ICD-10 and the Private Practice
by Eileen Garrity, R.N., M.B.A., FAHM
On October 1, 2014 the health care industry in the United States will transition from using the 9th edition of the International Classification of Diseases (ICD-9), to the 10th edition, also referred to as ICD-10. ICD-9 has been used since the 1970s and is antiquated at best. Unlike other developed countries around the globe that have been using the later version for years, the U.S. has only used ICD-10 for mortality reporting since the late 1990s.
Although ICD-10 requires greater specificity in documentation, it comes with some notable advantages over its older predecessor. It will provide us with a vehicle for more accurate differentiation of risk of mortality and severity of illness. The required specificity will also eliminate many questions by insurers about the patient’s condition, which should result in a decreased need to include supporting data with claims, thereby decreasing claims delays and denials. The increase in specificity will aid in the capture of cost and outcome statistics. It will enable us to acquire information for research and public health surveillance and an improved ability to measure health care data through updated terminology in line with medical advancement.
The original go-live date was pushed to October 1, 2014 but no further extensions are expected. With the deadline for ICD-10 readiness looming, it is imperative that you begin to develop a plan to ensure that your practice is ready to conduct business in the ICD-10 environment.
The purpose of this article is to provide private practitioners with information regarding where to begin in their efforts to become ICD-10 compliant in their practices.
It is foolish to assume that there will be no impacts from the conversion but with careful preparation providers can mitigate a good number of them.
It is vital that you begin your planning process NOW.
Begin by performing an inventory of every process in the practice that involves a diagnosis code. Start with appointment scheduling, referrals, consults, precertification, the office visit, the EMR, billing, practice management system, claims, appeals, other system applications. This is not a comprehensive list by any means and will differ by practice and specialty, which is why it is so important that you complete a walk-through from beginning to end to identify the processes which will be affected by the conversion.
Examine all forms used in your office. Do they contain ICD-9 codes? If so, they will need to be updated. Review your super bills. Take your most popularly used codes and cross-walk them from ICD-9 to ICD-10. Pay close attention to the timing of this action as there can be consequences if it is completed too soon. There is further information on the CMS website to aid you in this process.
Contact your vendors to see if updates to their software/applications are available and to learn if they will be ICD-10 compliant by the October 1, 2014 deadline. It is important to ask the vendors if their software will support a dual coding environment (but remember a claim cannot contain both an ICD-9 code and an ICD-10 code when submitted for payment). Inquire if the practice be charged for the software/application updates, maintenance, training, and support. When and how will testing occur? Who will coordinate the testing with payers--the practice or the vendor? Will new software/hardware be required to support operations? At what cost?
Training and staffing are additional considerations. Decide who will require training and how much--including physicians, clinical and non-clinical office staff, coders, billers, schedulers, etc. It is expected that due to the steep learning curve, there will be a decrease in coding accuracy and an increase in claims denials until a level of coding proficiency is reached. Decreased productivity should also be expected. Since the number of diagnosis codes will increase from approximately 13,000 in ICD-9 to over 68,000 in ICD-10, it will take coders longer to complete a record than it did in the past. Supplemental staffing may be required in the interim until coders are up to speed with the new coding process.
Since more specificity in documentation is required in order to support the diagnosis, we can expect a decrease in provider productivity as well. But there is a glimmer of hope. Medicare notes that nearly 25 percent of ICD-10 codes will remain the same as in ICD-9 except they will require specificity in noting laterality. Another 25 percent of the codes will differ only in the way they distinguish between the types of encounters, e.g. initial encounter, subsequent encounter, sequela. If your documentation includes these concepts you are halfway there.
For your next step, research the various types of training available, e.g. articles, courses at local institutions, distance learning, training provided by vendors. AHIMA (American Health Information Management Association) recommends 16 hours of ICD-10 training for coders. Coders will not need to learn ICD-10 PCS as it does not apply to the office setting.
Contact payers. Will they be ICD-10 compliant? Will they require claims submission in ICD-9 or ICD-10 format? Many in the industry recommend that cases be dual coded in preparation for payers who will not be ready to accept ICD-10 coded claims. Testing should be conducted with all vendors and payers. Check your applications/systems for interfaces with other systems to identify possible downstream impacts. Will there be changes to payer payment policies as a result of the conversion? Review payer contracts to identify potential impacts due to reimbursement tied to particular diagnosis codes.
Create a budget. Be aware that the numbers will change throughout the life of the project as new issues arise. Be prepared. Take into consideration the costs for training, supplemental staff, overtime, existing application and system updates, new coding applications/reference books, and hardware and software upgrades/replacements. Consider the financial impacts to billing. Be prepared for increased denials or increased lag time between claim submission and payment. Increase cash reserves and/or secure a line of credit. It is important to attempt to predict the impacts by looking at the variance between ICD-9 and ICD-10 codes. The CMS website has a free GEMS tool to assist you or your coders can perform this task manually.
Create an alternative plan in the event your vendors/insurers will not be ready by the go-live date.
Now that you’ve completed your evaluation it is time to create the project plan. List the tasks with realistic deadlines for completion and names of responsible parties with each line item.
Conduct regularly scheduled meetings to check status and provide updates.
Contact other physician offices in your area for input on their progress. They may provide information about issues they’ve identified that you didn’t consider. You may also be able to coordinate group training at a reduced cost by combining with other practices.
Well, it is time to get started. October 1, 2014 is just around the corner.
The CMS website contains an abundance of important information to help you prepare for the conversion. I have included two links that I referenced in order to write the article. They will point you to valuable step-by-step information which CMS has created to guide you in this process. One link is for small-to-medium practices and the other is for large practices.
Don’t wait until the last minute. Begin your project now and best of luck.
ICD 10 Implementation Guide for Small and Medium Practices
ICD 10 Implementation Guide for Large Practices