The Countdown Begins Texas Medicine February 2012

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Symposium on ICD-10 Conversion – February 2012

Tex Med. 2012;108(2):25-28.

  By Liz Carmack and Katie Ford

  Any physician in business for more than a few months knows how difficult it is to work on the business. Keeping pace with caring for patients, insurance company demands, government regulations, and the latest medical technology means there are never enough hours in a day. However, a looming federal deadline is prompting physicians nationwide to look at the bigger picture.

Unless organized medicine can stop it, on Oct. 1, 2013, medical practices, health insurers, and clearinghouses must begin using International Statistical Classification of Diseases and Related Health Problems (ICD)-10 to record all diagnoses and inpatient procedures. Mandated by the U.S. Department of Health and Human Services, the upgrade from ICD-9 will enable doctors' offices to collect and exchange more-detailed patient data. According to the American Academy of Professional Coders (AAPC), only a handful of countries – including the United States and Italy – have yet to adopt ICD-10 as their standard for reporting.

Spurred by its Texas members, the American Medical Association House of Delegates voted at its interim meeting in November to oppose the switch to ICD-10. Delegates adopted a Texas Medical Association resolution that asks AMA to "immediately petition the Centers for Medicare & Medicaid Services to stop implementation and development of all new coding and billing standards including ICD-10."

AMA delegates voted to direct AMA to "vigorously work to stop the implementation of ICD-10 and to reduce its unnecessary and significant burdens on the practice of medicine" and to "work with other national and state medical and informatics associations to assess an appropriate replacement for ICD-9."

"ICD-10 is going to be an absolute disaster in implementation for the physicians of this country," TMA Trustee David Teuscher, MD, of Beaumont, told the AMA Reference Committee on Legislation in urging the committee to support the resolution. "It will be disastrous for those who are our members, and they will ask, 'Why didn't the AMA do something?' Those who are not our members will say, 'See, the AMA didn't do something.' It is time for the AMA to stand up and say 'no' to the implementation of ICD-10."

He said estimated ICD-10 implementation costs for a three-physician practice are $83,000 per doctor and $28,500 per physician for a 10-doctor practice.

AAPC characterizes the transition to ICD-10-CM (clinical modification) for diagnostic code reporting and the implementation of ICD-10-PCS (procedural coding system) for inpatient procedural reporting as the most challenging initiative since the inception of medical coding. The number of diagnostic codes under ICD-10-CM will grow from 13,500 to 69,000. The number of codes for inpatient procedures under ICD-10-PCS will soar from 4,000 to 71,000.

"There's more to ICD-10 than just learning a new code set and upgrading your software," said Stephen Spain, MD, a Tyler family practice physician who sits on AAPC's National Advisory Board. "The transition will affect every aspect of your practice."

Anticipating the transition, stakeholders in the health care industry are working toward widening the electronic highway by upgrading the medical data exchange platform, Health Insurance Portability and Accountability Act (HIPAA), from Version 4010 to 5010. Completed Jan. 1, the HIPAA upgrade allows the industry to adopt ICD-10's new alphanumeric coding, which uses seven character spaces instead of five.

"One of the very first changes was everybody getting on board [with v5010] so we can communicate," Dr. Spain said. "It's as if we've been using a VW Beetle and now we need an eight-passenger van."

Though the v5010 conversion threw a learning curve at physicians and payers, it includes "fixes" for nearly all the implementation workarounds that sprang up under the nearly decade-old 4010 transaction standards. Some of the improvements include more functionality and relevant data behind authorization and referral transactions, enhanced present on admission (POA) reporting on claims, and greater detail behind eligibility transactions, which should reduce follow-up calls between medical practices and payers to clarify coverage.

Anticipated Benefits and Impact

According to Dr. Spain, ICD-10 coding will allow physicians to document patient data in much richer detail. For instance, if a patient has a broken arm, there are specific codes to identify laterality, whether the break occurred in the upper or lower arm, if it was distal or proximal aspect, and whether the injury was a first occurrence or a recurrent issue.

"The nice thing about ICD-10 is that we will be able to spell out very clearly the patient's clinical condition, which is not something we can do with ICD-9," said Rhonda Buckholtz, AAPC vice president for ICD-10 training and education. "The hopes are that we can compare better information. Now, when we do a clinical study, there are often times when we aren't able to compare apples to apples with other countries."

