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Care Mgm't, Communication Curriculum Tools and Diagnostic Coding

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Coding systems that support clinical decision-making, 'measurement and management,' communication, especially about transitions of care and outcomes (acuity-adjusted) become the modus operandi of the new Managed Care.

Given this construct and operational understanding, Dr. Andrew Wiesenthal* recommends the the ICD-10 coding system and that we shoiuld consider moving towards Convergent Medical Terminology (CMT), mapped to the Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT©).  It is more transferable or sharable than the ICD alternative and it is an internationally-accepted standard vocabulary and classification system.  Most importantly, it supports clinical decision-making because it is hierarchical (rather than simply an ICD-like list).  Wiesenthal says it is "a lot closer to doctor- and nurse-speak ... [Example:] If you want to identify a diabetic person with kidney disease, there is a unique naming in Snomed for diabetic neuropathy. It's in the diabetes and the kidney hierarchy."

* Dr. Wiesenthal directs the Deloitte Consulting firm's healthcare practice; prior, he was the Permanente Foundation's Assoc. Exec. Dir. for Information Support.  See: <>

Additional References

The Agency for Healthcare Research and Quality (AHRQ) offers curriculum tools that health care professionals can use to make care safer and improve their communication and teamwork skills. Information on these tools is provided here.

The following is the best and, perhaps the simplest explanation of the reason for ICD-10 that I have found

"ICD-10 is a modern conceptual framework for capturing information about disease and injury and the things we do to treat them. It is designed to be more flexible and expandable than ICD-9, so it can be used to store more precise information, and also be expanded as needed over the years...."

For those who are resisting this typology and vocabulary, "We can accept the mindset of no change, where beyond the known world “there be dragons,” where coded healthcare data is little better than a crude price tag, and improving healthcare through better information gets pushed on to the next generation, like the national debt. Or we can do better. ICD-10 is not perfect, but we don’t need perfect, we only need to be willing to try."

Rhonda Butler (a Senior Clinical Research Analyst with 3M Health Information Systems). "What Can an 18th Century Botanist Teach Us about 21st Century Healthcare?" Posted on November 12, 2014


By Robert Goff; ED, University Physician’s Network, News & Notes [slightly modified] May 21, 2015:

"Doomsdayer and consultants that want to take your money are quick to point to ICD-10’s 68,000 codes, up from the current ICD-9’s mere 17,000.  Yes, you do need to prepare, and you do need to ride-herd on your billing and EHR software companies, but panic?  No reason.

  • Over half of the codes (around 39,000) are in the Injury and Poisoning chapter of ICD-10.  ER Medicine and some limited specialty will be impacted, but most will be unaffected.
  • New 'Axes' of classification, (ways to differentiate a problem) account for some 46% (approximately 31,000) are about where,: i.e., left, right, bilateral, or unspecified.  Ophthalmologists now have quadrupled their codes, but is it that hard to know right from left?
  • Most physicians use regulatory 20-50 codes.  A simple cross walk, expanding for ICD-10 should not be overwhelming.
  • The number of codes does not affect basic documentation (where the real physician work is).
  • Even though the issue of billing and EHR software conversions to ICD-10 remain,  as of last year, most were ready to go, especially in the cloud based systems.  Thus, it is not a bad idea to get from your EHR/Billing software vendor their schedule to be ready for ICD-10, and mark your calendar to confirm their progress.  

See the CMS website for information about ICD-10 transitioning, especially for small groups or solo practices.  See, also specialty specific coding change information. 

Medical Learning Network's–MLN Connects, a Wonderful Intro Video to ICD-10 Coding Basics (YouTube Presentation, Run time: 26 mins. 23 sec.)

Sue Bowman from the American Health Information Management Association (AHIMA) provides a basic introduction to ICD-10 coding with Similarities and differences from ICD-9; ICD-10 code structure; Coding process and examples: 7th character, placeholder "x,” excludes notes, unspecified codes, external cause codes

Target Audience:

Medical coders, physicians, physician office staff, nurses and other non-physician practitioners, provider billing staff, health records staff, vendors, educators, system maintainers, laboratories, and all Medicare FFS providers

For More Information: See Slides from the ICD-10 Coding Basics video [PDF, 295KB]

Note: Since this video was published, HHS issued a rule finalizing October 1, 2015 as the compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10.

