Slim Year for ICD-10 Coding Updates

Just like the past couple of years, we've been waiting rather impatiently over the last couple of months for the release of the fiscal year (FY) 2019 ICD-10-CM and ICD-10-PCS code updates.  While the PCS code sets have been out for a month or two, the CM updates were released just last week, sans coding guidelines, which we are still eagerly awaiting.  FY 2019 codes will be implemented on October 1, 2018 (the federal fiscal year runs from October 1 through September 30).  In case you're wondering how the code changes stack up to previous years, what the process is for updating the code sets, or why they aren't released at the same time, this post is for you!

In comparison to past years, it's a slim year for code updates.  When the code sets were unfrozen for FY 2017 after ICD-10 implementation, we saw a whopping 2,710 CM and 4,330 PCS code changes.  Last year, for the FY 2018 release, there were 731 CM and 6,029 PCS code changes.  FY 2019 has a pretty sharp drop for both code sets with 473 CM and 616 PCS code changes. 

If you've been playing along at home and waiting for the code releases, perhaps you've been wondering why the CM and PCS updates are not released at the same time.  Even though both code sets are presented to the Coordination and Maintenance Committee for review and discussion before the Cooperating Parties and general public, each code set is maintained by a separate government agency. 

ICD-10-CM is maintained by the National Center of Health Statistics (NCHS), a component of the Centers for Disease Control and Prevention (CDC).  ICD-10-PCS is maintained by the Centers for Medicare and Medicaid Services (CMS).  Twice a year (every March and April), both agencies present proposed code changes at the Coordination and Maintenance meetings in Baltimore and then each agency works to finalize the code sets. 

Over the past couple of years, we've noticed that PCS changes happen more quickly and are released earlier than their CM counterparts.  CMS presented code proposals for FY 2019 as late as the March 2018 meeting.  On the other hand, most of the code proposals that NCHS presented for CM in March were for consideration for FY 2020.

The other trend we've been noticing since converting to ICD-10 is the last thing to be released is generally the ICD-10-CM Official Guidelines for Coding and Reporting.  We are still waiting for the FY 2019 coding guidelines to be released.  It's been common for NCHS to release the code sets first and the guidelines at a different time, whereas CMS has been pretty consistent with releasing the PCS code sets along with the ICD-10-PCS Official Guidelines for Coding and Reporting.

If you read this post hoping I would give some spoiler alerts, you'll have to wait for the webinars I'm presenting in August for Haugen Consulting Group.  I hope you'll click the links to the marketplace and register for one or both (CM and PCS) updates webinars where I will outline the changes with some background information and a healthy dose of Haugen fun.  Well, fun is relative - we're still talking about coding, but who said that has to be boring!

Here are the links to help keep you updated for FY 2019!

• 2019 ICD-10-CM Updates: Diagnosing What You Need to Know
• 2019 ICD-10-PCS Updates #FirstToKnow

Reflections of a Coder Coach: Ready to Get Back to Normal

A few weeks ago, it occurred to me that my job hasn't been "normal" for the last six years.  Right around this time six years ago is when I first went to AHIMA's ICD-10 Academy and earned my status as a trainer.  Creating and presenting ICD-10 training materials came soon after that and it wasn't until recently I realized that my job hasn't been normal for the last six years.  And since I've only known my husband for four years, one could argue that he's never known me when I'm normal... er.. at least when my job is normal!

As I look around the articles and social media related to coding, a lot has changed in this industry in the six or seven years that I've put myself out there as the Coder Coach.  When I first started blogging and meeting once a month with coding students and wanna-be's, there weren't a lot of people out there looking to mentor coders.  Now, my voice is one of many as people who never heard of coding before ICD-10 jump on the bandwagon to get a piece of the action.  There have been questions about certifications - which ones to get and how to make sure ICD-10 certification requirements are met.  There have been questions about how to code things we never had to think about before - initial vs. subsequent encounters for injuries and poisonings and root operations based on procedure intent.

I have to be honest and say that in my abnormal day-to-day life as a coder over the last few years, I've had trouble finding my voice and giving advice as a coding mentor.  I no longer feel qualified to tell a coder how to break into the industry because things are so different than they were 20 years ago when I got my start and coding is something that many people are now aware of - not something that people kind of fall into anymore.  Since I fill my days adding to my own intellectual bank by researching procedures and learning how to explain them - and how to code them - I wonder what it is that new coders need right now.  And for everyone who is trying to learn coding, I just want to reach out and give them all a virtual hug because this is, in my humble opinion, about the hardest time to learn this industry.

This week I am working on something I haven't done in years.  I'm reading the Final Rule for the 2016 MS-DRG changes.  That is something I used to read and summarize every year for my clients.  And even though the codes are different and there are some new sections to read in this super long file, I had a moment of realization, a sigh of relief if you will, that this... this is normal!  After we flip the switch on October 1 and everyone starts using ICD-10 (because I have pretty much zero faith in our congressmen to accomplish any earth shattering legislation in two weeks when they're so focused on Donald Trump's run for president), I'm sure there will be a few things that don't go as planned.  But for coders, it's a time for us to return to "normal."  I miss having a general confidence in assigning codes (although this has gotten better as I train more coders!).  I miss code updates!  Oh, how I miss those code updates!  We've had frozen ICD code sets for four years!  I've been following the recommendations made to the Coordination and Maintenance Committee and I can't wait to see which changes they decide to adopt on October 1, 2016.

And maybe when the dust settles a bit and we see how many people really want to stick with coding in ICD-10, I will find my voice again as the Coder Coach.  I sincerely hope so, because I miss meeting people with a passion to learn about my passion and giving them little nuggets of wisdom to help them make a difference in this industry.

So Many Books, So Little Time- Part 2

ICD-9-CM Has Procedure Codes?

In part two of my blog series about coding systems, I'd like to present ICD-9-CM, Volume 3. If you've taken classes that are preparing you to take the CPC exam, it might be news to you that ICD-9-CM has three volumes. Or procedure codes. So that's it: volume 3 of ICD-9-CM is procedure codes. 

Hospitals Use It

In part one of this series, I mentioned that HIPAA defines which code sets are used for each health care setting. Volume 3 ICD-9-CM codes are only mandated for hospital inpatient claims. They are a major factor in the determining DRG assignments, which drive hospital inpatient payments. 

Some hospitals also assign ICD-9-CM volume 3 codes for hospital outpatients as well. This is solely for data collection purposes but the codes get "scrubbed" off the outpatient bill and don't go to the insurance company. ICD-9-CM codes may be used to analyze volume of a particular type of procedure performed either as inpatient or outpatient. For example, most appendectomies are performed as outpatients, but if there are complications, a patient may need to be admitted as an inpatient. Hospitals often pull procedure volume for physician credentialing or planning purposes (e.g., to determine if a new specialty unit or more operating rooms are needed).  As a coding manager, which was a long time ago, I wrote reports that pulled data based solely on ICD-9 codes. We didn't use CPT codes to pull data at all at that time. 