The reams of new data collected will be a gold mine for researchers who want to study disease patterns and trends.

"As more data become available, researchers can put together protocols and practice patterns," Dr. Spain explains. "On a very large scale, we can start to maybe see how some treatments work and maybe which ones don't. We can conduct research on the best way to provide services and what services are the best to provide."

Dr. Spain admits that it may take up to five to 10 years of data collection before such research will be fruitful, but "conversion to ICD-10 is the first step."

Ms. Buckholtz said physicians are in a "wait and see" mode regarding how ICD-10 will affect reimbursement from payers.

"They need to work with their health plans as they make the changes. One thing common across the board is that this has to be revenue neutral," she said. "The health plans can't pay out more in going from ICD-9 to ICD-10. It's now up to doctors to document well enough to get reimbursed for all they are doing in their offices."

Pay-for-performance initiatives will change as well, but it's hard to know how that will be accomplished, Ms. Buckholtz said. In fact, it's probably too early to understand the full extent of how the switch to ICD-10 coding will affect the practice of medicine.

What is clear, however, is that if physicians haven't already begun reading up on ICD-10 coding or haven't taken any steps to prepare their employees or office operations, then the time to start is now.

Physicians can ease the transitioning process by taking a good look at the following areas.

Rethink the Way You Document.

Because ICD-10 codes provide a plethora of specific codes, it demands that physicians be very specific in documentation.

"It might not be easy to remember or to be in the habit of collecting that information," Dr. Spain said. "We have to improve our documentation. The doctor has to learn all this and take the time to gather the information and get it into the record."

For example, today, a physician has only one code choice under ICD-9-CM to record the diagnosis of a fractured clavicle. Under ICD-10-CM, there are 24 codes from which to choose.

"Coders can assign only a diagnosis code that best matches your assessment. The less specific your assessment, the less specific the code assigned," Dr. Spain said. "Here is where the trouble lies: Most payers will not reimburse for nonspecified or unlisted diagnosis codes. The result will be unpaid claims."

He adds that the large variety of ICD-10 codes offered will most profoundly affect orthopedic surgery and emergency medicine.

"For trauma and injury, there will be required codes for mechanism of injury and place of injury," Dr. Spain said. "Those two specialties see so much trauma and injury they will have to carefully document how the injury occurred and where it occurred to submit their services accurately for reimbursement."

Suggested Action

Ms. Buckholtz said physicians should start getting in the habit now by auditing their charts. She recommends reviewing the most frequently used codes and taking a look at the documentation behind some of those codes to see if it includes stringent enough data to accurately assign an ICD-10 code.

TMA Practice Consulting offers coding and documentation audits for physicians to determine if their documentation sufficiently supports the level of service coded and billed. Certified professional coders and medical auditors perform the reviews. (See "TMA Can Help Your Practice Switch to ICD-10.")

Practices can opt for a comprehensive audit, which is approved for 20 AMA PRA Category 1 Credits. The comprehensive audit concludes with a formal, written report that offers:   

  • An executive summary of the physician's practice.
  • An overview of audit findings, including coding trends. errors, and opportunities for improvement.
  • A summary of each medical record, indicating whether it was coded appropriately, along with the reason(s) for the determination. (Legibility, timing of chart authentication, diagnosis identification, practice fees, and billing discrepancies are also covered in this section.)
  • An evaluation and management (E&M) code utilization analysis, compared to specialty benchmarks, per provider. This includes graph illustrations and a breakdown of charges, percent code distributions compared to other providers in Texas, the calculated variance, redistribution of frequency and charges, and charge differentials.
  • Educational tools and resources, including coding guidelines, articles, and other reference materials.  

In lieu of a comprehensive audit, physicians can sign up for a more affordable medical records and coding "checkup," which is an abbreviated review of claims coding and medical record documentation. A checkup provides a glimpse into a practice's coding techniques and allows physicians to realize through visual illustrations the underlying trends that directly affect practice revenue.

"We can design elective coding and documentation reviews to fit within every practice's budget; it's not a one-service-fits-all or a flat fee," said TMA practice management consultant Heather Bettridge. Ms. Bettridge is a TMA practice management consultant who is certified as a professional coder and a professional medical auditor.

