ICD-10 Countdown Continued

TMA Offers Assistance for ICD-10 Prep  

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Cover Story — May 2014

Tex Med. 2014;110(5):22-29. 

By Kara Nuzback

Practices across the nation now have more than a year to prepare for ICD-10 implementation. 

The evening of March 31, the Senate finalized passage of the Protecting Access to Medicare Act, narrowly averting a drastic 24-percent cut to Medicare physician payments and pushing the ICD-10 implementation deadline one year to Oct. 1, 2015. This represents the third deadline extension for ICD-10.

Even with extra time, getting your practice in full swing for ICD-10 is no small feat. You and your staff need to learn the new system and coordinate with payers, claims clearinghouses, billing companies, and electronic health record vendors well before October 2015 to make sure the government and insurers continue paying you for treating patients.

The new coding system will yield more clinical data but require more precise and extensive documentation with each patient encounter. With ICD-10 containing more than five times the number of codes as ICD-9 and incorporating a completely different structure, the new code set will require broad changes for medical groups. Failure to get ready could result in a financial nightmare. 

The Centers for Medicare & Medicaid Services (CMS) mandated that physician practices, other practitioners, clearinghouses, and health plans use ICD-10, developed by the World Health Organization. But a Medical Group Management Association survey titled "ICD-10 Implementation Study" shows that as of January, more than 40 percent of physicians had not reached the halfway point in the implementation process, and 38 percent had not started at all. 

David Fleeger, MD, an Austin colorectal surgeon who serves on the Texas Medical Association Board of Trustees, says the delay will be helpful for many practices. 

"The good news is, I think a significant number of physicians weren't prepared for this," he said. 

Dr. Fleeger says the delay is frustrating and will cost more money for health care organizations that were already preparing for the switch. 

"We're going to need to retrain employees closer to the time of actual implementation," he said.

Dr. Fleeger's practice began preparing for the transition last fall and ramped up its efforts in January, expecting ICD-10 to take effect this Oct. 1. He started by creating a detailed timeline to systematically implement components of the transition. Dr. Fleeger says the hardest part of the transition is making sure everyone in the practice understands the magnitude of the project. 

Experts warn that planning for ICD-10 conversion is intricate and time-consuming. The American Medical Association estimates preparations take about 22 months. (See "Prepare for ICD-10 Now.")

In short, you and your staff should now be contacting 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. If you're not at that point yet, you and your staff need to get started. TMA offers webinars and tools to help practices get up to speed and make a smooth transition. (See "Don't Be Denied Payment.")

Prepare for Liftoff

Before Oct. 1, 2015, practices must install and test new software; train physicians, staff members, and administrators; develop new practice policies and guidelines; and update paperwork and forms. 

With so many short-term projects on practices' plates, long-term projects are easy to put off, Dr. Fleeger says. 

To help ensure his group practice, Central Texas Colon and Rectal Surgeons, experiences a seamless switch, he sent key personnel — the lead biller and coder, the office manager, and administrators — to TMA's ICD-10 training sessions early in the process. 

The practice's coders then took the top 50 ICD-9 codes and converted them into 150 ICD-10 codes. Practice staff also performed chart audits to determine whether sufficient detail was available to allow for ICD-10 coding.

The staff also identified sources to help physicians understand what is new and different to allow for more specific coding and documentation.

Dr. Fleeger hired an independent consultant, who was scheduled to begin helping the practice in its final stages of the transition this summer. He says he is now trying to arrange for the consultant to come to the practice closer to the 2015 implementation date.

"We want to be prepared. At the same time, we anticipate there will be hiccups," he said.

Sterling Ray, MD, chief of hospitalist services for Seton Healthcare Family in Austin, says he is one of three Seton physicians championing the ICD-10 switch. 

Dr. Ray says his staff prepared to make the transition before the end of this year.

He and two other Seton physicians took a comprehensive ICD-10 education course, and they now teach other physicians at the hospital about the new coding structure in a three-hour class.

"It's really a two-part training curriculum," he said. The first part covers general information about ICD-10, and the second focuses on coding for different specialties.

Dr. Ray expects to complete physician training by the end of May but says he plans to offer the curriculum well after the ICD-10 deadline to provide "ongoing education." 

Plan for a Rainy Day

Though he has not encountered any major difficulties making the switch to ICD-10, Dr. Ray says the change will likely mean a heavy workload for the coding department because the practice's CD-10 contains so many new codes. (See "There's a Code for That.")

Dr. Ray says procedural codes are complicated, and specialists who perform procedures, such as surgeons, must change their practice habits to create more specific documentation. 

"I think some specialists will have a harder time than others," he said.

Dr. Ray also worries some medical groups may be better prepared for the ICD-10 deadline based on their ability to pay for consultants with more robust training platforms. 

"There is an expense to this training that is easier for larger institutions to absorb," he said.

The American Health Information Management Association estimates coders should devote an average of 16 hours of training to ICD-10 diagnosis coding and 10 hours to additional practice. According to cost predictions by Nachimson Advisors, LLC, in "The Cost of Implementing ICD-10 for Physician Practices," released in February, consultants who train small practices say they charge about $1,500 a day for two to three days of training.

Dr. Ray says a standard education curriculum endorsed by CMS would have leveled the playing field for practices that could not afford extensive training to match that provided by hospitals.

"I like our platform and feel as though it will position us for success, but we looked at several consultants, and there is a lot of variability in how they approach ICD-10 training," he said. 

Dr. Ray also expects some errors and confusion in the claims process. 

"We may see a surge in denials, or there may be an increased payment lag," he said. 

According to Nachimson Advisors, a typical small practice should expect to spend $19,500 on cash flow disruptions. Medium practices should expect to devote $65,000, and large practices could spend up to $650,000 on cash flow disruptions.

Dr. Fleeger notes his private practice has cash reserves in place in case it encounters payment disruptions. 

"Obviously, we deal with scores of different plans and contracts … that could make cash flow a problem," he said. "We've got a line of credit in place if we need it."

CMS announced in February it would begin end-to-end ICD-10 testing the week of July 21-25 with a select cross-section of 500 health professionals. End-to-end testing encompasses submitting test claims with ICD-10 codes to CMS.

In March, CMS called for volunteer clearinghouses and physicians nationwide to participate in the testing. Find more information about testing in MLN Matters No. SE1409 Revised.

Margaret Jarvis, a Blue Cross and Blue Shield of Texas (BCBSTX) spokesperson, says the payer has been working to ensure physicians won't face payment glitches. 

BCBSTX, one of several payers in the state, has a network of 51,000 physicians and more than 650 hospitals in Texas. Ms. Jarvis says BCBSTX has been upgrading software and conducting internal testing for the past two years. At press time, she said internal and external end-to-end testing would begin in April.

"We have completed program impact assessments, requirements, and most design and development activities," she said. "BCBSTX is on schedule with the testing process and in fact intends to conduct testing well in advance of the revised implementation date."

She says BCBSTX will be prepared to process claims in time for the ICD-10 deadline. For more information on ICD-10 testing at BCBSTX, visit http://bit.ly/Puvvlk.

Kicking the Can

The ICD-10 transition comes with a hefty price tag. 

A 2008 AMA-commissioned report by Nachimson Advisors estimated a typical small practice with three physicians and two administrative staff would spend about $83,000 on ICD-10 implementation. Nachimson updated its cost predictions in February and now says the same small practice could spend up to $226,000 transitioning to ICD-10. 

The cost to a midsize practice with 10 physicians, six administrative staff, and one full-time coder ranges from $213,000 to $824,000, and the cost for a large practice with 100 physicians and 10 full-time coders could reach up to $8 million, Nachimson predicts. 

In January 2009, CMS pushed the ICD-10 implementation date from Oct. 1, 2011, to Oct. 1, 2013. Then, in November 2011, TMA delegates convinced AMA's House of Delegates to publicly oppose ICD-10. As a result, AMA approved a resolution urging CMS not to adopt ICD-10 at all because of its "bureaucratic and financial burden on physicians," saying it would force many small practices to shut their doors.

After AMA passed its resolution, CMS delayed implementation another year, pushing the new deadline to this October. Congress' March 31 vote marks the third extension of the ICD-10 deadline.

TMA continues to oppose ICD-10 implementation but is committed to helping you get ready for the new coding system. (See "TMA, Physicians: Wait for ICD-11.")

According to the World Health Organization, ICD-11 is due for completion in 2017. Dr. Fleeger says the latest delay could give opponents of ICD-10 more time to urge CMS to wait for ICD-11. 

"Maybe the ball is up in the air a little bit more than we thought it was," he said. 

Silver Linings

Dr. Fleeger says epidemiologists and institutions that study health and disease will benefit from the information collected using ICD-10. Whether the code set will prove useful for physicians in an average practice, he says, remains to be seen. 

"I'm a little skeptical, but having more information about your patients is never a bad thing," he said.

A CMS spokesperson said in an email, "ICD-9 is more than 30 years old and contains outdated, obsolete terms that are inconsistent with current medical practice. ICD-10 codes will provide better support for patient care and improve management, quality measurement, and analytics."

The spokesperson says ICD-10 will allow for easier research of patients' medical history and long-term tracking of illnesses. Ultimately, the new coding system will result in more accurate and complete clinical decisions from improved data collection and evaluation, CMS says.

