One of the biggest events to hit healthcare data in decades is the conversion of coded clinical data to the International Statistical Classification of Diseases and Related Health Problems: Tenth Revision, commonly referred to as ICD-10. The last change of this nature was in 1983 when Medicare implemented ICD-9 as part of the Inpatient Prospective Payment System (IPPS). Since that time, healthcare has advanced significantly and ICD-9 codes no longer represent the advances and complexities in care provided to patients; thus healthcare in the United States is expected to transition to ICD-10 on October 1, 2015.
ICD-10 is intended to support the systematic recording, analysis, interpretation, and comparison of morbidity and mortality data from around the world (World Health Organization, 2011). There are two parts to ICD-10: ICD-10-Clinical Modification (CM) and ICD-10- Procedure Coding System (PCS). Compared to ICD-9-CM with 14,000 codes, ICD-10-CM has 69,000 available codes to be used for diagnosis codes on all inpatient and outpatient accounts. In ICD-9-PCS there are approximately 3,000 codes; this will change with ICD-10-PCS to 72,000 available codes to be used only for inpatient procedural coding.
ICD-10 will touch everything from registration and scheduling, to revenue cycle and payer contracts, information systems, and ultimately will be used to improve patient care and outcomes. The important and widespread uses of ICD-10 data make it critical to understand these new documentation requirements. As healthcare prepares for ICD-10 and the coding of data using an electronic platform, it is important to ask, “What are the implications for nursing?” Although the answer to this question is not easily found, this informatics column will shed light on the issue by providing a sample case and highlighting the role of nurse informaticists in this historical change in healthcare data. We will conclude that nursing’s role in data collection and entry is important in the building of the ICD-10 database, and that the benefits to be achieved from this monumental effort are dependent on accurate documentation and coding.
Sample Case: Pressure Ulcer
Pressure ulcer was chosen as a sample case to examine in this column due to the costs incurred in treating pressure ulcers. It was also chosen based on the historical precedent whereby staging of pressure ulcers has been coded in ICD-9-CM from nursing charting/documentation (Centers for Medicare & Medicaid Services [CMS] & National Center for Health Statistics [NCHS], 2008).
Method
The following steps were used to identify nursing documentation needs for pressure ulcers related to ICD-10.
- Define pressure ulcers.
- Download the ICD-10-CM codes and identify all diagnoses related to pressure ulcers.
- Identify the data elements, i.e., the words used, in the pressure ulcer diagnoses in ICD-10-CM codes.
- Identify related data elements in the current electronic health record (EHR) nursing documentation on pressure ulcers.
- Perform a gap analysis between current EHR documentation by nurses on pressure ulcers and what is needed for nursing documentation in ICD-10-CM.
- Reconcile findings with other databases using nursing documentation on pressure ulcers in short-stay hospitals.
- Collaborate with health information management (HIM) to validate findings.
- Present findings to Chief Nursing Officers, as well as wound care nurses and physical therapists.
- Work with information technology EHR builders to build the data base related to ICD-10-CM that is needed for nurses to document in the EHR.
- Prepare educational materials for staff nurses regarding the changes in pressure ulcer documentation for ICD-10-CM.
- Pilot education materials among staff nurses, making adjustments as needed.
- Disseminate educational materials/offerings regarding nursing documentation of pressure ulcers related to ICD-10-CM.
Findings
Pressure ulcer was defined as a “localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear” (European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel, 2010, p. 7). The definition allowed nurse informaticists to identify whether words (data) currently used in the EHR to describe pressure ulcers were consistent with what a pressure ulcer is. For example, breast is currently listed in the EHR as a location for a pressure ulcer but breasts are not over a bony prominence. So while there may be a wound or an ulcer on a breast it is likely not a pressure ulcer.
The ICD-10-CM codes include 125 unique codes related to the diagnosis of pressure ulcers (CMS, 2013). The data elements of those codes represent anatomic location, laterality, and stage. The related data elements in current EHR nursing documentation include location, orientation, and wound therapy staging. The Table outlines the findings of the gap analysis. Column 2 illustrates the 65 unique data elements capable of being collected for pressure ulcers in the current EHR. Column 4 identifies the related 23 data elements capable of being coded in ICD-10-CM.
Other databases, which were identified as using nursing documentation on pressure ulcers in short-stay hospitals, included those from CMS on hospital-acquired conditions, Agency for Healthcare Research and Quality (AHRQ) on patient safety indicators, and the National Database of Nursing Quality Indicators (NDNQI) regarding nursing quality indicators. No contradictions were noted with ICD-10-CM data on pressure ulcers as these databases collect data on occurrence, prevalence, and stage, the latter of which is consistent with ICD-10-CM. Reporting of anatomic location is not currently required.