Review Office Technology Upgrade Requirements

Physicians should expect to upgrade their practice management and electronic health record (EHR) systems to accommodate the new ICD-10 code sets. You might need new hardware, as well.

"It's important for the physician to look at what their overall goals and plans are for technology upgrades first," said Shannon Moore, director of health information technology for TMA. "For instance, if they are getting a new practice management system, many electronic health record companies offer a companion practice management system that is included in the price of the EHR. What's nice about this is you don't have to integrate two disparate systems."

Suggested Action

Ms. Moore said that although TMA does not recommend physicians choose a combined practice management system and EHR software package, doctors moving toward implementing an EHR should compare the benefits against the costs of having two different systems. An electronic medical record system cost-comparison tool, which doesn't include potential hardware costs, is available to members on the TMA website.

When considering a practice's hardware needs, "you always want to buy above your current needs," Ms. Moore said. "Get a little bit more to allow for growth and additional capability."

Train the Entire Office

"Training and education are going to be key," Ms. Buckholtz said. "Almost every single person in the practice will need some training in ICD-10 to perform his or her job."

This spring, TMA is hosting a series of hands-on ICD-10 training workshops. Practices also can arrange on-site ICD-10 training sessions with a TMA practice management consultant.

"If there is not a certified coder in the office, the physician ought to look into getting staff certified as professional coders," Dr. Spain said.   

Nine Steps to ICD-10 Compliance

The ICD-10 compliance deadline is less than two years out on the horizon. AMA published the "ICD-10 Timeline: Meeting the Compliance Date" to help medical offices prioritize their preparations. The timeline's nine critical steps require a minimum of 22 months to complete, so most physician offices should already be taking action to ensure that staff, office technology, and internal operations are ready to make the switch on Oct. 1, 2013.

The estimated completion times in the AMA timeline apply to larger practices, according to Dr. Spain. Smaller practices should be able to move faster through the nine steps.

Step 1: Conduct impact analysis (minimum estimated time to complete: three months). Medical offices should review information about the ICD-10 code set and gain a basic understanding of the differences between ICD-9 and ICD-10. They then should conduct an impact analysis on their business practices and systems to determine how the switch will affect operations. Next, they should complete an inventory of all systems, both electronic and manual, that use ICD-9 codes. By conducting this review as early as possible, health care providers will be able to fully understand the scope of work ahead and prioritize important tasks.

Step 2: Contact vendors (minimum time to complete: two months). Physicians should contact their vendors to learn about the dates, expected costs, and other specific details regarding the installation of the ICD-10 upgrades to their computer systems. This could be included in the discussions they have about upgrading to v5010 HIPAA transactions.

"Make sure vendors are already testing v5010 transmissions," Dr. Spain said.

Physicians should ask vendors if they'll maintain updates to the ICD-9 and ICD-10 code sets during the transition period and if they'll provide any "crosswalk" tools between the two code sets.

"Have a conversation about whether the company will continue to support this system throughout the conversion," Ms. Moore said. "You don't want to be caught off guard because your practice management software company couldn't keep up."

Step 3: Contact payers, billing service, and clearinghouse (minimum time to complete: two months). Medical offices should reach out to their payers, billing services, and clearinghouses to learn when their ICD-10 upgrades will be completed and when they'll be ready to begin testing transactions using the new codes. Likewise, doctors should let these groups know when they expect to have their office system upgrades installed.

Moving to the ICD-10 code set may require renegotiation of contracts, so physician offices should ask about changes these groups plan to make to their processes for reviews, audits, coverage, and medical policies, as well as how those changes will affect coverage decisions and reporting requirements.

"It is important for doctors to work with health plans so that they continue to have feasible contracts for payment after Oct. 1, 2013," said Ms. Buckholtz. "Many payments are tied to quality reporting, performance, and medical necessity. Physicians will need to work with health plans to avoid any disruptions or decreased revenue."

Step 4: Install vendor upgrades (minimum time to complete: three months). Because the timing of system upgrades to a medical office is dependent upon the readiness of the vendors serving that office, it's important for physician office staff to talk with vendors about upgrades early on, even as vendors are preparing for the v5010 upgrade. This also may help reduce ICD-10 transition costs. Other systems, such as quality-reporting tools and public health reporting, should be upgraded at this time, as well.

