Real World Experience
In Recoding Charts In
ICD-10
By Karen G. Youmans, MPA, RHIA, CCS
President, YES HIM Consulting, Inc.
YES HIM Consulting, Inc.
OVERVIEW AND BACKGROUND INFORMATION
During April-May 2013, YES HIM Consulting, Inc. consultants recoded 2720 inpatient encounters from 4th Qtr
2012 from one healthcare system. The healthcare system consists of 9 hospitals including small acute care
facilities, Children’s and Women’s hospitals and large acute care facilities. The encounters were selected by
the healthcare system to represent their various patient populations and MS-DRGs. The inpatient encounters
encompassed all 989 MS-DRGs for both Medicare and Managed care payers. The main purpose and scope
of the recoding project was originally to provide coded data to the healthcare system for them to compare the
ICD-9 MS-DRG assignment to the ICD-10 MS-DRG assignment and develop a financial impact. However,
the experience of the YES consultants was priceless.
Eight (8) YES HIM Consulting, Inc. consultants recoded the encounters. The YES consultants all have 25-40
years of ICD-9 coding experience along with ICD-10 training including possessing the AHIMA-approved
ICD-10-CM/PCS Trainer status. Also, all eight consultants have worked with YES for no less than four (4)
years on ICD-10 documentation gap analysis reviews. The objective was to recode all inpatient encounters in
ICD-10 and calculate the MS-DRG. The goal was to code 3.25 charts an hour and to complete the
assignment within six weeks.
RECODING PROCESS
The healthcare system provided to YES all the patient demographics along with the ICD-9 codes and
MS-DRG assignment for the 2720 inpatient encounters in MS Excel format. The YES project manager
assigned each consultant a data file consisting of a specific hospital with various MS-DRGs to total 100
encounters at a time. The consultants then uploaded the data into the TruCode encoder into the ICD-9 tab.
The example below displays the TruCode ICD-9 tab for a patient encounter coded for diverticulitis of the
colon with an abscess and an abdominal paracentesis grouped to MS-DRG 391:
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The YES consultants then reviewed the specific patient medical record source documents within the healthcare system’s EHR to assign the ICD-10 codes via TruCode. TruCode provided the consultants with the ICD10 encoder, ICD-10 references, and ICD-10 MS-DRG assignments. The image below displays the TruCode
ICD-10 tab for the same patient encounter recoded for diverticulitis of the colon with an abscess along with
the abdominal paracentesis which grouped to MS-DRG 392.
The YES consultants could click on the TruCode ICD-9 tab to review the healthcare system’s code and
MS-DRG assignments for comparative analysis. The YES consultants utilized TruCode’s custom field 1 to
indicate the finalization of the ICD-10 code and MS-DRG assignments for each of the 2720 recoded inpatient
encounters. In this example, the consultant would select ID #2 Dx code not CC/MCC in ICD-10 as the
abscess is no longer a separate code and not an MCC.
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Additionally, all ICD-10 code and MS-DRG assignments were uploaded into the CMS pilot grouper for
comparison to the TruCode ICD-10 grouper. All ICD-10 MS-DRG assignments grouped the same in the TruCode ICD-10 grouper and the CMS pilot grouper. If the MS-DRG assignment was not the same as the original ICD-9 MS-DRG recoded to ICD-10, another consultant reviewed the inpatient encounter to ensure that
the original consultant recoded the encounter accurately. If the second consultant agreed with the original
consultant, the encounter was assigned for a third and final review by a YES manager. The
consultant
also wrote a brief description of the recoding specifics such as image below “ICD-10-CM has a combination
code for diverticulitis with abscess. ICD-9 had abscess as an MCC. Changes the DRG from 391 to 392.”
The custom field 1 selections for when the ICD-9 and ICD-10 MS-DRGs did not match included:
2. Dx code not CC/MCC in ICD-10
3. Dx code is CC/MCC in ICD-10
4. Pr code more specific in ICD-10
7. ICD-10 guideline/sequencing change
8. Pilot grouper error (potential)
9. Coding summary doesn’t agree with UB codes
Other custom field 1 selections when the MS-DRGs matched included the following:
1. MS-DRG same
5. Auditor disagrees w ICD-9 code/MS-DRG – NO MS-DRG change but notation made (listed
suggested codes and changed MS-DRG – both ICD-9 and ICD-10 - in notes – YES to discuss these
with healthcare system’s management team for them to review – YES assumption was if the coder
