  And this year, Ebola was delivered to our health system and we have nonspecific codes to report it.  But in ICD-10, we have a very specific code.  Hmm.  Perhaps this ICD-10 thing really could help with reporting and impact patient care.  Just a thought.

So Santa, if I can't have Ebola for Christmas this year, could I please have ICD-10 so that I can code it for those people who did get it?

Author's Note: I am not affiliated with Shenanigan's Toy Emporium or giantmicrobes.com in any way. I am just a really big fan!

Thursday, December 18, 2014

Diversity - and Flexibility - is Key

I've been pretty quiet lately around the blogosphere and some may even think I've disappeared.  And for about a year, up until about October, I really had disappeared a bit to plan and live through my wedding.  After a couple months of an identity crisis, I'll announce here that Coder Coach Kristi Stanton has disappeared and the new Coder Coach is now Kristi Pollard.  The new last name will take a couple of decades to get used to, but I am hopeful that if I'm quoted in the future, it won't be as the first actress to play Buffy the Vampire Slayer. True story.

For the last couple of months I've been waiting for inspiration to strike so I could once again become passionate about the blog.  I've been observing.  Don't get me wrong, with all the legislation and talk about more ICD-10 delays, I've also been writing my congressmen, participating in Twitter rallies (follow me at @codercoach), and making posts on Facebook, but I've spent more time just watching.  Watching the industry.  Watching my colleagues.  Watching hopeful coding professionals trying to break their way in.  And this is what I've deduced: if you want to make it in the coding field, you've got to diversify.

It didn't take long after the ICD-10 delay was announced in March to see the fallout.  Some of our clients stayed the course while others postponed some training.  There have been very few canceled trainings all together for ICD-10. A couple of months ago, I dusted off a couple of our CPT training manuals that hadn't been updated in awhile to get them ready to train in 2015.  It was comforting to fall back into something that still required the skill of a senior consultant that was a sure thing.  Of course, I hope for a future with ICD-10 and will continue to advocate for it, but there's always CPT as well.

Here is my message to the coding students and aspiring coders.  Coding is not steady and it's not comfortable.  Even without ICD-10, annual updates to the coding industry can rock your world (case in point all the new lower GI endoscopy CPT codes for 2015).  This field has a tendency to attract detail-oriented people who like to organize everything in pretty and neat little black and white buckets.  As coders, we don't like gray areas.  Well, as a coder, be ready for gray, purple, and yellow polka-dotted areas.  You need to be flexible.  You need to be ready when the House throws language into a bill at midnight the night before a vote that will impact your daily work.  And you need a backup plan just in case.

I feel a bit like a financial adviser as I tell you you need to diversify.  DI.  VER.  SI.  FY.  Don't put all your coding eggs in one basket.  As someone who has coded in ICD-9-CM, ICD-10-CM/PCS, CPT, and HCPCS, I understand what I'm asking you to do.  It's not easy.  They all have different rules and methodologies.  I understand that I'm asking you for a lifetime of education.  But the payoff for doing the work is immeasurable.  And the more you have exposure to, the more marketable you are as a coder.

Friday, August 29, 2014

From the Trainer: ICD-10 FAQ #1 - If the US is the last to implement, why are there so many unknowns?

For the last year, I've traveled across the country providing ICD-10-CM and ICD-10-PCS education to coders and clinical documentation specialists.  Our company's model provides three separate training sessions for our clients: basic, intermediate, and advanced.  This means lots of repeat visits to each client, lots of really hard questions, and tons of professional growth for me.  I thought it was time to start a new series here on my Coder Coach blog: ICD-10 FAQs.  This is a question I've been asked a lot lately as we get into advanced trainings and more controversial topics:

If the United States is the last country to implement ICD-10, why are there so many unanswered coding questions and why do we have to wait for Coding Clinic advice?