ICD-10 delay prompts talk of alternatives - IT Everything, the healthcare IT blog by Modern Healthcare's Joe Conn

For more information, see "Kaiser Permanente's Convergent Medical Terminology" [pdf] frp [failed access 4/3/13] 

If you are a Medscape participant [free to enroll if you have the proper credentials], the following are excellent reviews (CME/CE) on the subject of ICD-10:

"ICD-10 and Clinical Documentation"; "ICD-10: Getting From Here to There -- Navigating the Road Ahead"; "Preparing for ICD-10: Now Is the Time" [Sept. 18, 2014]

Check out the following excellent, eBook/PDF Download: "ICD-10: 5 Steps to Transition Your Pediatric Practice."

It cross-references: "ICD-10-CM Official Guidelines for Coding and Reporting, 2014."

Gadomski A, Wissow LS, Slade E, Jenkins P. "Training Clinicians in Mental Health Communication Skills: Impact on Primary Care Utilization." Academic Pediatrics 2010;10:346-352. [37 references] ProQuest document link


Although it is known that children with mental health problems utilize primary care services more than most other children, it is unknown how addressing mental health problems in primary care affects children's subsequent services utilization. This study measures primary care utilization in the context of a randomized trial of a communication skills training program for primary care clinicians that had a positive impact on child mental health outcomes. From 2002 to 2005, 48 pediatric primary care clinicians at 13 sites in rural upstate New York, urban Maryland, and Washington, DC, were randomized to in-office training or to a control group. Consecutive primary care patients between the ages of 5 and 16 years were screened for mental health problems, as indicated by a possible or probable score on the Strengths and Difficulties Questionnaire (SDQ). For 397 screened children, primary care visits during the next 6 months were identified using chart review and administrative databases. Using generalized estimating equation regression to account for clustering at the clinician level, primary care utilization was compared by tudy group and SDQ status. The number of primary care visits to the trained clinicians did not differ significantly from those made to control clinicians (2.5 for both groups; P = .63). Children with possible or probable SDQ scores made, on average, 0.38 or 0.65 more visits on a per child basis, respectively, during the 6-month follow-up period than SDQ unlikely children (P = .0002). Seeing a trained clinician did not increase subsequent primary care utilization. However, primary care utilization was greater among children with mental health problems as measured by the SDQ. Addressing children's mental health in primary care does not increase the primary care visit burden. Research on overall health services utilization is needed.

Discussion snippet--important because of the generic comments on the limitations of data, especially because of interoperability problems that plague us in health care.

Study limitations include using the SDQ as a screening instrument for mental health problems. Although the SDQ is a reliable and valid screen for identifying children who meet Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, it is not a diagnostic test. ' '37 Clinical diagnosis of mental health problems requires longer diagnostic instruments, which are less feasible in routine primary care practice. Misclassification of mental problems by the SDQ in this study would lead to more conservative estimates and thus could have partially obscured differences.

Other limitations pertain to the variation in medical documentation and administrative databases across the study sites. As described in the methods, we could not consistently capture utilization outside of primary care except for a subset of the participants. Therefore, our visit counts underestimate overall services utilization; however, this limitation applies equally to the study groups as well as the SDQ subsets. Practice variations in coding among sites may have also occurred, but again this limitation would have applied equally to the study groups and the SDQ subsets, as randomization occurred within each site.

Although our efficacy study showed that the training intervention increased skill uptake among providers,2 and that it was associated with a clinical benefit for patients," we still do not know the mechanism by which training was translated into benefit. The analysis we report here suggests that the mechanism does not involve more, or more complex, primary care visits, but we do not know how the content of visits might have changed. Future studies will need to include more comprehensive capture of service utilization before and after exposure to the intervention, and may benefit from longer follow-up periods. Both could be facilitated by increasing adoption of electronic medical records in primary care. Future studies may also need to find ways of directly documenting what trained clinicians do differently, as our study was only able to observe changes in clinicians' interactions with standardized patients.23'24

Chronic care management can become an additional revenue stream for practices, but it requires understanding how to use the codes.  (From Patient Notifications – Scope of Services).  For further information, click 'Modus Operandi.'


Communication-enabled workflow automation. Example: The Spok® system supports hospitals with communication technology. For instance, it allows them to "alert staff faster and with more relevant information than before.”