How to code 'episode of care' correctly in ICD-10

Q: I was told that the ‘episode of care’ 7th character in ICD-10 doesn’t mean what it appears to mean. That ‘initial’ encounter doesn’t always mean the first encounter. Is that correct?

A: Yes, that’s about the size of it. The three values usually assigned to the 7th character for episode of care are ‘A’ – Initial Encounter, ‘D’ – Subsequent Encounter for injury with routine healing, and ‘S’ – Sequela.
A commonplace and non-coding meaning of the word ‘initial’ is first. And most folks would think there can only be one ‘first’ of something. But that is not what it means here.
The ICD-10 guidelines for coding and reporting of fractures directs you to use the ‘Initial Encounter’ character “while the patient is receiving active treatment for the fracture. Examples of active treatment are surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.”
So a couple of versions of ‘initial’ are found here. ‘While receiving active treatment’ can include the entire hospitalization, not just the first day. That is the longitudinal version. ‘Initial’ can also include the first encounter (or maybe more as above) with a provider other than the first provider to treat the problem. So yes, ICD-10 ‘initial’ means more than one thing, and not necessarily what it may appear to mean.

‘Subsequent’ is a bit more consistent with traditional meanings: “encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.”
If in doubt, look to your guidelines; don’t rely on impressions.

Q: I am increasingly told that I need to spell out my thought process, differentials and concerns in the assessment and plan (A/P) portion of my notes. At the same time, my electronic health record (EHR) exports the comments from this part of the chart into the patient summary-a printed copy of which is given to the patient. Some of my impressions are not things I really want to share with the patient. Where do you go with this?

A: Excellent question, and one that points towards changes in the overall manner in which medical records are used-and to some degree a case of unintended consequences.
Per the Federal Documentation Guidelines: “Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments, and outcomes.

The medical record documents chronologically the care of the patient and is an important element contributing to high-quality care. The medical record facilitates:

• the ability of the physician and other healthcare professionals to evaluate and plan the patient’s immediate treatment, and to monitor his/her health care over time;

• communication and continuity of care among physicians and other healthcare professionals involved in the patient’s care;

• accurate and timely claims review and payment;

• appropriate utilization review and quality of care evaluations; and

• collection of data that may be useful for research and education.

The government was careful to broaden the description of medical record use to include not just the original and principal purpose of communicating among healthcare providers, but to include claims, utilization and research users as well. Those guidelines came from 1997 and are still in effect today.
But now we also have the requirements of meaningful use and the Health Insurance Portability and Accountability Act, whereby patients and others have access to the record. The same information that was once meant to drive care and was written primarily for other healthcare professionals now belongs to a variety of users with different levels of education, understanding and very different interests.
Your question focuses on two elements of the stage 1 meaningful use requirements:

• Provide patients with an electronic copy of their health information, upon request

• Provide clinical summaries for patients for each office visit

As you point out, some EHR’s have been set up to facilitate easier patient summaries by copying data from various parts of the chart. But what information do you want to share, and with whom?

Chart auditors and coding educators have long heard providers comment that the auditors desire to see the overall risk of morbidity and mortality spelled out, or the likelihood or discussion of differentials, could run contrary to medical legal advice. There seems to be some sense that it is better not to state these things explicitly, so that if there is an adverse or unexpected outcome you don’t look wrong, or worse, liable.
That said, in order to give you credit for your medical decision-making, you have to tell them how sick someone is. Remember that the tools the reviewers use depend on their ability to recognize risk, rule-outs, and the language that characterizes the ‘stages’ of the patient’s problems.
There is another kind of risk in speaking too clearly about a prognosis or diagnosis that could have a negative impact on a patient when the patient sees the words in the summary. One view is that if the patient is surprised by what you have written, then perhaps the truth of the situation was not adequately communicated to begin with. More likely the patient did not really hear, or choose to hear, what the provider said.
In the old world of paper charts many providers made their own cryptic notes in the margins, or their own little glyphs somewhere in the history area that told them things they needed to remember, or impressions about the patient: long-winded, drug- seeking, morbid obesity, poor hygiene, or social-type commentaries. This allowed the record to function as it was originally intended: as a note to self.
In the somewhat over-mechanized, over-shared universe of EHRs, perhaps the answer is to find a place in the chart to make those observations that is not intended for sharing or data-mining. Half sentences and your own shorthand should suffice to say what you need or want to remember without having it broadcasted and potentially misunderstood.
The transparency and access to the data in a record seems to be at odds with the privacy and security of this information. Our technology has, to some degree, outpaced our ability to use it. There are more variables to consider now. But in the end you need to balance the needs of the patient, the payer, the regulator, the researcher and your own good judgment.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns.