Trauma registrars: 13 practical tips for getting up to speed on ICD-10

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The U.S. healthcare system transitioned to ICD-10 on October 1, when Medicare began requiring all claims to use the new code set. This is a challenge for many trauma registrars who already face a significant backlog. Experts say the transition to ICD-10 could cut registrar productivity in half for several months.

What can trauma registrars and trauma data managers do to shorten the learning curve? Recently, several registry experts shared practical tips for coding trauma charts with ICD-10.

1. Focus on your top procedures
“At this point in the game, registrars should really focus their studies, and in my opinion the part to pay attention to is ICD-10-PCS,” said Nathan McWilliams, MPA, RHIA, director of technology/trauma registry at the Pennsylvania Trauma Systems Foundation. “PCS is not only a new coding system, but a new thought process.”

Start by running a report of the most common 25 procedures in your registry, McWilliams suggests. Then concentrate on learning the PCS codes for each of these top procedures. “That way you will not be wasting time learning procedures that you will only rarely be coding.”

2. Memorize the root operations
McWilliams also recommends that registrars devote time to memorizing the 31 medical and surgical root operations of ICD-10-PCS. “How we think about certain terms is a lot different now than it was in ICD-9,” he said. “Take the term removal. In ICD-10, you can’t ‘remove’ an organ anymore because ‘removal’ is specific to a device. You can remove a pacemaker, but not a spleen. The terms excision and resection can also be tricky. If you do a total nephrectomy, it’s a resection, not an excision.”

3. A picture is worth a thousand words
ICD-10 codes are highly specific in terms of anatomy. Kathy Cookman, BS, CSTR, CAISS, owner of KJ Trauma Consulting, LLC, recommends that all trauma registrars obtain a well illustrated anatomy book.

“Look for a good atlas of anatomy, one that includes pictures as well as descriptions,” she said. “We all tend to learn better when we can see the structures we need to get familiar with. Visual learning will be particularly important for registrars who are not clinically oriented.”

4. Use cheat sheets wisely
Quick reference “cheat sheets” are a staple of registry work. But their usefulness is now limited due to the high level of detail required under ICD-10.

“For some ICD-10 codes, your cheat sheet could list all seven characters, but for other codes it won’t be practical to list any more than the first three or four,” said Mike Trelow, vice president at Pomphrey Consulting. “A cheat sheet can help you get to the right tree, but then you need to find the right branch and the right leaf on your own.”

5. Make friends with the index
Trelow believes many registrars fail to take advantage of one of the most useful tools available. “It’s my experience that many registrars do not use the ICD-10 book correctly,” he explained. “When looking for a code, a lot of people go straight to the tables. But the first thing you really should do is look in the index. The index will list the alternatives and tell you where to look for a code within the tables.”

6. Start with AIS
Another strategy for quickly locating ICD-10 codes is to use Abbreviated Injury Scale (AIS) scoring as a starting point. “In most registry software when you enter an AIS code, the system will generate several possible diagnosis codes,” said Debra Myers, MSN, RN, owner of Panoptic Trauma & Quality Consulting. These system-generated suggestions can help registrars quickly narrow down the possibilities. “Starting with AIS is helpful to many registrars because it’s something they are very familiar with.”

7. Stay in the same table
One common mistake is trying to assemble ICD-10 codes from several different tables, Trelow said. “When you identify the correct table for a diagnosis or a procedure, you have to choose all the characters out of that one table,” he said. “We often see people trying to take half of the code out of one table and then the last three characters out of another table. It doesn’t work that way.”

8. Pretend it’s bingo
Cookman echoes the point. “Once you have found the initial code, you can only assign the additional characters by going straight across. You can’t jump up and down to different lines,” she said. “It’s like playing bingo, but with no diagonals and no ‘four corners.’ You can only get bingo by going straight across.”

9. Create a support group
Myers encourages trauma registrars to band together to hone their ICD-10 skills. “I recommend creating a network of people who can turn to each other to ask questions and explore ICD-10 together,” she said. “You can build a support system within your network or within your region or state, especially if your hospital’s registry team is small.”

10. Build ties with clinicians
According to Cookman, most registrars need to increase their understanding of medical procedures to assign correct PCS codes. “One issue that comes up a lot is how to code a chest tube procedure,” she said. “The challenge is not so much finding the right page in the book, but understanding the purpose of the chest tube. People want to call it an ‘insertion’ but the purpose of the procedure is really to drain.” She recommends that managers help establish strong lines of communication between registrars and clinicians. “Registrars need to work with clinical staff to understand the purpose of these procedures.”

11. Leverage clinical documentation specialists
Because ICD-10 requires greater specificity, poor documentation is a bigger problem than ever. Trelow encourages trauma program managers and registry leaders to make greater use of clinical documentation specialists. “They know the rules and they can make recommendations to surgeons on how better to document in the patient chart,” he said. “For example, they might point out that you can’t just document acute respiratory failure, but acute respiratory failure with hypoxia. That in turn will help registrars code more accurately.”

12. Watch for outliers
“Data managers are going to start seeing a lot of extra codes that do not really belong,” Trelow said. “For instance, if you run a report on all your femur fractures, you might see a lot of codes that are off by just one character.” Identifying and investigating these outliers will allow data managers to provide specific guidance to registrars.

13. Validate early and often
Many registry teams perform data validation once a month. According to Myers, performing validation more often will help catch ICD-10 coding errors more quickly. “Doing data validation early on can help prevent registrars from developing unhealthy habits in ICD-10. If a registrar does five charts in a day, a manager or fellow registrar could review one of them,” she said. “Running reports more frequently will also allow the manager to spot patterns that don’t make sense. For example, if you know your program has treated two gunshot wounds during the week but the reports show five, that’s a red flag to review the inputted v-codes.”

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