Most people receiving care probably assume their medical records include details like whether their condition is acute or chronic, how their illness is progressing or, at a minimum, which side of the body an injury may have occurred.
Believe it or not, there has not been a standard way to document basic information like this in patients’ medical records across the U.S. The new coding system – ICD-10 – will change that.
On October 1, Texas Children’s and healthcare organizations nationwide will transition to ICD-10, the coding system used to report and code diagnoses, injuries, impairments and other health problems and their manifestations. It will replace ICD-9, the current coding system used at Texas Children’s.
Why make the change?
In 2009 the U.S. Dept. of Health and Human Services formally adopted ICD-10 as America’s new national coding system and set October 1, 2014 as the deadline for facilities and providers to implement the new system.
ICD-10 is important because a patient’s record is a legal document. It notes exactly what care a patient has received, when they received it, why they received it and treatment plans going forward.
Before, a record could show that a patient had uncontrolled diabetes but had no additional documentation. Now, with the increased specificity of ICD-10, the record will show whether the diabetes was caused by an underlying medical condition or whether it was triggered by an external factor, like medication or chemicals. The new codes specifically ask for the type, any complications and the manifestations of a certain diagnosis.
“It’s all about improving the documentation of the care a patient receives,” said Texas Children’s Chief Safety Officer Dr. Joan Shook. “It’s critical because it can improve the quality of care. It ensures our compliance with CMS (the office responsible for Medicare and Medicaid) regulations, and it affects the hospital’s revenue.”
Know the two parts of ICD-10
There are two types of ICD-10 coding: ICD-10-CM, which means “clinical modification” and refers to diagnosis coding. The other is ICD-10-PCS, which stands for procedure coding system and refers to coding for inpatient hospital procedures. Both will be implemented at Texas Children’s on October 1.
How Texas Children’s physicians are preparing
Because ICD-10 will change the hospital’s Epic system, which is our electronic medical record (EMR), members of the hospital’s Epic support team have been meeting with physicians since November to determine the best way to refine it. Physicians will participate in “clinical documentation assessments” to determine what tools need to be refined or added to Epic to make it ICD-10-ready.
The hospital has partnered with Baylor College of Medicine to provide e-learning videos for the doctors about ICD-10. Each specialist will take three to four e-learning courses this summer, along with an e-learning course on Epic.
Throughout the process, a team of ICD-10 physician champions will serve as liaisons to the medical staff. Each specialty also has its own Epic physician liaison should they have any questions or comments.
How others at Texas Children’s are preparing
The coding staff is attending “boot camps” to learn the ins and outs of the new system.
Additionally, the hospital has been educating providers’ offices through the Texas Children’s Health Plan newsletter since last year.
How the rest of us can prepare
Even if you do not work in a role where you have to document or understand documentation codes, you should understand, in general, what’s happening and how it may impact your own medical record documentation. The best thing you can do in the months ahead is learn as much as you can about ICD-10. Below are links to a quick fact sheet and helpful sites with basic information.
For more information
ICD-10 Fact Sheet
ICD-10 Industry Updates
ICD-10 Myths and Facts