Why You May Have Never Heard of It

If you've never heard of volume 3 codes in school, then it's likely that you are taking a coding course for physician coding and billing. Physicians don't use volume 3 of ICD-9. But as mentioned above, hospital coders are using it and if a hospital requires its coders to assign ICD-9 codes on outpatients, they are coding procedures using both ICD-9 and CPT procedure codes. That isn't as complex as it sounds because most hospitals use encoder software that has a crosswalk between the two code sets. Unfortunately, any time you try to map from one code set to another, there can be errors. If they were easily translatable, we wouldn't need two code sets!

Here's another critical tip: if you are buying ICD-9-CM code books, it can be super confusing because there are various publishers and lots of code books with different-yet-similar titles.  If you purchase an ICD-9-CM code book for physicians, it will have only volumes 1 and 2.  If you buy ICD-9-CM for hospitals, you get all three volumes, or the complete ICD-9-CM code set.

What the Codes Look Like

The code format of volume 3 ICD-9-CM codes is different from other code sets with two numeric digits followed by a decimal point and then one or two more numeric digits. The code category ranges are 00-99. It's the most straightforward of all of the HIPAA code sets. 

Some examples of volume 3 codes are:

• 47.0, Appendectomy
• 36.97, Insertion of drug-eluting coronary artery stent(s)

Commentary on ICD-9 Volume 3 and Argument for ICD-10

If you weren't trained on ICD-9-CM procedure codes, let me tell you, you aren't missing much. It is the least robust of all of the coding systems. There just simply aren't enough three to four-digit codes to keep up with rapidly evolving healthcare technology. We have run out of available codes. This is my biggest argument for ICD-10 implementation. I hate to say that we can live without a diagnosis code update, but in comparison to procedures, the need isn't as great. We absolutely need a new procedural coding system for ICD in order to keep up with emerging technologies. Plus - and this drives the OCD coder in me crazy - there are hernia repair codes in the eye procedure chapter because it's the only chapter with available codes!  

If you were trained in CPT first and have to learn ICD-9 volume 3 codes, you may find it very difficult, but only because you are trying to find codes as specific as CPT. You will be disappointed because ICD-9 codes aren't that specific. While there are appendectomy codes in CPT for open and laparoscopic approaches, ICD-9 appendectomy codes don't differentiate between open and scope procedures. 

Who Needs to Learn it?

If you're planning to take a certification exam, here are the certifications that have traditionally tested on volume 3 ICD-9-CM codes, but keep an eye on test details for the testing switch over to ICD-10:

• CCA (Certified Coding Associate) from AHIMA
• CCS (Certified Coding Specialist) from AHIMA
• CIC (Certified Inpatient Coder) from AAPC (new)

The COC (Certified Outpatient Coder), formerly called the CPC-H (Certified Professional Coder Hospital-based) does not focus at all on ICD-9 volume 3 codes. It does focus on hospital-related CPT codes and, of course ICD-9 diagnosis codes because we all use that. 

The bottom line on volume 3 codes, in my opinion, is that it is a coding system with a limited shelf life that isn't worth learning at this point in the game if we really move forward with ICD-10-CM/PCS in October (or unless you are planning to take one of the above-mentioned certification exams before ICD-10 is implemented).  There are enough existing coders to focus on the ICD-9 back work that will be involved after ICD-10 implementation and since this code set is only required for hospitals, it affects a pretty small population of coders overall.  But hey, at least you now know what it is and can have an intelligent conversation about it. 

Next up: Level I of HCPCS (AKA CPT)...

All I Want for Christmas is Fewer RAC Denials

This December, coders across the country got the ultimate Christmas present: a bill passed the House and Senate without the addition of language that would further delay ICD-10 implementation.  As we breathe a sigh of relief and get ready for a worry-free Christmas (at least as far as coding is concerned), we aren't fully exhaling until the end of March when the SGR bill comes up again for a vote.

But how many people are aware that there is another type of legislation at work that could cut down on the number of RAC denials we get?  Sounds almost too good to be true, doesn't it?  While the legislation is real, it's in very draft form right now.  Unfortunately, from where I sit, it also seems to be flying very low under the radar among my peers and I think it deserves some attention.

First of all, if you are not yet familiar with RACs, those are the Recovery Audit Contractors hired by Medicare to recoup improper payments to hospitals and physicians and return that money - with penalties - to the Medicare program.  The idea is great - run all the claims data through proprietary software and analyze it to see what looks weird.  This can be anything from improperly coded claims to admitting a patient to the hospital for a short stay rather than treating them as an outpatient.  Side note: contrary to what a lot of Medicare patients are told, hospitals do not get paid more for outpatient claims; they actually get paid less.  Medicare patients pay more out of pocket for hospital outpatient services and in most cases, hospitals get paid less than if patients were inpatient.  But if hospitals admit patients who could be treated as outpatients for short stays, they can have to pay the money back plus RAC penalties.

There are two types of RAC audits: automated and complex.  Automated reviews can be identified just by looking at data without reviewing the medical record.  Complex reviews require review of the medical record (e.g., for coding errors).  But the RACs don't have the final say; there is a rather lengthy appeals process that providers can - and should - take advantage of because several RAC denials have been overturned.  The problem is, there are about eight levels of appeals that end with the administrative law judge and currently there is a backlog of appeals at the administrative law judge level.

Enter the Hospital Improvements for Payment (HIP) act of 2014 (don't you just love that so many healthcare laws start with "hip?!").  This is a draft proposal aimed at reducing RAC audit backlogs by creating a new Hospital Prospective Payment System (HPPS) for Medicare short stays (less than 3 days length of stay), including observation services.  In short, it calls for the following;

• Creation of the new HPPS by the year 2020
• Creation of an alternate reimbursement system for short stays from fiscal year 2016 to fiscal year 2019 as data is gathered for the 2020 system
• Elimination of RAC reviews for short hospital stays until HPPS is implemented

By now, there may be a lot of people jumping up and down with joy, but of course there is a catch.  The proposal calls for dual submission of claims by hospitals in fiscal year 2016 in order to establish payments.  This means that hospitals would have to submit both ICD-10-PCS and CPT codes for short hospital stays for 2016.  Yes, the proposal assumes that we will be coding ICD-10-PCS in fiscal year 2016, which incidentally, begins on October 1, 2015.  The proposal would also implement an ICD-10-PCS to CPT crosswalk.  If the dual coding of claims didn't make you nervous, the crosswalk should.  I've never met a crosswalk I trusted.  Let's face it, if one coding system easily crosswalked to another, then we wouldn't need two different coding systems, would we?  I can see lots of operational challenges starting with the productivity dive that would surely occur and ending with training challenges since it's getting harder to find inpatient coders who code CPT and many facilities have decided not to train their outpatient coders in ICD-10-PCS.

