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Health Services Research & Policy ■ Clinical Practice Management ■ Training & Education ■ Leadership
Health Services Research & Policy
■ Clinical Practice Management
■ Training & Education ■ Leadership

From ICD-9 to ICD-10: How We Converted Coding in a Radiology Department

Learn how one department solved an age-old problem in radiology


Whether you are the type of radiologist who reads the patient's clinical history before looking at the images or the type who waits until after you look at the images to read the history, you value thorough and accurate clinical histories because they improve your ability to interpret studies. In fact, a number of studies dating back to the early 1960s have shown that a relevant clinical history helps to improve the accuracy of a radiologist's interpretation.Despite this, many radiology departments still struggle with an incomplete or unhelpful clinical history entered by the ordering provider.

In October 2015, the Center for Medicare and Medicaid Services (CMS) required all HIPPA covered entities to convert their coding from ICD-9 to ICD-10. This conversion increased the number of potential codes from approximately 15,000 codes to more than 60,000 codes. While ICD-10 allows for collection of more specific data for public health purposes, the fact that the ICD-10 code is tied to billing adds an additional layer of complexity. In radiology, imaging studies are coded based on their final diagnosis. For abnormal studies, this final diagnosis is found in the impression section.However, if the study is normal, the study is coded on the symptoms responsible for the imaging study.These symptoms are usually detailed in the clinical history section of the report.Therefore, if you have inadequate clinical history provided for the indication, the ICD-10 code may be "unspecified" or not specific enough for coding purposes.In these instances, the exam is at risk of not being reimbursed.

In order to avoid "unspecified" final codes for normal studies, we expanded upon the work that our colleagues had initiated within our radiography section. Namely, we enabled the technologists working throughout our department to obtain the clinical history directly from the patient or his or her caregiver and then document the history within the electronic medical record. This information subsequently gets automatically populated into our department-standard, structured radiology reports. We entitled the project "Who-What-When-Where" after the four questions that we have instructed the technologists to ask our patients and/or their caregivers:

1. Who is providing the history?

2. What happened to the patient?

3. When did the patient first start having symptoms?

4. Where is the problem?

Through random audits of the documented clinical histories and focused teaching, we increased the percentage of studies containing a complete clinical history (defined as containing information relating to all four of the "Who-What-When-Where" questions) from 58% at our baseline to more than 95% 8 months later.

The improved clinical histories have been transformational.Not only have our radiologists confirmed that the improved clinical history has increased their ability to make a more specific diagnosis, but we have also heard anecdotes from our clinical colleagues that they are reviewing the radiology reports to get better histories about their patients.

Improving the clinical history in our report was one step we employed to decrease the percentage of reports with an unspecified ICD-10 code.Read our JACR article to see the other strategies we employed to successfully manage the conversion from ICD-9 to ICD-10. 

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Friday, 21 September 2018

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