"Be sure to ask your vendor about quality-reporting tools," Ms. Moore said. "Make sure that any quality-reporting tools you are using are integrated and interfaced with the ICD-10 code set, so those quality reports are translated correctly to the Centers for Medicare & Medicaid Services or to the Centers for Disease Control and Prevention."

Step 5: Conduct internal testing (minimum time to complete: two months). Once the upgrades are complete, staff should conduct internal testing to ensure the upgraded systems can generate transactions with the ICD-10 codes. Practices should allow extra time for troubleshooting and working with vendors to address any obstacles.

Step 6: Update internal processes (minimum time to complete: two months). Internal processes that support coding need to be updated, as well. These include superbills, encounter forms, quality data collection forms, and public health data collection forms. Physician offices should take this time to review clinical documentation to ensure it captures the necessary details of patient diagnoses.

"The concept of the one-page superbill may pretty soon be outmoded," Dr. Spain said. "When your diagnosis set has expanded so dramatically, you probably can't list them all to make it readable. Most physicians will probably want to keep a cheat sheet of the most common diagnoses they use, so they don't have to pick up the ICD-10 manual every 10 minutes."

Dr. Spain said some physicians may feel as if the switch to ICD-10 is pushing them to adopt EHR systems.

"If you're part of a big group, you won't have much choice but to go with the flow and adapt (if they adopt an EHR)," he said. "If you're by yourself and plan to retire in four or five years, you may just do what you can to get by without investing a lot."

To help physicians anticipate the changes ICD-10 will bring to the office environment, the AAPC website includes an illustration that shows how all parts of a typical practice will be affected -- from revising privacy policies and creating and ordering new forms to ensuring your coding staff has a more detailed knowledge of anatomy and medical terminology.

Step 7: Conduct staff training (minimum time to complete: two months). The transition to ICD-10 is definitely an "all hands on deck" event. Training should be readily available for every staff member. The training times should be staggered to prevent down time in the practice. Coding staff may want time to practice using the ICD-10 code set on sample claims, such as current claims, before the compliance date.

"Complete training in phases, and make sure to address all staff training needs," Ms. Buckholtz said.

ICD-10 training services and resources are on the TMA website. Additional ICD-10 information and guidance are available through multiple Texas health insurers and the Centers for Medicare & Medicaid Services. (See "Insurers Prepare for ICD-10.")

Step 8: Conduct external testing with clearinghouses, billing services, and payers (minimum time to complete: six months). During this step, offices should conduct external testing with their payers and billing services or clearinghouses to ensure that they can properly send and receive ICD-10 codes in transactions.

Medical practices should expect possible increases in rejected claims or a slowdown in their coders' and billers' productivity during this step. It is important to undertake this testing in time to work out any remaining issues and to give staff time to work with the codes before the deadline.

Step 9: Make the switch to ICD-10 (deadline: Oct. 1, 2013). All services and discharges on or after Oct. 1, 2013, must be coded with the new ICD-10 code set. ICD-10 codes will not be accepted before Oct. 1. Moreover, payers will reject transactions that continue to use the ICD-9 codes after Oct. 1, 2013.

Medical offices should continue to monitor the submission and receipt of transactions to ensure everything is working properly. They also should review reimbursements to determine if the amounts align with the services billed.

"If there are any problems, talk to your vendor immediately," Ms. Moore said. 

Readiness Challenges

Unquestionably, the transition to ICD-10 will be time-consuming and multifaceted, said Ms. Bettridge. Its implementation will add layers of complexity to daily operations.

"Physicians and staff will have to juggle this change along with all the other daily operational challenges they already face," she said. "For many practices, the cost of implementation is still uncertain and they may experience difficulty in getting staff and physicians on board. Underlying all of this is the real possibility of revenue loss."

Dr. Spain echoes these sentiments.

"For most of us, [the transition to ICD-10] has taken a backseat to keeping abreast of medical changes. Yet, this is probably the most profound, far-reaching coding and billing change that there's ever been," he said. "I think physicians will be surprised at how pervasive the changes will be and how much it is going to affect their work flow."

  Liz Carmack and Katie Ford are freelance writers in Austin.  

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November 13, 2017

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