Read All About It

This is just a small snipit of what HIP is about, but I encourage you to read up on it yourself, starting with information from the House Committee on Ways and Means and checking out the industry commentary to see where you stand.  Here are some links you should check out:

• Document from the House Ways and Means Committee - section by section of proposed bill 
• AHA Comments to Rep. Kevin Brady Re: Hospital Improvements for Payment Act of 2014 Discussion Draft dated December 18, 2014

Let Your Voice be Heard

For more information from the House Ways and Means Committee, including information on submitting comments, click here.  This proposal has the potential to rock the world of hospital reimbursement (again) and has some definite pros and cons.  While it's still only a draft and is not a done deal, it's time to take the opportunity to let our voices be heard and submit comments.

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.

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?

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.

Code for the Day: Getting Through the Operative Report without Crying Part 2 (R45.83)

Every once in awhile I get a complimentary email or message about a blog posting from a couple of years ago, "Getting Through an Operative Report - Without Crying."  It's always great to hear that people are reading my blog.  It's even better when people cite a particular posting and tell me how very helpful it was for them. This posting has been speaking to me lately too as I move beyond the shallow end of the ICD-10 coding pool and immerse myself neck deep in this new and strange coding world.  I'm not sure if this will make people feel better or if I risk losing part of my audience with this admission, but I've been crying a lot lately when it comes to ICD-10-PCS coding.

And thus, the code for the day:

• R45.83, Excessive crying of child, adolescent or adult

To say that ICD-10-PCS coding is foreign is an understatement.  My favorite statement about it - which I'm sure I've already blogged about before - is that ICD-10-PCS is like CPT on steroids.  Even the most experienced coders struggle with it and I've had my share of debates with colleagues about how to code something. And yes, there have been tears.

But the tears have not overshadowed the sheer excitement of learning this new coding system.  I find that I'm learning more about how procedures are performed and it's honing my coding skills further.  But there are a few things I really have a hard time with.

• The concept of root operation is a tough one.  Trying to determine the intent of a procedure is harder than it seems.  So many things we take for granted in ICD-9-CM will be so different in ICD-10-PCS.  Case in point: when you replace a device in ICD-9-CM, you will likely find that procedure indexed under the main term "Replacement."  In ICD-10-PCS, the root operation Replacement is only used to describe replacing a body part with a device.  When a device is replaced, it's usually two separate root operations: Removal and Insertion.
• Determining the approach is not something to take for granted.  How a physician approaches a procedure is easy, right?   We know laparoscopic versus open.  We understand that that there are certain body parts you can get to through an orifice while others can be access percutaneously by puncture.  But approach is more complex than you think.  For a transbronchial biopsy, the scope is placed through a natural orifice, but once inside the bronchus, a percutaneous puncture is made to obtain the biopsy, so the approach is percutaneous endoscopic.  The really unfortunate thing here is that many coders don't realize they are making mistakes with approach because it seems so darn easy!
• There's no such thing as unbundling in PCS.  Having coded both ICD-9-CM and CPT procedures, I strongly believe that CPT coding is a great prep for learning PCS.  The level of detail needed to code CPT is much greater than that needed for ICD-9-CM procedural coding.  But there are times when I initially miss PCS codes because I am applying CPT bundling rules to PCS.  In short, you can't do that.  We have specific PCS coding guidelines - if you have procedures that have more than one approach, root operation, or body part as defined in the PCS table, you code multiple codes.  And for a CPT coder, that's sometimes hard.  A specific example - we have a PCS guideline that says if they biopsy a structure and then remove it, you code two procedures since it is two root operations: Excision and Resection.  Weird, huh?!
• Where is the class on procedures?  We've been hearing for years that coders need to bone up on the biomedical sciences including medical terminology and anatomy and physiology, but I'm finding that many coders can't figure out the root operation because they don't understand the procedures themselves.  And while the training I've been working on does go into detail about how procedures are performed, I find there isn't really a college course you can take on procedures.  But YouTube has some great videos if you want to self study.

Okay, so that's the bad news.  PCS is hard.  Really hard.  The good news is this.  It's fun.  Super fun!  And it's opened up dialogue with other coders I haven't had the chance to have in a long time and I miss that.  So if you're starting to learn PCS and you're struggling -maybe even crying - you aren't alone.  And the best news of all is that they make some really cute tissue boxes these days!

Code for the Day: A Day at the Spa 8E0KX1Z

The last few weeks have been more than the usual crazy.  I knew going into September that I was going to have to take every rare opportunity I found for a little relaxation.  Since August, I have spent more weekend nights away than at home and while most of my trips have been for fun and not work, I am a person who relishes a routine schedule and values downtime - probably like a lot of coders out there.

My September travels began with a trip to North Carolina for a wedding followed closely by a work trip to Kansas City for training.  The whole time I had my eyes open, considering ideas for my blog and looking for inspiration in the normally mundane daily grind.  I have a few ideas that will take more thought before putting to paper - er, PC - so stay tuned.  But it was something quite literal that inspired today's code for the day: a heavenly day spent at the spa with coworkers.

I know what you're thinking. A relaxing day at the spa with coworkers is an oxymoron.  Well, you haven't met my coworkers!  We spent a nice Sunday morning at the spa and I do believe the topic of work came up only once and very briefly before we moved on to more important topics, such as, admiring each others' nail color and inquiring about the various facials, wraps, and massages we all received.

Oh, the massage.  Actually, after a busy week of lugging heavy suitcases and flying across the country and back and then back to the midwest and back again had left my feet as sore as my shoulders.  I was pretty much a goner after the pedicure, but I subjected myself to a hot stone massage anyway and I remember wondering afterward if there was a code for feeling like jello, because it's been awhile since I've felt that complete relaxation.  In fact, I did something I pretty much never get to do that afternoon: I took a nap!

My attempts at locating a jello code were not fruitful, so I went with the more obvious and here it is - the code for the day:

• 8E0KX1Z, Therapeutic massage

This code is found in ICD-10-PCS in one of the sections we trainers like to call the "stuff in the back of the book."  Most of the stuff in the back of the book includes codes we aren't likely to code and provide evidence that at one time, there were plans for PCS to replace CPT (this is not happening - I repeat, CPT is not going away!).  But I like this code and it was so appropriate for my weekend.

