HIMagine That! Queries for ICD-10

July 24, 2015 / By Sue Belley, RHIA, Donna Smith, RHIA

Donna: You know Sue, I think that people are really stepping up their ICD-10 game as we enter the home stretch.

Sue: The way I look at it, they’ve been stepping up their game for the last five years!

Donna: So true. Still, I’ve received a lot of emails lately from coding and CDI professional requesting assistance with ICD-10 queries that they can use to ensure they have ICD-10 ready documentation.

Sue: So what kinds of queries are they asking about? Donna: Well, some are pretty standard – like a query for the acuity of respiratory failure and whether it is hypoxic or hypercapnic. But, I find some of the query requests surprising.

Sue: For example . . .

Donna: I had a CDI professional ask about creating a query for an Orthopedic surgeon about the type of hip prosthesis implanted during a hip replacement procedure. They wanted the surgeon to document if it was a metal or a ceramic prosthesis, and whether it was a cemented procedure or not.

Sue: But that information should be available in the medical record – either recorded in the operative report or on the implant information sticker. Oh, wait, maybe hospitals aren’t scanning the implant sticker into the EHR these days . . .

Donna: Exactly. Another thing they could do is make sure they include implant options in the operative report template to remind the physician to document this information at the time of operative report creation.

Sue: Spot on, Donna. In fact, there’s even more work that can be done to support documentation capture through the use of templates in the EHR.

Donna: What else are you thinking of?

Sue: Well, an item can be added to a template for a radiology report that makes certain the name of any contrast media used is captured so the coding professional will be able to assign the correct character for the type of contrast in the radiology PCS code.

Donna: Right! Here’s another interesting question I got the other day. It was a request for a hematology/oncology query for bone marrow transplant procedures. The requestor wanted to query the physician for the route of administration for the bone marrow transplant in order to assign an accurate PCS code. Although this is essential information to assign an ICD-10-PCS code, I think it would be far better to request the administration route up front in the BMT template, don’t you?

Sue: Agreed – we don’t want to be querying physicians for routes of administration. That would frustrate them to no end.

Donna: That’s for sure! I think now is the time to determine less burdensome ways to obtain what I would call “routine” clinical information that can be collected in ways other than asking the physician a verbal or written query.

Sue: Amen to that!

Sue Belley, RHIA, and Donna Smith, RHIA, are project managers with the consulting services business of 3M Health Information Systems.

The ICD-10 is here.  How did your organization prepare for the change?  Share your journey and access valuable ICD-10 resources here.