What Does ICD-10 Really Mean to New Coders?

If you haven't heard yet, the coding system is changing on October 1, 2013 from ICD-9-CM to ICD-10-CM and ICD-10-PCS. I have told a lot of new coders and coding students that this gives them a more level playing field when it comes to getting hired on as a coder. But 2013 is still 3 years away. If you are graduating soon and will be looking for a coding position, what does ICD-10 really mean to you? Should you start training on ICD-10 now so that you are well-positioned for the coding switch?

Why ICD-10 is a Good Thing for Wanna-be Coders
I always start with the prerequisite disclaimer when I talk about coders: I am a coder, so I can poke a little fun at our idiosyncrasies. Many coders don't like change. And that's part of what makes them so successful as coders - the ability to work in a routine environment coding patient record after patient record. So to coders who really dislike change, ICD-10 is like an atomic bomb. I've heard some say they will retire or find a new line of work when ICD-10 is implemented. Add those open positions to the decreased productivity that is inevitable with the implementation of a new coding system, health care reform, and the current national coder shortage, and what we have is an awesome opportunity for new coders to enter the field.

Coders who learn ICD-10 in school will likely be called upon by their new employers to share their knowledge of the new coding system with more established coders. Getting into ICD-10 on the ground level means more opportunities for new coders in the future.

Why ICD-10 Coding Jobs Won't be Super Easy to Land
While the need for more coders trained in ICD-10 will be there in 2013 and the codes themselves will be different, the one thing that makes a coder truly special will not change: navigating the medical record, deciphering medical terminology, and applying coding guidelines. These are skills that are not easily taught in school - this is the "experience" that employers are looking for when they say they want two to three years of coding experience. And while new coders right out of school will have oodles of exposure to the ICD-10 code sets, experienced coders will have that other type of experience - the type that goes beyond looking up a code in a book. That skill will still be coveted by employers.

I talk to a lot of people who are pondering changing careers and getting into coding because of what they've heard about ICD-10 and the future need for more coders. But just because we're nearing this massive change doesn't mean that it will be any easier to get hired as a coder in 2013 than it is now. There are many considerations you need to make in determining when ICD-10 training is appropriate for you.

What Kind Of Coder Do You Want to Be?
I have been trained in ICD-10-CM and ICD-10-PCS. The only reason I am trained is because I intend to do a lot of ICD-10 training myself and those who are getting educated now are the educators. I recently had someone tell me she planned to wait a couple years to get trained in ICD-10 because she heard it was so different from ICD-9-CM and she didn't want to have to learn a dying coding system. So let's start with the first question you need to ask yourself: What kind of coder do you want to be?

This is important because ICD-10 is divided into two code sets: ICD-10-CM for diagnoses, which will be used by all health care settings, and ICD-10-PCS, which will be used only by hospitals for reporting procedures. CPT will not be impacted by ICD-10 implementation and the format of ICD-10-CM is very similar to ICD-9-CM (granted all the code numbers are different!). I see the transition from ICD-9-CM diagnoses to ICD-10-CM being relatively easy (notice I said relatively - it will still be a bear!).

ICD-10-PCS is a whole different story. The procedure portion of ICD-10 is set up like no codebook we've ever seen. There is no tabular listing - only a series of tables that allow the coder to "build a code." Furthermore, the level of detail and the coder knowledge required to code an ICD-10-PCS code as opposed to an ICD-9-CM procedure code is astronomical. For example, there is one ICD-9-CM procedure code for repair of an artery. In ICD-10-PCS, the coder will need to know which specific artery was repaired and how that repair was approached.

So when people say ICD-10 is very different from ICD-9-CM, I have to ask, which code set? While the code numbers and code format will be drastically different, the way we code will be the same for ICD-10-CM as it is now for ICD-9-CM diagnosis coding. But ICD-10-PCS is like... well, CPT on steroids. The level of detail in ICD-10-PCS coding is much more specific than what's required even by CPT standards.

Why the long explanation? Well, if you plan to code for a physician office, you won't need to learn ICD-10-PCS. So I say, go ahead and learn ICD-9-CM now because the main change for you will be the code numbers themselves (and a couple of coding guidelines). If you plan to code for a hospital, you need to be prepared for a whole new game with procedure coding when ICD-10 is implemented. The good news is, ICD-9-CM procedure coding really isn't very difficult, so I don't see anyone "wasting" time by learning it now until 2013.

Do You Want to be More Than a Coder?
Let's get one thing perfectly clear here and now. The implementation date for ICD-10 (both CM and PCS) is October 1, 2013. There will be no push on that date. Everyone will be expected to be up and running on October 1, 2013. Rumor has it that this date will get pushed back, but everything I have heard from government representatives says that there will be no push on that date. So spread the word!

