HIMagine That: Specificity unrecognized

June 6, 2016 / By Donna Smith, RHIA, Sue Belley, RHIA

Donna: Hi, Sue! I saw you at the ACDIS conference last week. How were the sessions you  attended?

Sue: Really good – I liked the diversity and range of topics presented.

Donna: Same here! Any thoughts you want share?

Sue: Actually, something I’ve been noticing lately while doing ICD-10 coding and DRG validations — coding and CDI professionals are missing ICD-10 specific documentation that is being recorded by physicians.

Donna: So, give me an example of what you’re seeing…

Sue: Well, I’ve noticed quite a few instances of physicians documenting the new ICD-10 terminology for atrial fibrillation . . . you know, persistent, chronic, paroxysmal, permanent . . . but when all is said and done the condition is coded and reported as unspecified atrial fibrillation.

Donna: Oh, I know what you mean. I’m finding the same thing for cerebral infarctions and nontraumatic subarachnoid hemorrhages. For example, the physician documents cerebral infarction due to thrombus of the MCA and it’s coded to unspecified cerebral infarction. The cerebral artery affected is oftentimes documented using abbreviations such as MCA or PCA which is being missed during the coding process.

Sue: Yes, and I also see it with acute myocardial infarctions – STEMIs. The affected coronary artery is documented, but the STEMI is coded to unspecified.

Donna: Why do you think this is happening?

Sue: I’m not sure. Maybe coding and CDI professionals are simply overlooking these terms because they haven’t incorporated all of the ICD-10 details into their practice yet.

Donna: Oh, so you’re saying it’s a “hard to teach old dogs new tricks” kinda thing?

Sue: Ha, I guess you could put it that way, but I was trying to be polite!

Donna: So, how did we transition from discussing the ACDIS conference to this?

Sue: I was thinking about how the focus of CDI this year is to work with physicians to improve their documentation to capture ICD-10 specificity, yet we have many instances where physicians are incorporating this specificity but sometimes it’s being missed on the back end – a reverse of what we expected.

Donna: Any thoughts on a solution?

Sue: Well, auditing to identify these situations in conjunction with an awareness campaign should help.  Employing CAC technology during the CDI and coding process to call out this specific terminology would insure much better capture and reliability.

Donna: I totally agree with you! 

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