coded it a certain way in ICD-9, then they would code it the same in ICD-10)
6. Cannot code ICD-10 – documentation gap – NO MS-DRG change but notation made (YES to
add these to healthcare system’s documentation issues to discuss at the ICD-10 HIM and CDI teams
–YES had to make some body part and/or approach assumptions to assign a code for this financial
audit -- note that these documentation gaps would not affect the MS-DRG assignment)
Each inpatient encounter was assigned a “reason code” from the drop-down menu within the custom field 1.
Once the YES consultants completed their 100 encounter files, they exported the data from TruCode. All of
the files were then compiled by the YES project manager and submitted back to the healthcare system for
their financial analysis.
For the financial analysis, the ICD-10 recoding of 2720 inpatient encounters produced a 96% MS-DRG
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STATISTICS
match. The following
statistics represent the data submitted:
Audit Outcome - All Facilities
Audit Outcome
Charts
MSDRG Same
2514
Auditor disagrees w ICD-9 code/MSDRG
64
Pr code more specific in ICD-10*
45
Cannot code ICD-10 - documentation gap
38
ICD-10 guideline/sequencing change*
24
Dx code not CC/MCC in ICD-10*
18
Dx code is CC/MCC in ICD-10*
8
Pilot grouper error *
7
Coding summary doesn’t agree with UB
codes*
2
TOTAL
2720
*4 % MS-DRG change 96% MS-DRGs remained the same
The 4% MS-DRG changes represented both some positive and negative dollar amounts with an overall
positive dollar amount. The healthcare system calculated their own internal MS-DRG calculations and
trending. However, the basic calculations from TruCode presented the following baseline numbers:
Facility
ICD-9 Reimbursement
ICD-10 Reimbursement
Difference
1
2
3
4
5
6
7
8
9
TOTAL
756,232.00
3,228,866.38
2,391,689.59
3,611,596.78
2,409,592.56
3,309,726.05
2,560,317.51
4,253,477.56
2,976,909.57
25,498,408.00
764,705.85
3,326,752.30
2,496,958.98
3,617,753.47
2,507,960.56
3,314,683.70
2,641,830.72
4,365,610.95
3,042,032.56
26,078,289.09
8,473.85
97,885.92
105,269.39
6,156.69
98,368.00
4,957.65
81,513.21
112,133.39
65,122.99
579,881.09
The first week of the recoding project presented some challenges for the YES consultants. Even with all of
PRODUCTIVITY
their coding experience, the pressure to be productive (goal was 3.25 charts coded per hour) displayed some
anxieties among the group. With all of the complexities of ICD-10 code assignments, most of the consultants
were only averaging coding 1 – 1.5 charts per hour. Many of the inpatient encounters had up to 30 diagnoses
coded in ICD-9. During the second week of the project, YES approached the healthcare system with a
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proposal to only code the significant ICD-10 diagnoses codes. Therefore, YES would not code status post
codes, external cause codes, or history codes. The healthcare system approved this process. The surgical
procedures were the most difficult and time-consuming to assign ICD-10 codes. Due to the lack of PCSrequired specifics in the brief procedure statements on the operative reports, the consultants had to read the
full operative report text to assign an accurate ICD-10-PCS code.
Example:
Procedure performed: Debridement of burn with autograft, thigh donor site (can code in ICD-9-CM
from this statement)
Full text: … the burn on the left lower leg was debrided through the skin and subcutaneous layer
down to the fascia. Split-thickness skin graft from the left thigh was used to… (terms in bold are
necessary for PCS)
By the end of the six weeks, each of the consultants was meeting and/or exceeding the goal of 3.25 charts
coded per hour. The chart below displays the average coding time per chart for each consultant for the
entire six week project.
Coding Time by Coder
Consultant
Charts Coded
Avg Coding time
1
490
8.0
2
497
13.4
3
189
11.6
4
112
21.3
5
106
6.1
6
644
12.7
7
563
9.1
8
119
10.4
2720
11.2
TOTAL
Note that we began the project by assigning all diagnostic codes (some encounters up to 30) but then
reduced our coding during the third week to exclude external cause codes, status post codes and history
codes. We averaged 9 diagnostic codes per encounter.
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MS-DRG CHANGES AND ICD-10 CODING SPECIFICS
The following paragraphs encompass our “reason codes” for the MS-DRGs not matching between ICD-9 and
ICD-10 along with specific examples:
Dx code not CC/MCC in ICD-10 – the ICD-10 codes that did not display their CC/MCC status included the following diagnoses:

Accelerated hypertension (note: accelerated / malignant hypertension is not separately designated within ICD-10-CM)

Gestation hypertension

Depression

Type II diabetic ketoacidosis (note: E13.10, Other specified diabetes mellitus with ketoacidosis
without coma is assigned for a patient with type 2 diabetes with ketoacidosis)

Diverticulitis with abscess is a combination code

Hepatic encephalopathy (chronic without coma)
Dx code is CC/MCC in ICD-10 – the ICD-10 codes that did display their CC/MCC status which were
not CC/MCCs within ICD-9 included the following diagnoses:

Previous myocardial infarction within 4 weeks

Opioid dependency

Dilated cardiomyopathy
Pr code more specific in ICD-10 – the procedures assigned a more specific code in ICD-10-PCS
which subsequently changed the MS-DRG included:

Colostomy take-down

Insertion PEG tube

Revision hip replacement (removal and replacement)

Revision of shoulder replacement (removal and replacement)

Revision of knee replacement (removal and replacement)

Replacement pacemaker device (removal and insertion)

Spinal tap

Revision A-V fistula

Percutaneous drainage of gallbladder

Bronchoscopy with lung biopsy

Thrombectomy (specific veins)

Debridement (fascia or bone level)

Angioplasty (specific arteries)

Dilations (i.e. veins, pylorus)

Drainage abscess (i.e. rectal, neck, pelvic)

Insertion stent (specific arteries)
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ICD-10 guideline/sequencing change – the following guideline and/or sequencing changes included:

Osteoporotic pathological fractures

Admission for rehab

Underlying chronic kidney disease

Maxillary sinus fracture (note: ICD-10 code for maxillary sinus fracture is included in maxillary
fracture; and ICD-9 assigns maxillary sinus fracture to base of skull fx)

Previous myocardial infarction (note: change from 8 weeks within ICD-9 and 4 weeks within
ICD-10)
Potential Pilot grouper error – we did encounter a few potential pilot grouper errors which we reported to CMS. The potential pilot grouper errors included:

“Revision of knee replacement: In ICD-10-PCS, revision of knee replacement, code both the
removal of old and replacement with new which should group to MS-DRG 467 (as in ICD-9);
For “revision of knee arthroplasty”, when the removal of the prosthesis is added to the
replacement, the MS-DRG is 467 (just as in ICD-9 MS-DRGs) with 7th character Z. However,
when the 7th character is 9 or A for cemented or uncemented, then the DRG changes to
464” (as reported to CMS on 3/28/12)

“Radiculopathy included in ICD-9 code and ICD-10 code for displacement vertebral disc with
radiculopathy; procedure is a fusion, so should group to the fusion MS-DRG 473 but is grouping to MS-DRG 030 spinal procedures. However if I choose the displacement code without
radiculopathy, groups to same MS-DRG as the ICD-9 (473)” (as reported to CMS on 3/28/12)
DOCUMENTATION GAPS
YES HIM Consulting, Inc. has been assisting this facility with ICD-10 documentation gap analyses for three
years so the documentation gaps within this project were minimal – 38 encounters. It should be noted that
this recoding project did not attempt to gain specificity in diagnoses nor improve clinical documentation for
additional CC/MCCs. The purpose and scope was to recode the 2720 inpatient encounters. The
documentation gaps were from the procedures and included:

Location of amputations (body part)

Transfusion specificities (body system and qualifier)

tPA injections (body system and qualifier)

PICC line insertions (ending body part)

Lysis of abdominal adhesions (body part)

Declotting of A-V fistula (body part)

Portion of esophagus dilated (body part)

Medical induction of labor (body system)