Let me get something else perfectly clear: ICD-9-CM will not "die" out. There will be a need for people to know ICD-9-CM diagnosis and procedure coding after October 1, 2013. Particularly if you work in a hospital, data analysis is often performed based on codes and we often compare case loads from year to year to see which services are growing, which are waning, and which are needed in the community that aren't currently offered. In the calendar year 2013, we will have data from both ICD-9-CM and ICD-10. That means a need to be able to crosswalk between codes for data analysis. And someone within the hospital needs to understand both systems. That might be you.

Take the Next 3 Years to Get Experienced
The biggest complaint I hear from wanna-be coders is that all employers are requiring 2-3 years of experience. So if my math is correct, if you wait 3 years to learn ICD-10 and it takes another 2-3 years to get experience, you won't really be working as a coder for another 5-6 years. Why wait? While it doesn't make too much sense to get trained specifically on ICD-10 right now because you won't remember it in 3 years, it does make sense to get hired on as a coder and start positioning yourself to take on a coding position in 2013. This might mean taking an entry-level position where you are exposed to the medical record, codes, or billing. Don't wait till 2013 because there will be a mad dash and employers who have open positions in 2013 probably won't have time to train someone who is complete green. As a matter of fact, I have been encouraging facilities to make education a part of their organizational culture now to lessen the impact of ICD-10 implementation.

Now is the time to hone your skills in coder detective work - where you find information in the medical record, how the patient's symptoms come together in the disease process, anatomy and physiology, medical terminology, and pharmacology. And the good news is, learning this now means you can also apply it to ICD-9-CM now and it will make it easier to make the switch to ICD-10.

Talk to Your School
If you're enrolled in a coding or HIM program or plan to enroll in one, do your homework. Ask the program director or coding instructor what the school's plan is for the ICD-10 transition. They should be referencing timelines like the one posted on AHIMA's website. If they don't have a plan now, you should be concerned.

Don't Hurry Up and Wait
I suppose the best way to sum up this posting is to say this: think of your coding education as a journey rather than focusing on the destination. Go ahead and get trained in ICD-9-CM now - it will not be a waste of time or money. Yes, you will need to train in ICD-10, but if you're credentialed, you will have every opportunity to train through AHIMA and the AAPC. And if you're employed, your employer will be be focused on training as well. Plus, I really do believe that those coders who know both ICD-9-CM and ICD-10 and can analyze and compare data across both code sets will be hot commodities.

Getting Through an Operative Report - Without Crying

One of the things I love about the mentoring I do for students is it reminds me of what it was like to be a newbie. And I don't just mean the excitement of being on the cusp of a new career. I am also grateful to be humbled and reminded that I knew absolutely nothing when I got started. These days when I stand in front of an audience of coders or students and teach the latest and greatest on whatever topic I'm discussing for that day, it's the culmination of years of experience and hours (or weeks) of research and preparation. But you might be interested to know that in my first coding job I did come home from work on more than one occasion in tears.

I can't explain that helpless feeling when you've trained so hard - and studied and taken numerous tests and graduated, etc. etc. etc. - and you land that first job and they hand you an operative report. And you freeze. Because it's like Greek. You have no idea what to do. Where are the short coding scenarios you learned in school? What does that first paragraph really say? You know you could find the code if you could just figure out what the heck the darn report says (incidentally, I now consider myself trilingual: English, medical terminology, and coding!). You know you're qualified, but are you really?

So I sometimes forget when I'm working with new students what it was like. Of course, there are still days when I feel like crying because I keep getting myself into uncharted territory. I actually relish researching and "figuring out" things that other people may abandon because they are too foreign or "difficult." But it wasn't always that way. I used to be an overconfident novice coder who, when a chart was placed in front of her, did a lot of tap dancing to make it look like she was competent. The good news is, 15 years later, I feel competent (most of the time anyway!).

The Word Search
I've worked in coding education now for about 8 years. In that time I've been asked to work on a lot of different projects related to coding education. In addition to training coders, I've been asked to evaluate people to see if they would make good coders. And I always start with the word search test. Do you like word searches? If not, you might want to consider a different career. Because coding is one big word search. You have to decipher the medical record (or operative report) and decide which words are important and which ones you can ditch.

Bunionectomies are a Kick
The first time I was given a bunionectomy report to code, I'm pretty sure I cried. After all, the procedure title was something like "Mitchell-Chevron," which meant nothing to me. And I knew enough about coding to know I had to read the report to figure out if it really was a Mitchell-Chevron. And the report was surely about 4 pages - pretty standard for a thorough podiatrist. And when I went to a class to learn how to code bunionectomy procedures, I realized that out of the entire 4 pages, I focused on about 3 sentences. That was it. The rest was coding garbage. In case you're wondering, a Mitchell-Chevron bunionectomy involves removing the medial eminence (AKA bunion) and making an osteotomy (bone cut) into the first metatarsal (the foot bone connected to the big toe). I'm still amazed that it takes 4 pages to describe that.

Deciphering the Operative Report
I am often asked to explain how to decipher an operative report. Well, it depends on the procedure, really. And if you are a new coder and you ever have the opportunity to go to a seminar where they will present case studies, this is the best way to learn. I've taught dozens of classes and nothing drives home my point more than walking through the cases and coding them. But I will give you some basic elements here to get you started. While these rules don't apply to all specialties (e.g., interventional radiology has "special" rules that drive the even the most experienced coders - that would be me - batty!), this should get you started on some of those basic surgical reports.

• Rule 1 - Doctors Lie: Admit it, you watch House and have heard him say on more than one occasion that patients lie. Well, Dr. House, I would like to point out that doctors lie too. They will state the procedure one way in the title and then proceed to describe a completely different procedure in the body of the report. For example, the doctor may state a left heart catheterization was done, but after reviewing the report, the catheter never made it all the way to the heart - only to the coronary arteries. So keeping this in mind, you should never believe what you read in the procedure title. Honestly, I rarely even read the procedure title anymore - it's often fiction. As for Dr. House, I would love to see a strong-willed coder have it out with him on the show about his documentation, which I'm sure is a mess.
  

• Rule 2 - Get a Medical Dictionary: There's no excuse anymore. When I learned how to code, we were still using Windows 3.1, so there was no way the hospital was using the internet. But even without online resources, I had a medical dictionary on my shelf. And it was used often. How will you know if something is important if you don't even know what it means? While you're at it, make sure you also have access to an English dictionary. I know it's a novelty, but you will also find complex nonmedical words in the operative report (or even in your code descriptions). If you don't know what it means, look it up. Tedious, I know, but you will learn. Of course, you might feel like Billie Dawn from Born Yesterday, but you will learn. (Don't understand the movie reference? Look it up!).

• Rule 3 - Just Like Ragu, It's Probably in There: In school we hear terms like "it's bundled" or "separate procedure" but what does that really mean? Well, it means it's integral to the main procedure and don't code it out separate. What's included? Well, pretty much anything that has to be done in order to accomplish the main procedure. Taking out an appendix? Well, then the incision (or creation of ports for laparascopic instruments) is included. So is the closure at the end of the procedure. I don't know about you, but if I have my appendix taken out I sure hope the physician remembers to suture me closed at the end. All those things are like regular ingredients in Ragu pasta sauce - tomatoes, oregano, garlic. It's in there! So don't code each component out separately. Now, had they decided to do a liver biopsy while in there, that's different. That's like throwing a banana in the pasta sauce. So it gets coded separately.
  

• Rule 4 - You Will Only Use 10-20% of the Operative Report: Don't feel like you need to use every word in the operative report to code the case. The fact is, the operative report isn't about you, it's about the patient and it's a communication tool for clinicians. It just happens to double nicely as a recording of everything that happened to the patient and can substantiate coding and billing. It's up to you to determine what's important in the documentation. There's a reason we use coding for billing - your codes actually fit on a 1-page claim form so the insurance company doesn't have to read through every single medical record.
  

• Rule 5 - Know the Procedure: Okay, maybe I should have led off with that one. Medical terminology is, quite literally a foreign language. In fact, it's at least two foreign languages: Latin and Greek. So when you say "it's Greek to me," you're being quite literal. A really good medical terminology class will solve a lot of problems. You may think esophagogastroduodenoscopy is a really big word until you break it down and realize it's visualization (scopy) of the esophagus (esophago), stomach (gastric), and part of the small intestine (duodeno). You also need to know your anatomy. You need to know when they operate on a structure that's part of a bigger structure (e.g., mesentary of the intestines) vs. a different organ altogether (like in the appendix/liver example above). After you learn medical terminology and anatomy and physiology, that's half the battle. The rest of the battle can typically be solved with Google. Come to think of it, there are few things that can't be solved with Google. I'm pretty sure there will be a support group some day for Google-aholics, but in the mean time, I highly encourage you to google a procedure if you don't know what it is. I never remember what a Whipple procedure is. But I can google it in about 10 seconds. Just be careful which website you select from your Google search list - something from the Mayo Clinic is probably more reliable than lazy-Dan-explains-medical-procedures.com.

• Rule 6 - There is Crying in Coding, Just Don't Let Anyone See It: Oh, how I wish I could tell you I had that one down. But I'm pretty transparent when it comes to being frustrated. And I've had students cry in frustration when trying to code case studies. But try to minimize your public displays of tearful frustration and remember this - we've all been there and this is hard. It's okay to not know all the answers all the time.
  

I hope this at least gets you moving in the right direction. When people ask me how I learned everything I know I, 1) laugh, because I know there is so much more for me to learn, and 2) tell them how the rules above worked for me.