Synoptic Reporting Can Solve ICD-10 Woes

The medical community has been given a short reprieve. ICD-10-CM, the new system for coding diagnoses, has been pushed back from October 1, 2013 to October, 2014. Considering that the change will mean that the number of diagnosis codes will go from 14,000 to about 155,000 - it's probably for the best that physicians, coders, billers and other healthcare providers are given ample time to prepare. It is a large change, to be sure, one that must be carefully approached - but that doesn't mean it's time for panic or anxiety. Instead, I see this as a possibility to examine and revise the way reports are generated and codes are captured.

mTuitive specializes in synoptic reporting for the healthcare industry - we create these reports using intuitive user interface, intelligent fields and structured data. Pathologists, surgeons and other users of our products complete their reports using computers to navigate through fields and sections that are specifically generated depending on the unique case on which they are reporting. The isolated answers are then able to be used for data mining, quality initiatives or - in this case - in determining the diagnosis of a particular case.

ICD-10-CM has been designed with an internal logic to the structure of its codes. Each digit within the 6-7 digit long code has a separate meaning and unique meaning. As seen below:

structured data format of ICD-10

What this means is that if you are entering the information for each of these 6-7 fields in a report, you can easily derive the correct ICD-10 diagnosis code. Pathologists fill out a pathology report on a possible cancer case by reporting on such things as tumor size, margins, site location, laterality. In traditional reporting, this would be done by dictation and then transcription into an unstructured paragraph. Then someone else would have to go through to find all of these elements in order to determine the correct diagnosis for that biopsy.

But if that pathologist or pathology lab manager used a synoptic reporting solution that captured this structured data - there'd be no need for dictation, transcription, or the redundant process of combing through all those words. Instead, these fields are captured individually and electronically and - when brought together - can automatically produce the correct diagnosis code for that case.

xPert for pathology captures information for ICD-10

Being able to automatically capturing the correct diagnosis code would be hugely beneficial for a number of reasons. Let's look at it specifically from the perspective of a pathologist or a pathology lab manager:

  1. Eliminates lag time for coding - by automatically deriving the ICD-10 code from the pathology report, there is no need for a coder to look at or assign codes to the case.
  2. Ensures improved continuity of care - once the code is derived, automatically at the end of a pathology report without any redundant efforts of other staff, it can be automatically uploaded with the report into the facility's system. That diagnosis will reach the physician faster which means that proper care and treatment will begin sooner.
  3. Improve customer satisfaction - the physicians that receive the pathology reports will be much happier with a clear, concise report that they can easily read and see the clear diagnosis at the end. More satisfied the customer, the more business s/he will give you, the better the word of mouth on your services.

These are just some of the reasons why ICD-10 may not be as worrisome as it could be. Not only has more time been given to prepare, but technologies and practices exist that will make the conversion much easier than most think. That looming deadline of October 1, 2014 doesn't have to be met with peril - just preparation.