The Only Good GEMS Are The Ones We Wear

Remember when physicians were granted a ‘grace period’ of sorts to be able to code unspecified codes? The rest of us have had to deal with lack of documentation, payers that reject unspecified codes, prepayment reviews and medical review policies.

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Well, that grace period ends October 1, 2016. And while we may think of the celebrations we’ll have when, all of a sudden, physicians begin specifically documenting what they mean, what we are seeing is unspecified codes when specific documentation is present.

CoDR (pronounced Coder) has found through many audits that the most common error made by coders is choosing unspecified codes, when the documentation is actually there so that the coder could have chosen a more specific code. Now, why is that? My theories:

1. Agencies have chosen to use the GEMs (Generally Equivalent Mappings) developed by Medicare. Medicare developed those GEMs to assist us in learning coding. They were NEVER meant to be a substitute for correct coding. Many EMRs included the GEMs, and EMR clients and salespeople alike touted the convenience of having a map from ICD-9- CM to ICD-10- CM. The problem with those GEMs is they often point to the unspecified code. I always say “they may get you to the right neighborhood, but not to the right house.” CMS has warned us NOT to use GEMs, but to “native code” (which makes me visualize those pictures in the National Geographic magazine I used to sneak a peek at as a kid). Using GEMs or mappers to code leads to inaccuracy and, in time, CMS will note trends and change medical review policies and case mix scoring to the industry’s detriment.

2. Coders are in a hurry. They jump on the first mention of a diagnosis and do not search further for more information. Now why are they jumping on the first mention of the diagnosis? Productivity standards, payment by the assessment, a lack of confidence in the documentation all could be reasons.

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The American Health Information Management Association (AHIMA) has some advice on how to assess a medical practice’s ICD-10 specificity and I think this advice works well for home health agencies and hospices as well, so I’ve added to it.

1. Run reports of top ICD-10 diagnosis codes, paying particular attention to identify unspecified codes. How often are unspecified codes assigned?

2. Conduct analysis of diagnosis codes assigned by clinician and/or coder to identify any patterns or trends in unspecified ICD-10- CM (diagnosis) coding. Drill down into trends in using unspecified codes. Are there patterns?

3. Review clinical documentation:

a. If more specific diagnosis codes can be assigned based on the documentation, provide education to the appropriate staff on proper code assignment. Review the documentation in question. Was there specific information available? Were the appropriate physician queries made?

b. If documentation is not complete for desired level of diagnosis specificity, provide clinical documentation improvement education to clinicians and intake personnel so that the appropriate queries can be made. Is the EMR being used making appropriate recommendations or is there faulty logic involved?

c. Hire a coding company, such as CoDR, to audit your coding to see where your trends are and provide education to correct those trends. CoDR can help you by providing a detailed report of the findings along with rationale.

What else should you do?

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Hire a Credentialed Coding Professional

The importance of a competent and credentialed coding professional to tighten ICD-10 coding practices and establish a compliant coding program cannot be understated. Options are to 1) employ a credentialed coder directly through your agency, 2) train a current employee, or 3) contract with an outsource coding company, such as CoDR.

We can help you with all three! Selman-Holman will be adding an employment opportunity section to the website soon.

Selman-Holman provides the most highly acclaimed home care and hospice training for ICD-10- CM in both on-site and on-line media. Visit and/or for available courses.

Contracting with an outsource company may be the best option for a quality coder. Although, we hope you contact CoDR for your coding needs, any coding company should answer these questions:
1. Are all the coders HCS-D certified? If so, what score did they obtain?
2. Did the coders receive mentoring or training prior to being assigned?
3. Will the same coder(s) be assigned or will coders be assigned randomly?
4. Is there a quality assurance audit process in place to assure the coders maintain the high standard CoDR expects?
5. How do your coders get continuing education and get updated in changes to coding guidance?

Looking Ahead

Home health agencies and hospices face two final coding challenges in the year ahead: a plethora of new ICD-10 codes and a “fluid” ICD-10- CM environment in which the powers-that- be are constantly challenged to make sense of the codes once we started using them. October 2016 brings a flood of new ICD-10 codes as CMS thaws a three-year partial code freeze. There are nearly 2,000 new ICD-10- CM codes, and that does not include changes to the tabular list instructions and guidelines. While no individual agency or hospice will use all of the new codes, agencies should prepare for the changes ahead. We’ve also had major changes to the meaning of ‘excludes 1’, ‘with’ and 7th characters that even seasoned coders are having trouble wrapping their heads around.

Purple diamondA proactive approach to mitigate unspecified documentation, coding, and billing is the best remedy for post-grace period concerns. Now is the time to consider hiring credentialed coding professionals and/or partnering with coding consultants.

Call CoDR for information on our coding audits and/or coding services. 940.383.2130 or 806.831.4914. Do not use the GEMs…contact CoDR for the true “gems” of coding.

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