After years of pushbacks, alterations, and delays, ICD-10 has finally arrived on the shores of the United States. An explosion of diagnosis codes, ICD-10-CM (as its American flavor is known) is both a blessing and a curse. The blessing is that the codes are actually more specific to diagnoses, including laterality and other such specific issues with the patient. That means the information being entered is more specific, easier to track, and easier to use for Big Data purposes. The curse is that it's a ridiculously large number of changes, about 50,000 extra codes for coders and admins to learn and apply to the various paperwork with which they must deal. As of October 1, 2015 everyone will have to switch over and start using ICD-10-CM instead of ICD-9-CM. It's a massive undertaking that has many people fretting about how this transition will occur. One group of people that shouldn't fret? OpNote customers.
For the uninitiated, OpNote is mTuitive's synoptic reporting solution for surgery. Instead of dictating and transcribing a postoperative report, users simply open up a default report and make small changes that pertain to that particular patient or procedure. This saves time, improves accuracy and completeness of reports, and greatly accelerates the turnaround time for reimbursement. Included in OpNote are codes for the procedure - specifically procedure codes (CPT) and diagnosis codes (ICD). Those who are familiar with the product see that their inclusion helps jumpstart the coding and billing process. Many people using OpNote had questions about the readiness of the product with the ICD-10 conversion, and many others who don't use the product may wish to know how mTuitive is handling this jump to a new set of codes. Hopefully, this blog post will elucidate the process and allay any fears people may have about this giant change in healthcare.
mTuitive has licensed Intelligent Medical Objects (IMO) to be the carrier for its ICD-10 codes. We've been using them in Canada with ICD-10-CA for a few years, and are already to make the switch over to the new system when October 1 hits. There will be some changes to how people select codes, but mostly it will be a huge improvement that will actually make choosing diagnosis codes easier, even though there are now much more from which to choose. Efforts began early in 2015 to prepare for this switch over and we are now ready to accommodate the new codes. What IMO brings to the table is a highly searchable database of diagnosis and procedural codes. Imagine a database where the vernacular that surgeons actually use are able to be found, without having to exactly match the language of the ICD or CPT code. That is what IMO brings, where a surgeon can look up "gall stones" as a diagnosis and get the correct ICD-10 code instead of having to search for "Calculus of gallbladder" or something equally antiquarian.
This dynamic search will speed up finding diagnoses without relying on knowing ICD codes or the exact language of the description. We know in the past that has been a stumbling block to finding diagnoses in OpNote, and with IMO's search, it's much easier to find what you're looking for. OpNote will automatically build up a "Common" tab that reflects the most commonly chosen diagnoses by each particular surgeon. This "Common" tab will also speed up putting in diagnoses and further enable surgeons to complete their reports in a timely fashion in between cases, meaning a faster sign out, faster import into EHRs, and faster reimbursement for the facility (ASC, hospitals, private doctors' offices, etc.).
The other place where the new codes will come into play is in the surgeons' defaults. Defaults are the most common procedures filled out with the most common responses, including the most common diagnosis codes. For those filling out reports, there's a handy conversion wizard we've launched that will quickly allow surgeons to choose the new default diagnosis with ICD-10. Doctors will be able to select the most appropriate diagnosis codes (with some suggestions baked in based on the ICD-9 code that was previously in there) and then never have to worry about updating the codes again.
At mTuitive, we're dedicated to staying up to date with the most current coding and concepts in healthcare. Hopefully this blog post has demonstrated not only our readiness for ICD-10-CM for OpNote users, but also our ability to change with the times and remain able to capture vital information in operative reports.