While it seems logical that someone would have figured out all of this ICD-10 stuff within the last 20 years as we've been "messing around" here in the US (please note the sarcasm, because I don't really think we've been messing around; we've actually been quite busy), the reality of the situation is that the US version of ICD-10 is different from everyone else's.  The core ICD-10 code set was developed by the World Health Organization (WHO) and classifies causes of morbidity (i.e., diagnoses) and every country has the ability to adapt it further (e.g., ICD-10-CA in Canada, ICD-10-AM in Australia, ICD-10-CM in the US).  Two things should have jumped out at you based on this statement:
  1. ICD-10 diagnosis codes may be different in Canada, Australia, and the US
  2. The international code set does not  include procedures

Let's tackle #1 first.  The US version of the ICD-10 diagnosis codes, ICD-10-CM, is a clinical modification (BTW - that's what the "CM" stands for; it's not "coding manual" like some people seem to think).  It is based on the WHO version, but has been adapted for use here in the good ole United States of America.  I haven't had a ton of time to compare it to the original, but what I do know about the CM version is this:
  • The Excludes1/Excludes2 convention, which solves a lot of problems from ICD-9 (and creates a few new ones) is not part of the WHO version
  • The use of 7th character extensions for injuries and poisonings is not part of the WHO version
  • The expansion of the external cause codes, which are not required for reporting, are not nearly as extensive in the WHO version
  • While we have adapted diabetes terminology in the US to Type 1 and Type 2 diabetes, the WHO version still uses the insulin-dependent diabetes mellitus (IDDM) and noninsulin-dependent diabetes mellitus (NIDDM) terminology that we've worked so hard to banish from our medical record documentation here in the States
Most of the really hard diagnosis questions I get about coding ICD-10 diagnoses revolve around the changes that are unique to the CM version.

As for the procedural component, ICD-10-PCS (which stands for procedure coding system), that was developed in the US by CMS under contract with 3M.  Although I've heard that other countries have plans to adopt PCS, right now the US is the only country using it.  Although other countries have procedural coding systems, it's important to remember that we are the only ones using coding for reimbursement.  For that reason, we will likely place more weight on those procedure codes than other countries and when it comes to PCS, it's uncharted territory.

Hopefully that answers a couple of questions about the ambiguity of ICD-10.  And may I also just point out that this is nothing new.  Coding has always undergone an evolutionary process.  We have seen it with ICD-9-CM and CPT.  It's the reason we have official publications like the Coding Clinic and CPT Assistant.  If you are not familiar with these publications, you need to be.  They are official resources that answer a lot of questions.  And as of second quarter of this year, the American Hospital Association has stopped publishing Coding Clinic for ICD-9-CM and is only publishing Coding Clinic for ICD-10-CM/PCS.  My colleagues and I have been monitoring the publication very carefully each quarter because their advice does change some previous assumptions many have made based on what we know about these new coding systems.

Thursday, March 27, 2014

Are Legislators Suffering from R41.9?

In terms of the blogosphere, I've been severely slacking for the last several months. In terms of ICD-10 preparation, I would argue I've done my fair share. As an AHIMA-Approved ICD-10-CM/PCS trainer for nearly 5 years, AHIMA ICD-10 Ambassador, and a senior consultant specializing in ICD-10 education, I've spent much of the three years with my current employer writing ICD-10 web-based and instructor-led training, coding cases using the ICD-10 code sets, and spending countless hours face-to-face with coders across the country conducting basic, intermediate, and advanced ICD-10-CM and ICD-10-PCS training. For three years I chaired Colorado's ICD-10 Task Force, which has worked hard to raise awareness and push implementation efforts forward. 

I've been in the coding industry for 19 years and we've been talking about ICD-10 for my entire career. I remember where I was when the proposed rule for ICD-10 was released and who told me. It was that big of a deal. I remember reading the final rule with elation. I remember ICD-10 being held just after Obama took office because the final rule was released in the last month of the Bush's administration. That delay was short-lived. And, of course, I can still feel the utter frustration I felt the day CMS announced that ICD-10 would be delayed until October 1, 2014. 

And now the fate of ICD-10 hangs in the balance. Again. For crying out loud, US Government, can't we just move on?

If you haven't heard, some language was slipped into House bill 4302 late Tuesday night that would delay ICD-10 for another year. And this morning, the bill passed. Now it's on to the Senate. 

I can only believe that the reason this passed is because our legislators are suffering from R41.9, Unspecified symptoms and signs involving cognitive functions and awareness.  They just don't know what they don't know. 

I'm just not buying the excuse that we can't be ready for ICD-10 in 6 months, even after we've been given a one-year delay already. I've been getting ready for several years, my company has been getting ready for several years, and providers and insurers have been padding their budgets for ICD-10 prep over the last 2 years. I've never seen hospitals buy into IT and training initiatives like they have for ICD-10. And I just don't think postponing ICD-10 again because some providers aren't ready because they didn't think it would really be implemented is a viable reason for a delay. 

To be fair, this bill isn't really about ICD-10. It's about the sustainable growth rate for physicians that they are trying to address before a 24% pay cut for physicians goes into effect on April 1.  The last payment fix for them expires at the end of the month. However, I am bewildered as to how 7 lines of text calling for a one-year delay on ICD-10 managed to make its way into this bill. I am also bewildered as to how a bill that was released 24 hours before it was sent to vote actually passed. Did our congressmen and congresswomen really read the whole bill? And by "read," I mean "read for comprehension." I can only hope that the bill gets killed in the senate. Seriously, the government can't keep leading us on like this!  And more importantly, how will we, as an industry, get enough credibility to ever implement ICD-10 if we have another delay?  If we delay now, we lose all momentum (and dollars) spent by the parties who actually thought the government was serious about ICD-10. 

Here's what you can do: become informed and get your senators informed. The bill claims it will save more than $1 billion over the next 10 years. But what no one is telling them is that those 7 lines that address the ICD-10 delay are projected to cost between $1 billion and $6.6 billion by delaying ICD-10 by one year. And that is only 10-30% of the money that has already been spent by the healthcare industry so far. Are we really willing to throw all that money away when our healthcare industry is already under too much scrutiny for spending?

Go to www.ahima.org and see how you can contact your senators by phone or email.  You don't need to be an AHIMA member to do this and you can even read more information about why the language to delay ICD-10 implementation should be removed. Please act today and share this information with your fellow professionals so they can respond too. 

Now if you'll excuse me, I have some emails to write and phone calls to make...

Thursday, September 5, 2013

Newsflash: The AMA is Fighting ICD-10 - is my Blog to Blame?

Okay, so it's not really news that the American Medical Association is showing R45.4 (Irritability and anger) and R45.5 (Hostility) when it comes to ICD-10.  But are their R45.82 (worries) really worth all the R45.83 (Excessive crying of child, adolescent, or adult)?

Okay, all kidding aside, I hate to admit that blogs like mine might be partly to blame for the backlash, but are they?  In learning ICD-10-CM, it's just not fun to write blogs and articles about how the ICD-9-CM code for unspecified hypertension will be I10 in ICD-10.  Okay, bad example.  ICD-10 gives us I10 (hypertension).  Oh wait, you've heard that one? 

I'll go out on a limb here and just say it.  Coding is boring.  But I love it anyway and find it fascinating and go out of my way to try to make learning coding fun and enjoyable.  And since in my day job I don't get to spend a lot of time reflecting on the fun and entertaining external cause codes, I have decided to take to my blog to explore some of the more entertaining ICD-10 codes and inject some humor where I can.  And it's hard.  Because, as I mentioned, coding is boring.

But with all of the hype on ICD-10 we've managed to fool a lot of people into thinking that it's not really boring no-nonsense work and that what we do is actually very trivial and unimportant.  In an April interview on Fox News, Congressman Ted Poe (R-TX) gave several arguments against ICD-10-CM implementation in the United States and several examples of why the new coding system is ridiculous and unnecessary, including the various codes for injuries by turkeys and dog bites by specific breeds of dogs (BTW - dog bites by breed codes do not exist). 

Indeed, there are some very silly external cause codes, but in an article by the American Health Information Management Association, which wasn't as well publicized as Congressman Poe's interview, AHIMA states that there is no national mandate to report external cause codes in ICD-10-CM.  In fact, if providers are not reporting E codes in ICD-9-CM, they won't be required to report external cause codes in ICD-10-CM.  And since the 1500 billing form, which is used by physicians to report codes to Medicare, only has space for four diagnosis codes, the external cause codes are not likely to play a large role in pro-fee coding and billing.  And then all that's left is those boring codes in the remaining ICD-10 chapters.

But why isn't anyone pointing that out?  Well, I suppose it's just more fun to talk about a code for being pecked by a chicken.  Or struck by a chicken (is that a live chicken or, say, a frozen chicken from the supermarket?!).  But in reality, we are training coders on the important enhancements that ICD-10 coding brings.  Here are a couple of important "for instances" for you:
  • Somewhat simplified sepsis coding (okay, so they couldn't do it all, but we'll take somewhat simplified over super confusing any day)
  • One diagnosis code for admission for vaccination (the procedure code indicates the specific vaccine given)
  • OB codes that actually make sense - most of them classify conditions by trimester rather than that "delivered with antepartum complication" nonsense
  • New and specific codes for subsequent acute myocardial infarction (AMI) that occurs within the timeframe of an initial AMI
  • Codes for blood alcohol level (here in Colorado we're waiting for the blood marijuana content codes - I'm pretty sure Washington is interested too)
  • Bye-bye to encounter for therapy codes (talk about administrative burden - insurance companies hate those V codes for admission for physical/occupational/speech therapy codes; the new code system has a way of denoting that an injury is in the healing phase)
  • Combination codes for diabetic complications (because half the time coders forget to code the second code anyway)
Now don't get me wrong.  I am not saying that physicians won't be impacted at all because they will.  We will be asking them to document more clearly but in general we want documentation that really should already be there.  It's nice to know whether the left or right femur is broken.  I'm pretty sure that it's not just the coders who are interested.  And even though physicians won't have to code ICD-10-PCS procedure codes, we will be prompting them for more specific documentation within operative reports. 

And while we're at it, let's talk about the volume of codes.  Yes, there are a lot more ICD-10-CM codes than ICD-9-CM codes.  That's to be expected when they create codes for left, right, bilateral, and unspecified where applicable.  And my favorite quote regarding this issue came from Don Asmonga of AHIMA at a conference last spring: "There are a lot of words in the dictionary, but that doesn't mean you use all of them."  Indeed.  There are many codes that we will never use.  And coders aren't supposed to memorize codes anyway.  In the training I've done thus far, coders have actually expressed that having more codes is better - they are able to better drill down to what's really going on with the patient instead of sticking a junky nonspecific code on the case.

So if you come across a physician who is arguing against ICD-10 implementation, I would suggest that you put the kibosh on the fun code talk and get straight to the boring benefits.  Will ICD-10 impact patient care?  Probably not as directly as nurse finding a medication error before meds are administered.  But the data that is collected on the back end will have implications for future quality initiatives; in fact many of the quality initiatives coming up depend on ICD-10 data.  Besides, even the boring ICD-10-CM codes are more exciting than the same old boring ICD-9-CM codes that no other industrialized nation in the WORLD uses anymore.  I mean, I hate to play the peer pressure card, but seriously, we should be leaders in in medicine - and in collecting medical data.  Who else is on board?

How I Spent My Summer, by the Coder Coach (Y93.E6)

I really don't care if I ever see another cardboard box as long as I live.  After a summer of botched real estate closings and not one, but - count them - two moves spaced two weeks apart (complete with my office and two cats), I think I've arrived in my new home with everything except for potentially my sanity. 