On a side note, I am not crazy about advertising on my blog, but I have to give mention to this amazing spa.  If you ever find yourself in Denver and need a little pampering, the folks at Woodhouse Day Spa will take great care of you.  This particular location at 17th and Ogden is located in the historic Merritt House.  There's just something about relaxing in this Victorian setting that makes it seem extra special!

No Code Today - Why Isn't There a Code for Struck by Cat?

Meet Jake

Meet Jake.  I can't see your reaction, but I've introduced enough people to Jake that I can pretty much guess.  You were immediately drawn in by his beautiful blue eyes and unusual coloring (he's a blue point Himalayan mix).  He is, without a doubt, one of the most gorgeous cats I've ever seen.  A select few of you - those who really pay attention to detail have zeroed in on  his tag - a skull and cross bones with the words "Bad Kitty."  Some of you have a phobia of cats and were immediately disturbed to see him when you opened up my blog this morning.  I am never one to encourage phobias of cats because I think they're awesome.  But in this case you should be afraid.  Very afraid.  You see, Jake is evil.

Cue intro to "Bad to the Bone" music.

Jake is a rescue.  He was a stray who was pulled off the dangerous streets of a Denver suburb when I adopted him at about 5 months old.  I was immediately smitten!  And let's just say he knew how to get adopted.  He snuggled and purred and then showed off his playful spirit and we were on our merry way.  And then Jake didn't purr again for about 4 years.  As it turned out, he was a manipulative little jerk whose favorite game is ambush.  And I am his favorite target.

I've worked with Jake over the years and now I consider him somewhat of a miracle cat.  The miracle is that he's lived with me for 8 years and I haven't killed him yet.  I lovingly refer to him as my little jerk, but he does have a softer side - thanks in large part to another very even-tempered cat who has shown him how to be civil.  When no one is looking, he's a total mama's boy.

But as he gets older, Jake gets a little more nervous.  He doesn't like crowds and I like to entertain, so Christmas dinner with my entire family resulted in my grandmother getting bitten.  And lately I've had a tendency to drop things on top of his food bowls while I am getting kibble out of the pantry.  In 2 out of the last 3 times, he ended up biting me.  Last night when I dropped something, I immediately reached my hand out to console him and didn't get attacked.  It's true - people don't train cats, cats train people.

So this morning when I opened my eyes and thought, "what will I blog about today?" I focused on Jake and remembered the last scars he left.  A few weeks ago he hit the back of my legs with such force that he not only left bite marks, he left impact bruises. 

And I headed to my encoder. 

You see, there are many external cause codes (what we call E codes in ICD-9-CM) for being struck by animals.  But as I soon found out, there is no code for being struck by a cat.  What?! I double checked.  Yes, there is struck by dog, struck by horse, struck by raccoon (?!), struck by cow, struck by other hoof stock, struck by alligator, struck by pig, struck by dolphin, and struck by various types of specific birds (what the heck is a psittacine anyway?!) - but no code for struck by a cat. 

I suppose it sounds silly - to be struck by a little pussy cat.  But I have to tell you that 13 pounds of force from a cat with a purpose can definitely leave a mark.  And while I can assign a code for the bite - W55.01xA, Bitten by cat, initial encounter - there is no code for the striking part.  Which I find incomprehensible.  Perhaps I should write a letter to the Coordination and Maintenance Committee...

Code for the Day: Z99.89 - Dependence on Smartphones?

My brother was in town yesterday and we got the family together and had dinner.  It was organized over a series of text messages as I sat across from my mother and grandmother during lunch on Sunday.  I knew Mom would give the 411 to Dad.  And I texted my BF to give him the invite as well.  Done.  And all in a matter of minutes without talking to any people (other than my mom and grandmother). 

While I had my phone out, I checked Facebook to see if anyone had posted any new pictures from my high school reunion over the weekend.  I love seeing the little red numbers at the top of my Facebook app telling me how many new notifications, messages, and new friend requests I have.  It's more satisfying than seeing the little red numbers by the email icon telling me I have new email.  Because let's face it, most of my email these days is junk mail trying to get me to spend money at one store or another.  And if someone important really wants to reach me, they'll text... But I digress...

So at dinner last night, my brother was telling me about some study saying that we are addicted to technology and it's making us stupid.  Not him and me, per se, but people in general.  Apparently they measured people's brain activity when they were doing mindless things on their smartphones - like checking Facebook - and found there was pathetically low brain activity.  And he told me there was no code for it.  Yet. 

Game on!

No code for it?!  Maybe not a specific code, but I decided I must find one!

Yes, I love purple.  And polka dots.

First of all, I didn't spend a lot of time researching this supposed study.  Partly because I really think he's right - I do think smartphones can reduce us to potatoes quicker than a TV (if we let it) and partly because I have ADD, but mostly because - hello! - I have a job!  Which means I have limited time.  Okay, I looked a little.  I googled it, of course, and found what some are lovingly referring to as Ari Gold syndrome.  That's a reference to the manic agent played by Jeremy Piven on HBO's Entourage in case you missed it.  And the article hit a little too close to home.  I sleep with my iPhone on the nightstand.  I check email and Facebook first thing in the morning.  I have been guilty of texting my BFF while my BF is trying to talk to me.  I can't let go of my old iPhone in case the new one breaks.  I have multiple cases for both phones (see picture).  And I am sorely disappointed that I can't find a place to hang the cute Coach charm I had on my Blackberry on my iPhone (the Blackberry was a long time ago and way before I entered into a commitment with Apple!) .  But after reading the article, I decided to make a conscious effort to stop. Well, slow down anyway.

So here's the scoop.  Is there a code for Ari Gold syndrome?  Well let's break down the symptoms of Ari Gold syndrome  - these are things like sleeping next to your phone, being disappointed when there are no emails, Facebook, or Twitter updates, buying "outfits" for your phone (guilty - again, I refer you to the picture), ignoring people in your immediate presence because you are too busy texting or Facebooking or tweeting or whatever.  If the worst thing in the world you can imagine is losing your smartphone, you might have Ari Gold syndrome.  If you can't communicate without all the LOLs, BRBs, BFFs, and BFs (please note - the text lingo was used on purpose in this posting to drive home my point!), you might have Ari Gold syndrome.  If you get a sudden rush every time the text message tone rings, you might have Ari Gold syndrome.  I'm no doctor, but this sounds like dependence to me. 