Angiography (fluoroscopy or plain)
ICD-10-PCS Transfusion – see 302 table below:
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EXAMPLES OF ICD-10-PCS SPECIFICITIES NEEDED
ICD-10-PCS - Insertion of PICC line –
see 02H table:
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SUMMARY AND LESSONS LEARNED
pose and scope of the recoding project was originally to provide coded data to the healthcare system for them
to compare the ICD-9 MS-DRG assignment to the ICD-10 MS-DRG assignment and develop a financial impact. There was a 4% MS-DRG change with a minimal overall increase in revenue predicted.
However, the experience of the YES consultants was priceless. As previously noted, all of the eight YES
consultants were very experienced coders and auditors, but when they were put under pressure to be
productive in coding ICD-10, it was initially a stressful situation. Remember that change is hard for each and
every one of us. There are numerous changes due to combination codes and specificity in ICD-10-CM and
everything changes in ICD-10-PCS. In order to assign the correct ICD-10-PCS code, we needed to read the
detailed operative reports. Each consultant was very glad that we had previously taken the YES Coding
Clinical Concept Courses to review Medical Terminology, Anatomy, Pathophysiology and Pharmacology with
ICD-10 concepts.
An area of concern regarding productivity were the numerous ICD-9 diagnoses codes currently assigned
such as non-specific status codes, family history codes with no connection to the current episode of care,
non-treated secondary diagnoses codes, etc. In addition, procedures such as blood transfusion, therapeutic
injections and radiology procedures are being coded in ICD-9-CM. While the coding of some of these
additional secondary diagnoses and procedures are for quality measures and/or severity and mortality groupings, it is our recommendation that each facility review their policy regarding secondary diagnoses and noninvasive procedure codes.
There is a lack of detailed references and guidance for ICD-10 to date. For the recoding project, there were
only two published Coding Clinics for ICD-10. Additional references are needed for us to assign ICD-10 codes
accurately and consistently across the U.S.
We could not have performed our scope of work without the usage of the TruCode encoder system. We
imported the data, utilized the ICD-9 and ICD-10 tabs, and utilized the supplementary tab with the custom
field for reporting. The TruCode encoder system permitted us to review the ICD-9 code and MS-DRG assignment against our ICD-10 code and MS-DRG assignment. The export feature was essential to report our data
back to the healthcare system.
We highly recommend that the coders (especially the inpatient coders needing to assign ICD-10-PCS codes)
take clinical courses/training prior to their ICD-10 in-depth training. The in-depth ICD-10 training needs to
focus on the differences between ICD-9 coding and ICD-10 coding with various scenarios and exercises. We
then encourage all healthcare facilities to allow their coders time to practice coding in ICD-10 prior to the
go-live date of 10-1-2014. Dual coding will provide the inpatient coders the experience in comparing the
ICD-9 MS-DRG to the ICD-10 MS-DRG and analyzing the variations. Note that when coding ICD-10, productivity will be decreased in the first few weeks, so plan accordingly. However, with coding practice (and
more practice), the productivity will stabilize.
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ABOUT THE AUTHOR
Karen G. Youmans, MPA, RHIA, CCS, is the President of YES HIM Consulting, Inc. based in Largo,
Florida. Ms. Youmans has over 25 years of experience in the healthcare industry and the HIM and coding
professions. She was previously the Executive Vice President for a national healthcare consulting firm.
Ms. Youmans has also held positions as an Instructor/Assistant Professor in the university of Central
Florida’s RHIA program, the Program Director for the RHIT program at St. Petersburg Junior College,
and the Practice Manager of coding products and services with AHIMA. Over the years, Ms. Youmans
has also been an HIM and coding consultant in various capacities, including all aspects of HIM operations
and revenue cycle improvement projects as well as ICD-9-CM and CPT-4 coding education. She has
given numerous presentations at local, state and national levels on a variety of topics including ICD-10
implementation. Her clients include hospitals of all sizes, healthcare systems and encoding vendors. Ms.
Youmans is a past president of the Florida Health Information Management Association and has served on
the AHIMA Board of Directors. Ms. Youmans obtained her Master of Public Administration degree in
Healthcare Administration from Golden Gate University and a Bachelor of Arts degree in Health Information
Administration from the College of St. Scholastica. She attended the October 2009 AHIMA Academy for
ICD-10 and is an AHIMA-approved ICD-10-CM/PCS trainer.
ABOUT YES HIM CONSUTING, INC.
YES HIM Consulting, Inc. is a health information management consulting firm that provides extensive ICD10 coder education, training and assessments. We offer ICD-10 implementation plans, project management and ICD-10 clinical documentation reviews. Our training program is based on AHIMA and CMS recommendations and includes online seminars, online HIM coder clinical assessments and training, and ICD10-CM and ICD-10-PCS code training offering AHIMA and AAPC approved CEUs.
ABOUT TRUCODE
TruCode is a company focused solely on medical coding. We empower medical coders with a streamlined
coding experience and the intuitive guidance and support of our intelligent Research Pane. The result is a
balance of power, flexibility and support that allow medical coders to work faster and more efficiently to
deliver accurate results throughout the coding process.
Our philosophy is simple: design specifically for the way coders think and work – and empower them to do
everything better. This means intuitive function, clean presentation and the continuous guidance of
on-screen medical coding reference support whenever it’s needed. The results are immediate and
far-reaching and include:
 Optimal insurance, Medicare and Medicaid reimbursement through increased coding accuracy
 Reduced A/R days through increased medical coder productivity
 Increased healthcare regulatory compliance by providing official medical coding guidance during the
coding process
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