I'm not sure which was more foolish - deciding to move the summer before we enter the home stretch of the last year before ICD-10 implementation or deciding to plan a wedding that will occur just a couple of weeks before ICD-10 implementation.  Just for good measure, I decided to do both.  The comforting thing is, ICD-10 is still there waiting for me even after the dust has settled from all of those cardboard boxes and I never did lose sight of my ICD-10 codebooks during the move - er moves.  In fact, my training calendar is booking up fast between now and September of next year!

I was pretty excited to find that there was indeed an ICD-10 code to describe how I spent my summer:

  • Y93.E6, Activity, residential relocation
This code includes packing up and unpacking involved in moving to a new residence.  I wish there was a code for hernia acquired by moving boxes of code books.  I swear those things multiply like rabbits.  And for the record, I have informed my fiancĂ© that we are never moving.  Ever. Again.

Wednesday, June 19, 2013

The Great Cat Extraction - 10D07Z8

I've been spending the last couple of months training clients on ICD-10-CM and ICD-10-PCS and one of the things I love most about it is that I continue to learn more about ICD-10 and it's getting easier.  As a matter of fact, I now feel more qualified to teach ICD-10 than ICD-9.  But of course, I could pick ICD-9 back up again quickly if I had to.  You can't erase nearly two decades of experience overnight!

Many who know me well and have sat through my training sessions know that I like to teach by analogy (much the same way this blog is written).  So when I unpack my laptop and training materials at a client, I also unpack a series of stories, jokes (well, I think they're funny), and tricks to remembering all the knowledge that I'm about to lay on them.  Probably one of my favorites is the Great Cat Extraction, which I was reminded of yesterday when I took my sweet little Mandy to the vet.

My cat Mandy is 6 petite pounds of pure purring pleasantness.  Until you try to get her into her pink fluffy carrier to go somewhere.  Then she develops the will and strength of an Olympic wrestler and I'm still not quite sure how it happens, but the neck arches back and in true cartoon form, her extremities extend in all directions so that she resembles a star.  Try shoving that into a carrier.  And yesterday when we got to the vet, I thought I would be clever getting her out and unzip the top of the carrier.  No go.  Somehow, she buried her head into a corner and it kept getting caught as I tried to pull her out.  Poor kitty.

You may be wondering what the heck the Great Cat Extraction has to do with coding.  Well, it comes up in our discussion of the root operations Delivery and Extraction in the Obstetrical section of ICD-10-PCS.  The root operation Delivery is defined as, "Assisting the passage of the products of conception from the genital canal," or more cleverly, simply defined as "catching the baby" without the use of instrumentation or manipulation.  The way this was described to me is that the baby is going to come whether the doctor or midwife is there to catch it or not.  There is only one code in the Delivery table: 10E0XZZ (I still think that looks like a license plate number). 

The root operation Extraction, on the other hand, is defined as. "Pulling or stripping out or off all or a portion of a body part by the use of force."  Okay, first: ouch.  Second, if you look at the options for this table, which I've pasted here below for you, you will see that Extraction includes everything from cesarean section (the row that includes Open as the approach) to vacuum extraction (the row that has Products of Conception as the body part and Via Natural or Artificial Opening as the approach) to dilation and curettage (the last row, which has Products of Conception, Retained and Products of Conception, Ectopic as the body parts). 


Normal position for a fetus at the time of delivery is head down, but some babies are breech.  Version is usually attempted on breech babies to turn them into correct position, but they can be delivered in breech position with some finesse.  But a breech extraction is by no means a normal or simple delivery.  Trying to get the baby's limbs to deliver without injuring it or getting caught is very much like the Great Cat Extraction.  The code for a breech extraction is 10D07Z8 - this is assuming that no internal version was performed.  So when you think breech extraction, think Mandy the itty bitty kitty with the strength and limb extension of a gymnast.

 By the way, everything came out okay at the vet.  Including the cat.  Eventually.