And even though I've had a long day and really don't want to see another code for another 10 hours or so, I looked it up.  And alas, there it was - the code for the day - and the closest thing I could find to smartphone dependence:

• Z99.89 Dependence on other enabling machines and devices

Okay, here we go.  Coders all across America are screaming at their computers after reading this.  They are probably saying this is a medical device code, but it doesn't say that.  It says other enabling machines and devices.  What is a smartphone anyway?  I rest my case.
 This is also what I refer to as the Wall-E effect (great movie - rent it if you haven't seen it!).  And it's the reason the ICD-10 Task Force I chair in Colorado never meets via conference call.  Because we need to renew the art of meeting and talking to people in person.  It's why I always recommend to new students who are looking for work as coders to go to meetings and talk to people.  Using the latest form of smartphone technology is a great skill to have.  So is effective face-to-face conversation. 


So if you found this blog through Facebook, Twitter, or Linkedin - welcome!  If you are reading it right now on your smartphone, bravo!  And now I challenge you to put down your smartphone and go have a nice conversation with someone.  I need to go check Facebook.  Ha!  Just kidding!  Okay, seriously, I will check Facebook and then go read one of those paper things.  What are they called?  Oh yeah, books.

Code for the Day: Mondays and Debridement

Happy Monday!  Sorry if you find the statement annoying or offensive.  I am actually not a fan of Mondays.  As my Tinkerbell coffee mug reminds me, "Mornings are not magical" - and neither are Mondays.  This is why the Tinkerbell mug is my Monday choice for guzzling (partially caffeinated) coffee.  I try not to fall into the misery that many do on Mondays, though, because I don't want to set a negative tone for the week.  But I got a double whammy today.  Not only is it Monday, I had an email from a client this morning asking me a question about coding debridement.

Deep sigh.  Sip some coffee.  Get ready for the long email explanation back.

If you've coded at all recently, you know that debridement codes are under scrutiny by Medicare's recovery audit contractors (RAC) because of the vast payment differences between nonexcisional and excisional debridement.  And as I dusted off what has become my typical response to the documentation requirements for coding excisional debridement, this morning I found myself doing additional research.  And it reminded me of what is often the next question when I give advice for coding debridement in ICD-9-CM: will this be fixed with ICD-10-PCS?  Well, in a word, no.  As a matter of fact, it's going to be worse.

Sorry to add more bad vibes to your Monday.  Go grab another cup of joe and we'll talk about it.  Go ahead.  I'll wait....

Here's the deal.  In ICD-10-PCS - which, by the way, is completely different than coding in ICD-9-CM - we code according to root operations.  Debridement fits into two different root operations, depending on the method used: excision and extraction.  Here are the definitions of these root operations - straight from the ICD-10-PCS code set:

• Excision - Cutting out or off, without replacement, a portion of a body part
• Extraction - Pulling or stripping out or off all or a portion of a body part by the use of force

As you can see, excision involves cutting.  With a sharp instrument.  Like a scalpel.  So logic dictates that an excisional debridement would code to excision.  Easy peasy!

As far as extraction is concerned - first of all, ouch.  Lots of interesting things fall under extraction, like cesarean section, dilation and curettage, and of course, nonexcisional debridement.  Nonexcisional debridement can be performed using various methods, such as using enzymes, ultrasound, or simply sloughing off the tissue with gauze.

As you can see, not only does the debridement issue not go away with PCS, it has the potential to get a lot worse.  We can code excision or extraction or almost any body part.  So we still need to know these important elements in order to properly code:

• Condition requiring debridement (e.g., ulcer, fracture)
• Location of the debridement (e.g., foot, sacrum)
• Depth of debridement (we code to the deepest layer)
• Method(s) used to remove tissue (e.g., cutting away of tissue)
• Specific tissue removed (e.g., skin, muscle) - the removal of "necrotic tissue" doesn't help us for coding purposes!
• Instruments used to remove tissue (e.g., scalpel, scissors) 

To make it even more interesting, there is no default here like there is in ICD-9-CM.  So tell your doctors they need to be specific or we will be querying even more than we do now!

Want to see what this might look like?  Here's an example of a patient presenting with a right foot ulcer involving only the skin (note that the ICD-10-CM code specifies depth of ulcer involvement too).  A couple of disclaimers here - the reimbursement information is estimated based on the current MS-DRG grouper version 29.0 and the hospital base rate is fictional - I just wanted to give you an idea of the payment differences between excisional and nonexcisional debridement.  Also, the only codes I grouped are the ones you see here.

I don't want you to get hung up on the money here, other than to realize the potential compliance issues this presents.

Don't you feel so much more equipped to handle your Monday now?  See you Tuesday!

Code for the Day

I wish I had a humorous and witty code for the day, but I'm just not feeling that chipper this morning.  I did say that my codes for the day would be inspired by my daily life.  And today's inspiration is drawn from the terrible tragedy at a movie theater not to far from me here in the suburbs of Denver.  While I'm not the type to go to a midweek midnight showing of the latest movie, I am the type of person who has friends who are the type to go to a midweek midnight showing of the latest movie.  I am happy to report that those friends who are "most likely to" have checked in on Facebook this morning.  But there are many who weren't so lucky and my heart goes out to them and their families.

A quick recap in case you haven't seen any news today - a man apparently burst into a packed movie theater and threw some gas canisters into the crowd and waited for them to explode before opening fire on the defenseless audience.  At this time, it sounds like 12 are dead and many others are being treated at Denver's various trauma centers.  

So today's code for the day came to mind as I was listening to the news and a PR statement from a local hospital where some people were treated.  I was paying particular attention because I used to work at this hospital.  And when the spokesperson said they weren't sure what kind of gas was in the canisters, but it was a type of tear gas or something similar and people are being treated for eye irritation and burns, my first thought was - how awful and my second thought was there's a unique ICD-10 code for chemical  burns.  Sorry, I just can't turn off the coder inside!

In ICD-10-CM, we have newly divided burn codes - those for thermal burns and those for corrosion.  I don't know about you, but I think this distinction is a long time coming.  Like burns, corrosions are also classified by depth, or degree of the chemical burn as first, second, or third degree.  So for example, let's say someone was admitted with second degree chemical burns to the face.  This is coded as:

• T20.60xA, Corrosion of second degree of head, face, and neck, unspecified site, initial encounter

So I ask you - as you do your daily coding, do your physicians document degrees of severity on chemical burns?  

I hope everyone has a safe and happy weekend and let's hope next week's inspiration comes from something happier.

ICD-10 Code for the Day

I received an email from a former coworker today, who was looking everywhere she could think of to find a posting I made about a code for the day.  She was checking Linkedin.  What she found was a snarky comment I made on my personal Facebook page earlier this week.  Actually, I also made another posting last week with a code for the day. So no wonder she thought it was "out there," so to speak.  And since I've been feeling rather uninspired to blog lately, I decided to go public with the code for the day and post it here.

