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ICD-10 Changes Everything

Assigning an accurate diagnosis code occurs in almost every corner of a medical practice. The October 2014 implementation for the new ICD-10 coding system is likely to cause turmoil in some medical clinics and groups.

In this article, you will learn how to:

  • Estimate training needs for ICD-10
  • Identify steps to incorporate frequently used diagnosis codes
  • Recognize required contingency funding related to ICD-10 changes
  • Develop accountability for the transition to ICD-10

The task of assigning diagnosis codes occurs in almost every corner of a practice: from superbills to laboratory orders. Despite advanced warnings – the Centers for Medicare & Medicaid Services (CMS) formally announced in 2009 its plans for a 2013 conversion to ICD-10 and shortly thereafter issued a one-year delay – the implementation of the new coding system is likely to wreak short-term havoc in medical practices.

The ICD-10 scale numbers nearly 70,000 codes, a five-fold increase over the current list of 14,000 diagnosis codes available today. The conversion is indeed a necessity – the current list cannot accommodate any further updates, having run out of characters. This shortcoming has resulted in a scale that is disorganized and, frequently, too nebulous to meet today’s needs. As a result, the current scale’s “unspecified” and “not elsewhere classed” descriptions seem to have become the norm rather than the exception. Worse, the inadequacies of the ICD-9 code set have led to a multitude of claims denials by insurance companies based on medical necessity (or, more aptly, the lack thereof). The result? Possible frustration, rework and financial losses for medical practices.

Despite the clear need for a new and more expansive scale, expect that the transition will be difficult and costly, especially in the beginning. The new scale calls for more detailed documentation in order to assign diagnosis codes of 3 to 7 alpha-numeric digits in contrast to the current 3 to 5 digits. Unfortunately, the vast majority of codes in use today do not directly map to an equivalent ICD-10 code (see Figure 1), meaning that physicians, providers and practice employees (as well as payers and vendors) will need to start from the ground up with the new system.

Figure 1: ICD-9 to ICD-10 Mapping Categories
Figure 1: ICD-9 to ICD-10 Mapping Categories

With the October 1, 2014, go-live date for ICD-10 approaching, focus on these key areas to get prepared:

Determine the impact. Education and training for coders is readily available, but don’t stop with these employees. Indeed, analyze your entire practice to understand the full impact of the new scale. These areas include, but are not limited to, the pre-authorization and referral process (which is typically driven by diagnosis codes), procedure and surgery coding, charge capture, laboratory and imaging orders, pay-for-performance programs (e.g., Physician Quality Reporting System) and denial management in the business office. You’ll set the stage for a smoother transition if all physicians, providers and employees in the practice have the training to become confident users of the new scale.

Review documentation requirements. Where many practices can expect to struggle most with ICD-10 is not the scale itself but in supplying the additional documentation required to assign the correct code. Unlike the current system, ICD-10 codes hinge on disease etiology, healing stages, episodes of care and anatomic site. In addition to general ICD-10 training, you, as a physician, would be wise to seek out specialty-specific education about using the new scale. Assess examples posted by experts in your specialty to determine opportunities to improve your own documentation.

Review common codes. Don’t let the enormity of the new structure frazzle you. Extract a report of the top 50 diagnosis codes you use now, and then map them to the new scale. Create a map in writing, noting that you can certainly reference the General Equivalence Mappings (GEMS), a crosswalk tool created by the government to aid in the transition to the new scale. Although there may be a few revisions to come, go ahead and purchase the ICD-10 manual now. The approximately $100 it costs will be a good investment in preparation. Ask every employee whose duties will be affected by the new scale (including coders, billers, and pre-authorization nurses) to convert at least three transactions every week between now and next fall. Although you won’t need the ICD-10 today, this real-world experience of assigning the new codes will help prepare staff for the day when ICD-10 prowess really matters.

Create a plan. After you’ve had a chance to understand the impact on your practice, develop an action plan. Assign accountability to one person (consider offering a small bonus for their efforts, if successful) – and keep a written record of the project’s evolution. Although paper is certainly an option, consider a project management software program like to keep everyone on the same page – doing so will facilitate your ability to monitor progress and, perhaps, avoid missteps.

Testing. There is no transition period between ICD-9 and ICD-10; insurers will start accepting claims with the new codes on October 1, 2014 – and not one day earlier. While the deadline allows stakeholders to focus on their needs, it makes the potential problems too difficult to predict before cash flow is on the line. Seek out your insurers that allow you to file pre-October 1 test claims – and test, test, test.

Lean on vendors. The companies with which you contract for information systems are most certainly aware of the new scale, but don’t expect all of them to be well prepared. Start now by communicating with your vendors regarding their ICD-10 readiness, particularly your billing clearinghouse, as well as the vendors of your practice management and electronic health records systems. They should demonstrate the ability to work with ICD-10 codes by or before August 1, 2014, so you will have 60 days to pinpoint and fix any challenges.

Get money. With the planned “big bang” implementation of ICD-10, there are sure to be glitches that could have been anticipated had CMS opted for a phased-in approach. Because the majority of your revenue is tied to insurance claims, which rely on ICD-10 codes, expect that your practice’s cash flow will be adversely impacted during the initial days. Even if the consequences last only a week or two, it’s important to have access to funds that will keep your business running smoothly during this time. Confer with your banker to ensure that a line of credit is open. Given the challenges, consider limiting employees’ time-off requests between mid-October (when claims will start to return with payments or as denials) and late November. Well before October, you may need to find funds to support the impact of the transition on your technology systems. Review your vendor contracts carefully; if regulatory compliance is not included in your agreements, you may find yourself on the hook for system upgrades or the addition of features to support ICD-10.

Stay focused. Alarm bells are already going off about ICD-10, but it’s important to recognize that physicians and hospitals will be affected differently by the new system. Physicians can still utilize CPT® codes, while hospitals must change their procedure coding system for all inpatient services in addition to adopting the new diagnosis coding scale. While you can offer emotional support to your colleagues who run hospital inpatient departments, don’t let their anxiety bring you down.

Ultimately, ICD-10 will create value for physicians: You will be able to more precisely describe both the care you provide and the acuity of your patients. The completeness of the scale, which allows you to better display the complexity of your care, will result in fewer denials, more advantageous reimbursement and better cash flow. In the interim, however, get ready for turmoil as ICD-10 will indeed change everything.

Pearl 02/03/14

Dollars and Sense
Arrange in advance to obtain an accessible line of credit with your bank. Although the financial consequences of transitioning to ICD-10 may only short-term, your practice’s cash may be depressed temporarily. Denials and delays can spike while staff learn to work with the new documentation requirements. You may also be faced with cash needs to upgrade information systems and other technology systems to work with ICD-10.

United States