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Letter to the Editor

Informatics: International Classification of Diseases-10: Implications for Nursing

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Linda Harrington, PhD, DNP, RN-BC, CNS, CPHQ, CENP, CPHIMS, FHIMSS
Jalyna Cook, MBA, MSN, RN
Tracie Buckland, MPA/HSA, BSN, RN
Jared Boynton, BSN, RN

Citation: Harrington, L., Cook, J., Buckland, T., Boynton, J., (July 1, 2014) "Informatics: International Classification of Diseases – 10: Implications for Nursing" OJIN: The Online Journal of Issues in Nursing Vol. 19 No. 32.

DOI: 10.3912/OJIN.Vol19No03InfoCol01

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  Since that time, healthcare has advanced significantly and ICD-9 codes no longer represent the advances and complexities in care provided to patients; thus healthcare in the United States is expected to transition to ICD-10 on October 1, 2015.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.

  1. Define pressure ulcers.
  2. Download the ICD-10-CM codes and identify all diagnoses related to pressure ulcers.
  3. Identify the data elements, i.e., the words used, in the pressure ulcer diagnoses in ICD-10-CM codes.
  4. Identify related data elements in the current electronic health record (EHR) nursing documentation on pressure ulcers.
  5. Perform a gap analysis between current EHR documentation by nurses on pressure ulcers and what is needed for nursing documentation in ICD-10-CM.
  6. Reconcile findings with other databases using nursing documentation on pressure ulcers in short-stay hospitals.
  7. Collaborate with health information management (HIM) to validate findings.
  8. Present findings to Chief Nursing Officers, as well as wound care nurses and physical therapists.
  9. 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.
  10. Prepare educational materials for staff nurses regarding the changes in pressure ulcer documentation for ICD-10-CM.
  11. Pilot education materials among staff nurses, making adjustments as needed.
  12. 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
Ankle
Arm
Back
Breast
Buttocks
Chest
Coccyx
Ear
Elbow
Face
Finger (Comment which one)
Foot
Greater Trochanter
Groin
Hand
Head
Heel
Hip
Ischial tuberosity
Jaw
Knee
Leg
Mouth
Neck
Nose
Pedal
Pelvis
Perineum
Penis
Ribcage
Rectum
Sacrum
Scleral
Shoulder
Scrotum
Sternum
Tibial
Throat
Toe (which one)
Umbilicus
Vagina
Wrist
Other

right elbow
left elbow

Elbow

right elbow
left elbow

right upper back
left upper back
right lower back
left lower back

Back
Shoulder

right upper back
left upper back
right lower back
left lower back

sacral region

Sacrum
Coccyx

sacral region

right hip
left hip

Greater Trochanter
Hip

right hip
left hip

right buttock
left buttock

Buttocks
Ischial tuberosity

right buttock
left buttock

contiguous site of back, buttock and hip

 

contiguous site of back, buttock and hip

right ankle
left ankle

Ankle

right ankle
left ankle

right heel
left heel

Foot
Heel
Pedal

right heel
left heel

 

head

head

head

other site

 

other site

 

Abdomen
Arm
Breast
Chest
Ear
Face
Finger (Comment which one)
Groin
Hand
Jaw
Knee
Leg
Mouth
Neck
Nose
Pelvis
Perineum
Penis
Ribcage
Rectum
Scleral
Scrotum
Sternum
Tibial
Throat
Toe (which one)
Umbilicus
Vagina
Wrist

Words to the left moved out of pressure ulcer documentation and into new section on wounds.

Orientation

Anterior
Distal
Dorsal
Inner
Lower
Left
Mid
Outer
Palmer
Plantar
Proximal
Right
Superior
Upper
Other (Comment)

 

Orientation

Anterior
Distal
Dorsal
Inner
Lower
Left
Mid
Outer
Palmer
Plantar
Proximal
Right
Superior
Upper
Other (Comment)

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.   

Authors

Linda Harrington, PhD, DNP, RN-BC, CNS, CPHQ, CENP, CPHIMS, FHIMSS
Email: lindaharrington@catholichealth.net

Dr. Harrington is Vice President and Chief Nursing Informatics Officer for Catholic Health Initiatives (CHI) in Englewood, CO, Texas Region. In this role, she oversees the strategic and operational aspects of clinical information systems for nurses. She is currently building the nursing informatics program at the St. Luke’s Health System, a new acquisition for CHI. Dr. Harrington is certified in Executive Nursing Practice by the American Organization of Nurse Executives. She is also a Certified Professional in Healthcare Quality, a Certified Professional in Healthcare Information & Management Systems, and a Fellow in the Healthcare Information Management System Society. Dr. Harrington speaks nationally and internationally on nursing informatics. Her new book, Usability Evaluation Handbook for Electronic Health Records, was recently published by the Healthcare Information and Management Systems Society. She is board certified in nursing informatics and holds both a DNP and a post-master’s degree in nursing informatics from Duke University in Durham, NC.

Jalyna Cook, MBA, MSN, RN
Email: jcook14@stlukeshealth.org

Ms. Cook currently serves as a Clinical Informatics Nurse at the Catholic Health Initiatives’ St. Luke’s Health System in Houston, TX. Her focus is on the end-user of clinical information systems. She works to make clinical information systems easier to use and more useful. She has also served as a healthcare software superuser for both her current and previous employer, and has provided leadership and support as a clinical nurse leader. Ms. Cook holds a MSN degree with an emphasis in leadership in healthcare systems, and a MBA degree which has given her a foundational understanding of business processes and analytics.

Tracie Buckland, MPA/HSA, BSN, RN
Email: tbuckland@stlukeshealth.org

Ms. Buckland currently serves as a Clinical Informaticist Nurse at the Catholic Health Initiatives’ St. Luke’s Health System in Houston, TX.  Her past experience has included the implementation, training, and optimization of clinical information systems. In this role, she has worked to improve the dialogue between information technology developers and clinical end users, to enhance patient care outcomes, and to increase clinical staff satisfaction. She has also consulted in system designs to facilitate compliance with state and federal regulations. Ms. Buckland has worked in a variety of nursing positions, including staff nurse, unit director, house supervisor, and clinical educator. She received her BSN from Creighton University in Omaha, NE, and her Masters of Public Administration in Health Services Administration Management from the University of San Francisco (CA). 

Jared Boynton, BSN, RN
Email: jboynton@stlukeshealth.org

Jared Boynton currently works as a Clinical Informatics Nurse at the Catholic Health Initiatives’ (CHI) St. Luke’s Health System in Houston, Texas.  He holds a BSN degree and is pursuing a Master’s Degree in Information Technology, with a concentration in Healthcare Informatics. He has served as a mentor and educator of clinical documentation since 2011, working to improve and standardize current processes within the healthcare system at CHI. Prior to becoming a Clinical Informatics Nurse, he served as an educator and trainer to facilitate the implementation of Electronic Health Records (EHR). His experience as both an end user, as well as an Informatics Resource Nurse, have given him unique insights that help to improve and enhance clinical documentation.

References

American Academy of Professional Coders. (2013). Non-pressure chronic ulcers in ICD-10-CM. Retrieved from http://cloud.aapc.com/documents/Non-PressureChronicUlcers_ICD-10-CM.pdf

Centers for Medicare & Medicaid Services and National Center for Health Statistics. (2008). ICD-10-CM Official Guidelines for Coding and Reporting. Retrieved from www.ama-assn.org/resources/doc/cpt/icd9cm_coding_guidelines_08-09_sm.pdf

Centers for Medicare & Medicaid Service. (2013). 2013 ICD-10-CM and GEMS. Retrieved from www.cms.gov/Medicare/Coding/ICD10/2013-ICD-10-CM-and-GEMs.html

Centers for Medicare & Medicaid Services and National Center for Health Statistics. (2014). ICD-10-CM official guidelines for coding and reporting. Retrieved from www.cdc.gov/nchs/data/icd/icd10cm_guidelines_2014.pdf

European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. (2010). Pressure ulcer prevention: Quick reference guide. Retrieved from www.npuap.org/wp-content/uploads/2012/02/Final_Quick_Prevention_for_web_2010.pdf

World Health Organization. (2011). International statistical classification of diseases and related health problems, 10th revision. Retrieved from www.who.int/classifications/icd/ICD10Volume2_en_2010.pdf?ua=1


© 2014 OJIN: The Online Journal of Issues in Nursing
Article published July 1, 2014 

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