Before I get to the first official Coder Coach Code for the Day, let me tell you this: these codes will be ICD-10 codes because I've been living and breathing ICD-10 lately and it's given me the opportunity to find some very interesting codes.  It's also led me to some very inspiring philosophical questions - you know, something along the line of why do we have an ICD-9-CM code for vomiting alone (787.03) and not one for vomiting in a group?  Couldn't a code for vomiting in a group come in very handy for St. Patrick's Day, New Years Eve, and countless 21st birthday parties?!  I know, I know, the code is really differentiating between vomiting with and without nausea.  But this gives you an idea of what goes through my mind as I read some code descriptions.  Besides, coding can be so boring, so why not make it fun and amusing?

So now that we've established my unique brand of coder humor, you need to know that there is no method to my madness regarding the selection of the code for the day.  I am not going to start at the beginning of ICD-10.  I am not going to randomly open an ICD-10-CM or ICD-10-PCS code book and pick a code.  The code (or codes) I choose will most likely be something inspired by a daily event or something I come across in my work and find incredibly interesting.  For example, last Tuesday, I worked a 16 hour day.  I started to come up with one code on the following day, but upon further reflection, I decided two would more accurately and completely report my condition (and we coders are about accuracy and completeness!):

• Z72.820, Sleep deprivation 
• F15.20, Other stimulant dependence [caffeine)] uncomplicated

I suppose coders who know ICD-10 will tell me I sequenced it wrong since the substance abuse code should go first followed by the Z code (which is ICD-10's equivalent of an ICD-9 V code), but I decided since one led to the other - that is, the sleep deprivation led to an excessive need for coffee on Wednesday, the sequencing was appropriate in my case.  And these codes will not be reported on a claim to CMS on behalf because 1) I didn't see a health care professional and 2) I don't have Medicare (how old do you think I am anyway?!). 

What I find interesting here is the new subcategory of Z codes for sleep problems - the one that jumped out at me was poor sleep hygiene.  I first found the set of codes while doing a documentation review for a sleep lab clinic in preparation for ICD-10.  I admit.  I had to google it.  What is sleep hygiene?  If I drool in my sleep, does that mean I have poor sleep hygiene?  Turns out it means a host of other things like irregular sleeping habits or leaving the lights on when you're trying to sleep.  Come to think of it, I think my head hit the pillow around 3am Wednesday morning and I was up again around 7am, so perhaps I should have added Z72.821, Inadequate sleep hygiene to the list above as well.

And really, I am not addicted to caffeine.  Anymore.  But I sure felt like I needed it on Wednesday.  The uncomplicated part could probably be argued by my boyfriend since I was pretty much exhausted for the rest of the week.  But really, the ICD-10 code is more referring to medical complications of drug dependence.  Think I'm kidding about the classification of caffeine as a drug you can be addicted to?  That part is no joke.  When you look up addiction, it takes you to dependence and caffeine is listed right there in the index!

This the kind of thing you'll have to look forward to in my Code for the Day posts.  Consider it my way of shaking my pom pons and getting you excited about ICD-10 again - since we still don't have a final rule yet.  I'm still plowing ahead and getting ready and I think the least I can do is make a little fun for my readers.

If you found a code that tickles your funny bone, send it to me at codercoach@gmail.com!

What's New With ICD-10?

You may be wondering where I've been. Well, I've largely been off Twitter and the Coder Coach Facebook page and I obviously haven't been blogging. But like many other current coding professionals I've been very busy. For those of us preparing for ICD-10, it's being done in addition to our daily jobs. For me, that means switching hats between performing ICD-10 documentation reviews (I've coded over 300 records in ICD-10 so far!), writing training material, and presenting training to coders on ICD-9-CM and CPT subjects. I continue to chair the ICD-10 Task Force for the state of Colorado, although I now have a co-chair thanks to a very motivated and active task force.

Last month we received "the announcement" that the ICD-10 implementation is going to be pushed back. But so far, it's still a guessing game on when that will be. I have folks from organizations and students from schools asking me what this means. And you may also be wondering, what has changed with the announcement that ICD-10 is going to be delayed? Well, as of this writing, I can tell you in a two words: absolutely nothing.

Most experts agree that the thing to do now is stay the course and keep preparing for ICD-10 as if it will be implemented on October 1, 2013. Most speculations are that there will be a one-year delay, which means 1 more year for training and testing. Some providers here in Colorado are planning for dual coding of claims if they have extra time. Most agree that we are already so far behind as an industry that a short delay at this time would mean a sigh of relief for most providers. But let's be clear about one thing: this additional time is only a good thing if we keep pace with our current ICD-10 preparations.

The American Medical Association's efforts to stop ICD-10 have been well documented as have concerns from other associations alerting CMS that we need more time for testing and implementation. I would encourage everyone to become educated on the history of ICD-10 in the United States, as it dates back to 1993. That's right, nearly 20 years ago. That means that when I took my first coding class in 1993, we were talking about the impending conversion to ICD-10. Testing of the system started in 1997. In a letter to Secretary Kathleen Sebelius, the National Committee of Vital Health Statistics presented a timeline of ICD-10 in the US. The insurance industry has reportedly already spent billions of dollars in the ICD-10 transition process. So for every argument you hear against adoption of ICD-10, there is an argument for it.

Will There Ever be an ICD-10?
If you're wondering if ICD-10 is really going to be a go, here's my two cents. Yes. It will be a go. There are various government health care initiatives on the horizon that require it. Every other industrialized country besides us uses it and we need it to compare data with them. In order to make sense of SNOMED-CT codes, which are used in electronic health records, we need ICD-10.

What About ICD-11?
ICD-11 is slated for release by the World Health Organization in 2015. Once published, the US will adapt the clinical modification (CM) we utilize here in the States. That conversion will take years. Most experts agree that we can't wait for ICD-11.

Should You Become a Coder Right Now?
If you're wondering if now is a good time to enter the coding profession, I still offer a resounding yes. Learn the basics now - there is so much to learn in ICD-9 that will carry over to ICD-10. Take the time to learn about disease process and procedures because, as I recently told someone, ICD-10 is going to separate the men from the boys. After coding ICD-10 almost full time for the last couple of months there are days when I want to cry and when it seems that no amount of googling will answer my question about a procedure. If you are the analytical type who isn't afraid of research, this could be the profession for you.

In addition, many organizations are taking advantage of this possible delay by implementing computer assisted coding (CAC) systems. When I first saw a CAC about 10 years ago I was not impressed. But I looked at a couple at the AHIMA conference in October and they have really come a long way. I was looking at the systems different from most of my colleagues. I was specifically looking at them as a training tool for fresh faced coders who are right out of school and I see a lot of potential there for newbies. So get your foot in the door now and start learning!

What's new with ICD-10? I say nothing. We're still moving forward as if October 1, 2013 is our deadline. Because one thing is for sure. If we - that is, an industry prone to procrastination - are given another delay, we don't want to be caught unprepared. And I don't think CMS will be gracious about allowing further deadline changes.