The upside for physicians making the switch, Dr. Ray says, is that technology has surpassed what ICD-9 can codify, and technology will only continue to evolve.

"We've really been challenged with the current coding nomenclature," he said. "Having an expanded scale … is going to be ideal."

Because ICD-10 is more specific, physicians can now look at a code and know exactly how to care for a patient, without even glancing at supporting documents, he says. He expects the increased accuracy of ICD-10 will reduce the number of rejected charges, expedite payment turnaround, and improve measurement capabilities.

"Essentially, we can track how well we perform patient care," he said.

Many countries have already made the switch to ICD-10, including France, Australia, Canada, China, Germany, South Africa, the Netherlands, and Sweden. Dr. Ray says it's time to level the playing field. 

"The world is so much more connected now," he said. "Being able to speak the same language will be key in how we approach patient care."

Kara Nuzback can be reached by telephone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email


Don't Be Denied Payment

If your practice is behind in ICD-10 implementation, it's time to set the process in motion, and TMA can assist with transition software, webinars, and online training courses.

"ICD-10 Now! How and Why," an on-demand webinar from TMA, offers a detailed look at everything you need to know and do to prepare for ICD-10. Another on-demand webinar, "ICD-10 Starts With Physicians," targets physicians, office managers, and coders. It highlights the ICD-10 transition process, the code structure, and the impact of ICD-10 on your practice. 

TMA's Ready10 Code Translation Component software helps reduce the time it takes to convert ICD-9 codes to ICD-10. The software can generate a medical practice's top 50 codes in minutes and create coding flash cards of most-commonly-used diagnoses that you can share with your staff. Ready10 also allows you and your staff to search ICD-9 and ICD-10 by code, description, and keyword; create and save a list of commonly used codes; and develop and print quick-reference conversion lists. 

Ready10 Basic from TMA addresses every aspect of preparation for the code switch, including policies, procedures, processes, relationships with other organizations, and technology. The toolkit comes with two licenses for Ready10 Code Translation Component software and instruction videos. 

TMA also offers a three-hour Specialty-Specific ICD-10 Documentation Training course online, which allows physicians to tailor their ICD-10 training to 21 different practice types. Register for the webinars, and purchase ICD-10 software and toolkits online.

You can view a four-minute demo of the toolkit and watch interviews with TMA staff about the new coding system in the ICD-10 Video Vault

Be sure to bookmark TMA's ICD-10 resource page for the latest news and resources. 

Use the TMA Knowledge Center alert service to stay up-to-date on the latest ICD-10 developments. Complete the online form to receive alerts from the TMA Knowledge Center.

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Prepare for ICD-10 Now 

The American Medical Association's "ICD-10 Timeline: Meeting the Compliance Date" outlines the critical steps to implementation and estimates how many months you should allot to complete each step.

6 Months  

  • Conduct external testing with clearinghouses, billing services, and payers. 

3 Months  

  • Conduct an impact analysis on business practices and systems, and inventory all ICD-9 systems. 
  • Upgrade other systems, such as quality reporting and public health reporting tools. 

2 Months  

  • Contact vendors regarding the dates and expected costs of installing the ICD-10 electronic upgrades.
  • Contact payers, billing services, and clearinghouses about ICD-10 upgrade completion and testing transactions. 
  • Conduct internal testing and allow extra time for troubleshooting and working with vendors to address any obstacles. 
  • Update internal processes that support coding, and review clinical documentation.
  • Train every staff member.  

Oct. 1, 2015  

  • Switch to ICD-10. Payers will not accept claims with ICD-10 codes before Oct. 1, 2015, and will reject transactions that use ICD-9 codes after Oct. 1, 2015.  

Source: American Medical Association.

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There's a Code for That

With more than five times the number of codes as ICD-9, physicians can be incredibly specific in their diagnoses using the ICD-10 code set. Whereas ICD-9 might not have allowed you to specify your patient was struck by lightning while crocheting in the swimming pool of a mobile home, ICD-10 has a code for that.

Here are a few code combinations that might raise an eyebrow:  

  • W5611XD: Bitten by sea lion, subsequent encounter
  • Y92026: Swimming-pool of mobile home as the place of occurrence of the external cause
  • T7501XA: Shock due to being struck by lightning, initial encounter
  • Y93D1: Activity, knitting and crocheting
  • W5922XS: Struck by turtle, sequela
  • Y92253: Opera house as the place of occurrence of the external cause
  • W2202XA: Walked into a lamppost, initial encounter
  • W201XXA: Struck by object due to collapse of building, initial encounter
  • Y9272: Chicken coop as the place of occurrence of the external cause

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TMA, Physicians: Wait for ICD-11 

The Texas Medical Association continues to work to stop ICD-10 implementation. In November 2011, TMA delegates convinced the American Medical Association House of Delegates to publicly oppose ICD-10. AMA then approved a resolution urging the Centers for Medicare & Medicaid Services (CMS) not to adopt ICD-10, calling it a bureaucratic and financial burden on physicians and saying it would force many small practices out of business.

