A Funny Thing Happened on the Way to an ICD-10 Gap Analysis

October 25th, 2013 - Codapedia Editor
Categories:   Coding   Diagnosis Coding  
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You’ve heard the scary facts, maybe even from me.  The number of diagnosis codes is increasing from about 16,000 in ICD-9 to 70,000 in ICD-10. The sky is falling.  I usually add, we won’t be able to memorize diagnosis codes any more. 

And then I did a gap analysis for a women’s health group.  My mission was to audit 60 records for accuracy in CPT/ICD-9 coding with the additional task of identifying any additional documentation that would be needed in the transition to ICD-10.   And the funny thing that happened: at note 42, I remembered an ICD-10 code without looking it up. 

Here’s the process: start with the documentation and compare the documentation with the ICD-9 code selected.  In this women’s health sample, the ICD-9 coding was accurate and there were few unspecified or non-specific codes.  (A review of oncology claims I did last month was dominated by ICD-9 codes ending in .9, and needless to say that group has work to do.  The first step in ICD-10 readiness is to clean up ICD-9 coding, and use specific codes whenever possible.  If the documentation doesn’t allow you to select a specific code, educate the clinician about what is missing.)  But, back to this group of claims, the ICD-9 coding was accurate and specific.  I used a free, internet-based crosswalk to find ICD-10 codes, keeping my paper ICD-10 book at the ready.   

  • Many codes had one-to-one direct matches, such as V25.11, encounter for insertion of intrauterine contraceptive device.
  • Some unspecified codes, accurately selected in ICD-9 by their alternative terminology will need to be reviewed.  625.9 is unspecified symptom associated with female genital organs.  The alternative terminology includes pain in female pelvis.  There are two suggestions for this code: N94.89 other specified conditions associated with female genital organs and menstrual cycle and R10.2 Pelvic and perineal pain.  N94.89 is the code to select if the source of the pain is known to be related to the GU system.  R10.2 is in the signs and symptoms chapter.  At the start of the section for R10.- the excludes notes states “Excludes1 symptoms referable to female genital organs.”  That is, if the patient in this sample had pelvic pain that was diagnosed as part of GU disease, use the more specific N94.89.  If the patient presented with pelvic pain but the clinician did not assess it as part of a GU problem, but perhaps sent the patient to a general surgeon for an assessment, use the symptom diagnosis of R10.2.  This example illustrates the drawback of a crosswalk program.  At first glance, R10.2 seems to be the correct match for pelvic pain.  But it is in the signs and symptoms chapter and the excludes notes clearly states it is not to be used for problems related to the GU system.
  • A commonly used code, V72.31 routine gynecological examination crossed to two codes and required the documentation to show if the results of the GYN exam were normal or abnormal.  Z01.411 encounter for gynecological examination (general) (routine) with abnormal findings or Z01.419 encounter for gynecological exam (general) (routine) without abnormal findings
  • In women’s health, supervision of pregnancy normal or high risk explodes to multiple codes.  For normal pregnancy, whether it is the first or subsequent pregnancy and the trimester need to be known to assign the correct code.  Although there are about twenty possible codes to describe types of high risk pregnancies in ICD-9, in ICD-10 there are seventy or eighty codes that describe the condition and trimester.  The ICD-9 codes are found under 648- other current conditions in the mother classifiable elsewhere but complicating pregnancy childbirth or the puerperium.  These conditions in ICD-10 are in the O09.- heading, list conditions and require the coder to know the trimester for accuracy.

You can do this analysis in your practice.  Of course, it’s easier in a single specialty group than in the ED or General Surgery where a range of problems are seen.  In that case, do the gap analysis repeatedly by system to facilitate learning.  Use a internet based program if it shows the includes/excludes notes or buy a book.  By the way, I suggest you buy a spiral bound book. I didn’t and pages are falling out of my book, and honestly, I haven’t used it that often. 

But, it was a funny thing: on note 42 I had memorized the two ICD-10 codes for an annual GYN exam.

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