I Bet You're Wondering What I've Been Up To...

Oh wow, has this been a crazy fall! Up until this year, "Rocktober" was a term we used in Colorado whenever our beloved Colorado Rockies made it to the playoffs. This year Rocktober took on a whole new meaning for me. And while it was a great month, I am so happy to say it's over and now I can concentrate on the less busy holiday season. Yes, October was that busy!

As you saw from some of my blog postings, I kicked off October in true coder fashion by attending the AHIMA Convention and Exhibit in Salt Lake City. What a great opportunity to learn the newest, latest, and greatest from some of the nation's best HIM and coding minds and get in some serious networking as well. This year was particularly busy at convention as I was honored with an AHIMA Triumph Award for mentoring, mainly due to my efforts with the Coder Coach blog and some of the networking and educational events I've hosted over the last couple of years. It was an incredible honor and to help commemorate the occasion, I took my personal and professional mentor - my mom (pictured here with me) - along with me. It's hard to tell who was more excited about my award!

This was also the first year that I was chosen to speak at the national level. I presented an outpatient track at the coding meeting on the overlap between coding and charging in the cardiac cath lab. As if that wasn't enough, I just couldn't say no when another Triumph Award recipient and fellow Coloradan, Dee Johnson, asked me to be a part of the Student Academy. Dee is a student at Arapahoe Community College, my alma mater here in Colorado, and was a key planner in this year's Student Academy. The academy is a free event for students in AHIMA programs at the convention each year. I was a part of the mentor lightning rounds where several established professionals spent a few minutes with each group of students to share our experience and answer questions. All of that and Apolo Anton Ohno too! The Olympic athlete and Dancing with the Stars champion was our closing keynote speaker and he had an inspiring message about giving it your all.

Once I was back at home, there was no rest for the weary as I delved into not one, not two, but FIVE client trainings. For those who aren't aware, training sessions take about 4-5 times as long to prepare as they do to present but the work is always well worth it when I get to training. That is my favorite part of my job because it combines two of my great talents: coding and talking! My last week of training involved three training sessions, work-related road travel, a snow storm, and, of course, that inevitable sinus infection as a result of a crazy month. I would love to tell you that following that last training on October 28 I headed out for happy hour with my friends, but truth be told, I had a nice evening vegging out on the sofa and catching up on all my DVR'd shows!

So here we are in November and I'm trying to wrap a few things up before the holidays. Last weekend I met with a fantastic group of super coder geeks (birds of a feather!) who were so amazing to not only spend their own time coding some records in ICD-10, but to also give up a Saturday to come together and talk about the results. This is a project that the Colorado Health Information Management Association's (CHIMA) ICD-10 Task Force has undertaken to assess documentation readiness for ICD-10. I have had a great year chairing this task force and working with an enthusiastic group who is making great strides as a clearinghouse for ICD-10 information in the state of Colorado.

Last week I was interviewed by ICD-10 Watch, a terrific resource for anyone interested in ICD-10. We specifically chatted about the fantastic opportunities that await coders as we transition to ICD-10. The interview is recounted in the blog posting How ICD-10 can create opportunities for medical coders.

Whew, I think I need to take a nap now that I've recounted the previous month's events! I plan to get back to the ICD-10-PCS series in another week or two, but bear with me - November's calendar is starting to fill up, so it might be 2012 before I can give the series the attention it deserves. In the meantime, I hope everyone has a terrific holiday season.

I Love ICD-9-CM - What if I Don't Feel the Same Way About ICD-10?

I think there are a lot of students out there learning ICD-9-CM right now who are feeling a certain apprehension about the ICD-10 implementation. It's a tricky time to be educated in coding right now - you may decide you love ICD-9-CM only to have it ripped from your grip in 2013 and replaced by something that doesn't closely resemble your new found love. So maybe you've been reconsidering a field in coding.

Well, let's not overreact! First of all, let's look at what it is you like about coding, what will be changing, and then decide if it's time to overreact!

First of all, ICD-9-CM, Volumes 1 and 2 (the diagnosis codes) are being replaced by ICD-10-CM. And although there are some tricky areas and all of the code numbers are different, the overall feel and use of ICD-10-CM is not that dissimilar to what we're used to today. Yes, it will be more difficult to roll codes off the top of our heads like many of us can now with ICD-9-CM, but it will not be impossible (after a week coding in ICD-10, I found it was not difficult to memorize frequently used codes. The major changes? We have extensions now to indicate the episode of care for patients with injuries and we have codes for underdosing of medications - something that's completely foreign. And although in ICD-10 there are two types of excludes notes instead of one (not coded here vs. not coded in addition), that's a nice change that most coders are happy about.

ICD-10-PCS on the other hand, is very different from Volume 3 of ICD-9-CM, which includes procedures. In fact, ICD-10-PCS is very different from anything we've ever used for coding. The fact that there are no inclusion and exclusion notes - no tabular listing, in fact - only pages of tables, makes it seem daunting. This will be a huge impact, no doubt.

But should you worry about it? Remember - ICD-10-PCS has limited application. It is only required for billing on hospital inpatient claims. So if you work for a physician - or plan to - you will not have to learn ICD-10-PCS. If you code outpatients in a hospital, the jury is still out. Many hospitals still collect ICD-9-CM procedure codes for outpatients so they can use the data internally (remember - coding is about data collection too, not just billing). There is much discussion in the industry on the productivity impact of having coders code in both ICD-10-PCS and CPT for hospital outpatient services.

CPT is not at all affected by ICD-10 implementation. If you code for a physician, you will continue to use CPT to code and bill for his services and procedures.

Of course, if you find you have an affinity for ICD-10-PCS, perhaps this will help you determine your career path and you can look for opportunities to code in a hospital. Inpatient coding is usually a higher level coding position, so it may take time to get promoted up, but if you have the skill for ICD-10-PCS, it's my belief that you will be in demand. I think some current inpatient coders may decide they don't care for ICD-10-PCS at all and make some changes in their career paths.

31 Flavors of Ice Cream, 31 Root Operations in ICD-10-PCS

Sunday I decided to give up ice cream. Not forever, just for a few weeks or so while I try to kick what has become a rather troublesome sugar addiction. It turns out Sunday was not a good day to give up ice cream because that was National Ice Cream Day. How that very important holiday was omitted from my Outlook calendar when I imported all the US holidays, I'll never know, so I will have to be more watchful next year. I am proud, albeit unsatisfied, to tell you I stuck to my guns and didn't celebrate National Ice Cream Day this year. There's always 2012!