After AMA passed its resolution, CMS delayed ICD-10 implementation for one year, to Oct. 1, 2014. On March 31, Congress once again pushed the deadline to Oct. 1, 2015, with passage of HR 4302, the Protecting Access to Medicare Act of 2014.

Dawn Buckingham, MD, an Austin ophthalmologist and chair of TMA's Council on Legislation, says in early March she visited with legislators in Washington, D.C., to urge support for a bill that would halt the new coding system. 

Dr. Buckingham says her practice, Eye Physicians of Austin, has been preparing for the switch since last September by purchasing new software and training staff and physicians.

"It's been a very costly, cumbersome process," she said.

A separate bill, HR 1701, the Cutting Costly Codes Act of 2013, would prohibit the secretary of Health and Human Services from implementing, administering, or enforcing ICD-10 entirely.

Rep. Ted Poe (R-Texas) introduced HR 1701 in the House last April. The bill currently sits in the House Subcommittee on Health, awaiting a hearing. 

AMA and TMA sent letters to Representative Poe last April in support of HR 1701. In the letter, former TMA President Michael Speer, MD, urged the Department of Health and Human Services to hold off on a new code set until ICD-11 becomes available.

"Physician practices do not have the capital to switch to ICD-10 for the relatively short period that the code set will be relevant," Dr. Speer wrote. 

Dr. Buckingham says the legislators she spoke to in March were receptive, agreeing there was no reason to implement ICD-10, "especially with ICD-11 right around the corner." 

According to the World Health Organization, ICD-11 is due for completion in 2017. Proponents argue ICD-10 has already been adopted by many other countries. Dr. Buckingham argues the United States will use the new code set more extensively than other countries do currently.

"ICD-10 is used in Europe, and it's an information-gathering tool. It's not a clinical tool," Dr. Buckingham said. "It's all this cost and all this extra effort for absolutely nothing that improves patient care."

She says Europe does not use ICD-10 for billing, as the United States plans to do after Oct. 1, 2015. She worries the specificity of ICD-10 will make it difficult for physicians to find the codes they need for billing.

"To find that code is going to be very, very difficult. It's going to be like finding a needle in a haystack," she said. "It's going to make it impossible to get reimbursed." 

Dr. Buckingham also says doctors can't always comply with the degree of specificity required by ICD-10. She says a patient bitten by a spider might not know the type of spider. Technically, the physician would not be able to properly code the diagnosis, she says.

"Is that fraud?" she asked. 

CMS announced in February it would begin end-to-end ICD-10 testing in July on a select cross-section of 500 health professionals. Dr. Buckingham says she is glad CMS will conduct end-to-end testing but says she would like to see the tests conducted on a larger scale.

"Five hundred providers is nothing," she said.

Dr. Buckingham says specialty societies are advising practices to have six months' worth of cash on hand in case they encounter glitches in the system and can't get reimbursed. She says her practice has some cash set aside. 

"But to have six months of cash reserves? It's not really a viable option if my employees want to get paid," she said. "That's just not feasible."

Dr. Buckingham says it is vital that TMA continue its efforts to cast aside the new coding system.

"TMA is always there to help us," she said.

Dr. Buckingham is the district chair of TMA's political action committee, TEXPAC. To learn more about TEXPAC and what you can do to help advance the association's work to elect medicine- and patient-friendly candidates, visit the TEXPAC webpage.  

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 The Texas Medical Association Political Action Committee (TEXPAC) is a bipartisan political action committee of TMA and affiliated with the American Medical Association Political Action Committee (AMPAC) for congressional contribution purposes only. Its goal is to support and elect pro-medicine candidates on both the federal and state levels. Voluntary contributions by individuals to TEXPAC should be written on personal checks. Funds attributed to individuals or professional associations (PAs) that would exceed legal contribution limits will be placed in the TEXPAC administrative account to support political education activities. Contributions are not limited to the suggested amounts. TEXPAC will not favor or disadvantage anyone based on the amounts or failure to make contributions. Contributions are subject to the prohibitions and limitations of the Federal Election Campaign Act. 

Contributions or gifts to TEXPAC or any CMS PAC are not deductible as charitable contributions or business expenses for federal income tax purposes.

Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation, and name of employer of individuals whose contributions exceed $200 in a calendar year. To satisfy this regulation, please include your occupation and employer information. Contributions from a practice business account must disclose the name of the practice and the allocation of contributions for each contributing owner. Should you have any questions, call TEXPAC at (512) 370-1361.