Our findings were validated by Health Information Management (HIM) and then presented to the chief nursing officers for approval. Following their approval, the findings were discussed with the wound care nurses and physical therapists who also validated the findings on what is needed in nursing documentation. They also helped to identify the key terms needed for clinical decision support, thus enabling staff nurses to more accurately document pressure ulcer staging in the EHR. Additionally, they requested that ‘Suspected Deep Tissue Injury’ be added to the staging, recognizing it would be coded as unstageable but requiring something that need to be watched closely.
| Table. Gap Analysis of Pressure Ulcer Documentation in EHR | |||
| Current State | ICD-10 Data Elements | Crosswalk | Future State |
| Location Abdomen | right elbow | Elbow | right elbow |
| right upper back | Back | right upper back | |
| sacral region | Sacrum | sacral region | |
| right hip | Greater Trochanter | right hip | |
| right buttock | Buttocks | right buttock | |
| contiguous site of back, buttock and hip |
| contiguous site of back, buttock and hip | |
| right ankle | Ankle | right ankle | |
| right heel | Foot | right heel
| |
| head | head | head | |
| other site |
| other site | |
|
| Abdomen | Words to the left moved out of pressure ulcer documentation and into new section on wounds. | |
| Orientation Anterior |
| Orientation Anterior | Words to the left removed as ICD-10 data elements are a combination of laterality and location. |
| Stage I | Stage 1 | Stage I | Stage 1 |
| Stage II | Stage 2 | Stage II | Stage 2 |
| Stage III | Stage 3 | Stage III | Stage 3 |
| Stage IV | Stage 4 | Stage IV | Stage 4 |
| Unstageable | Unstageable | Unstageable | Unstageable |
| DTI (Deep Tissue Injury) | DTI (Deep Tissue Injury) | Deep Tissue Injury suspected | |
Discussion
The diagnosis of pressure ulcer under ICD-10-CM requires documentation on the anatomic location, laterality where appropriate, staging, and whether or not the pressure ulcer was present on admission. Nurse practitioners, physicians, or physician assistants must document the diagnosis of pressure ulcer, including the anatomical location and laterality. Similar to ICD-9, the ICD-10 code assignment for the staging of pressure ulcers can be based on nursing documentation (CMS & NCHS, 2014). It is important for nursing documentation to align with the data needed to properly code and bill using ICD-10-CM.
The finding that data for pressure ulcer documentation in our current EHR will decrease when aligning ICD-10-CM codes seems paradoxical to the increased granularity in ICD-10. This finding can be attributed in large part to a) the combination codes in ICD-10 composed of site and laterality and b) incongruence of data elements in the current EHR with the definition of pressure ulcer. Non-pressure ulcers can be caused by gangrene, atherosclerosis, chronic venous hypertension, diabetic ulcers, postphlebitic syndrome, and varicose ulcers (American Academy of Professional Coders, 2013).
Noticeably missing from ICD-10-CM is deep tissue injury (DTI). In ICD-10-CM, DTI may be documented as unstageable (CMS & NCHS, 2014). Coding as unstageable is used for pressure ulcers whose stage cannot be clinically determined or are documented as DTI not caused by trauma (CMS and NCHS, 2014).
Implications for Nurse Informaticists
For nurse informaticists, the view of ICD-10 as a database should be readily appreciated. Investigating whether data in the ICD-10-CM codes differ from those currently being used in the EHR, which is actually another database, is essential. This requires an identification of the ICD-10 data elements pertinent to nursing followed by a gap analysis of what is current state versus what should be the future state in their informatics practice setting.
One question/issue to ponder is whether or not to choose usability over database standards when changing the EHR. The pairing of words, such as ‘right elbow’ or ‘left elbow,’ goes against standard principles for database building. On the other hand, should the build match ICD-10-CM thereby requiring only one click from the nurse? What does that do to the database structure and the ease of retrieving the data? For example, it is often easier to search for ‘elbow.’ Would EHR search engines include both ‘elbow, right’ and ‘right elbow’ for ease in searching? What happens if other databases, such as CMS, AHRQ and NDNQI, start requiring anatomic location that does not match those in ICD-10-CM even if the terms are broken down into single words?
There are other informatics issues to consider as well. For example, should the words already in use be placed in a dropdown menu under ‘other’? Or should nurses be limited in the options listed under ‘other,’ based on an acceptable definition of what constitutes a pressure ulcer? If too many additional words are placed under ‘other,’ what will be the impact on data analyses especially as data are exchanged across organizations?
A potential benefit of the staging of pressure ulcers is that staging provides an opportunity for clinical decision support. This is important as staging can be coded from nursing documentation. Adding descriptions in the EHR with key criteria for each stage, criteria that are readily accessible to nurses, can improve accuracy in staging and coding.
Preparing the nursing staff for ICD-10 should focus on actionable information. Pressure ulcers provide a good example of changes from the data currently being collected and documented to data that will need to collected and documented in ICD-10. Tying data to sound definitions and large databases, such as ICD-10, has the benefit of adding value to learning.
Conclusions
In addition to billing, ICD-10 codes will be used to advance the science of healthcare including nursing. Nursing’s role in data collection and entry is important in the building of the ICD-10 database. Ensuring nursing documentation on pressure ulcers is congruent with ICD-10-CM is an important role for nurse informaticists as the country builds this national database. The benefits to be achieved from this monumental effort are dependent on accurate documentation and coding.
Linda Harrington, PhD, DNP, RN-BC, CNS, CPHQ, CENP, CPHIMS, FHIMSS
Email: lindaharrington@catholichealth.net
Jalyna Cook, MBA, MSN, RN
Email: jcook14@stlukeshealth.org
Tracie Buckland, MPA/HSA, BSN, RN
Email: tbuckland@stlukeshealth.org
Jared Boynton, BSN, RN
Email: jboynton@stlukeshealth.org