You might be laughing right now, but ice cream is a very serious matter to me. When asked what my favorite ice cream is, I will inevitably ask you "from where?" and then launch into a tirade about how the manufacturer is key in determining what flavor to eat and continue with a discussion about proper chocolate-to-ice-cream ratio that would make Sally Allbright from When Harry Met Sally proud. I consider myself a bit if a connoisseur, which my mother tells me goes all the way back to that first ice cream cone I "shared" with her. The words "death grip" come to mind when I think of her telling the story. In short, she didn't get any ice cream that day and so began my love affair with the creamy treat.

Monday morning, ice cream ban still in full swing, and ready to start another work week, I shuffled into ICD-10 Central (aka, my office), where it's quite obvious there is some serious ICD-10 work going on: the two large flipchart posters on the wall listing the root operations, stacks of ICD-10 books from current and past years, and a hot pink post-it stuck to my July (national ice cream month!) calendar stating quite simply: "31 Flavors of ice cream - 31 Root Operations."

The ice cream post-it is the only way I can remember how many root operations there are in ICD-10-PCS. I heard a speaker once tell the audience to take a root operation a month and study it in preparation for ICD-10-PCS and then she said there weren't enough months before implementation. And sure enough, here we are in July 2011 and the October 1, 2013 deadline is looming ever closer - only a couple years away.

When I tried to relay that story to one of my audiences, I decided it was pathetic I couldn't tell anyone off the top of my head how many root operations there were. So thank you, Baskin Robbins, for helping me out with this one and loaning me your 31 Flavors terminology. Even though at last count there were more than 31 flavors behind your counter. And even though, in my mind, there is only one flavor of Baskin Robbins ice cream (accolades for proper chocolate-to-ice-cream ratio!).

So there you have it. There are 31 root operations in ICD-10-PCS that hospital inpatient coders must become familiar with. It will be quite impossible to code without knowing the root operations. For ease of use as I have sat down with medical records and began coding my little ICD-10 heart out, I posted the wall charts right in front of my desk, arranged in categories I wish I could take credit for creating:

Root operations that take out some or all of a body part:

• Excision
• Resection
  
• Detachment
• Destruction
• Extraction

Root operations that take out solids, fluids, or gases:

• Drainage
• Extirpation
• Fragmentation

Root operations that involve cutting or separation:

• Division
• Release

Root operations that involve putting in or putting back or moving some or all of a body part:

• Transplantation
• Reattachment
• Transfer
• Reposition

Root operations that alter the diameter or route of a tubular body part:

• Restriction
  
• Occlusion
• Dilation
• Bypass

Root operations that always involve devices:

• Insertion
• Replacement
• Supplement
• Change
• Removal
• Revision

Root operations that involve examination only:

• Inspection
• Map

Root operations that involve other repairs:

• Control
• Repair

Root operations with other objectives:

• Fusion
• Alteration
• Creation

Some root operations have very limited use: mapping is used only for cardiac electrophysiology mapping; the root operation creation has only two possible uses - gender reassignment from male to female or vice versa. Some are more commonplace: excision is removal of part of a body part while resection is removal of the entire body part. That contradicts the way we code today where excision is a complete removal.

But don't worry - this alien new coding system comes with its own set of guidelines that define these root operations and tell you when to code out separate components of a procedure. For example, there is a hierarchy for spinal fusions that utilize bone graft, internal fixation, and cages so you only end up with a single code. On the other hand, placement of a completely embedded vascular infusion device requires two codes: one for catheterizing the vessel, and one for placement of a subcutaneous port.

If you're wondering how to get a leg up on ICD-10, don't bother learning to code it right now. We've all heard that, right? You will forget it unless you use it every day. But you can and should start reading the coding guidelines and become familiar with the table format of ICD-10-PCS. It's different for everyone who codes now (that was spy code for all you novices looking for a level playing field!). ICD-10-PCS coding will identify a whole new population of coders with the skill to properly categorize root operations. It will mean knowing not only the name of the procedure, but what that procedure is trying to accomplish and how it's performed. So brushing up on surgical procedures is a great way to bide your time until it is time to get moving with hands-on training.

So are you ready to test out those 31 flavors of root operations? I will start posting some teasers for you and you can test your ability to name that root operation. If you would like to download the latest version (2012) of ICD-10-PCS, the files are free at CMS' website - guidelines included! Check it out here at: http://www.cms.gov/ICD10/11b15_2012_ICD10PCS.asp#TopOfPage. While you start reading, I am going to go hide my car keys and my Ben and Jerry's pint cozy. I suddenly have a craving for ice cream. Weird.

Opportunity Happens: ICD-10 is Mine

To quote my recent Facebook posting, "Ever notice that amazing opportunities are followed by boatloads of work?" That's my excuse for where I've been: opportunities and their resulting heavy workload. For me, opportunity is cleverly disguised as ICD-10. What is your opportunity?

Just to catch you up, I recently accepted a senior consulting position with a new consulting firm. Haugen Consulting Group is based locally in Denver and while I will be pretty much doing what I've been doing - coding consulting and education - I will also be working with a team of amazing consultants as we lead our clients through the ICD-10 implementation.

I am also chairing the Colorado Health Information Management Association's ICD-10 Task Force, which is gaining momentum each month. For the last month I've visited two of Colorado's three regional HIM associations and also had the opportunity to speak on ICD-10 and HIPAA 5010 implementation last month in Montana and do an audio conference on the new leg revascularization CPT codes for HCPro. Later this month I will present at CHIMA's spring meeting on the importance of mentoring our future workforce (I'm going to bat for all of you!) and will also moderate an ICD-10 panel. These speaking engagements lead to more speaking engagements, which is what I love to do. And sometimes the speaking engagements lead to contracts, writing opportunities, and other networking opportunities.

While I've been working on some exciting prospects of my own, some of the people I've been mentoring have also received some opportunities. I recently got a call from a recruiter asking about one such candidate and another recent grad got a part-time position in an HIM department based on her work there as a volunteer. And my advice to them now that they have their feet in the door is to work hard to keep those opportunities coming.

So if you've completed a coding or HIM program and are having trouble finding work, here's a reminder of some of the things I recommend for getting your start:

• Network! I've received jobs from 4 people I knew or worked with in the past. And I've hired people I've worked with in volunteer organizations. Who you know matters!
• View everything as a learning experience. Work is work, no matter how much you enjoy what you do. There are days when you won't like the tasks that have been assigned, but there may come a day when you need to tap into that experience.
• Find a workplace mentor. Once you get your foot in the door, find someone you can go to with questions. This doesn't have to be a manager - it can be a lead, a person who has worked there "forever" or even a team of people.
  
• Keep a positive attitude. No one wants to work with someone who is negative and miserable. A positive attitude goes a long way in any industry.
• Don't give up - because opportunity happens!