One Year to Go

 ICD-10 Coming in October 2014

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Tex Med. 2013;109(10):23-29.  

By Crystal Zuzek 
Associate Editor  

Failure to prepare for the Oct. 1, 2014, deadline to begin using the ICD-10 coding system will result in financial hardship — possibly even ruin — for you because payers will reject your claims.

The ICD-10 deadline is one year away, but experts warn that planning for conversion is intricate and time-consuming. You and your staff need to learn the new system and coordinate with payers, claims clearinghouses, billing companies, and electronic health record (EHR) vendors well before next October to make sure the government and insurers continue paying you for treating patients.

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 with more than five times the number of codes than ICD-9 and a completely different structure, ICD-10 requires extensive changes.

Kevin Spencer, MD, an Austin family physician and member of the Texas Medical Association Ad Hoc Committee on Health Information Technology, says his practice is in ICD-10 preparation mode. Premier Family Physicians formed a committee of physicians, nonphysician practitioners, and a billing project manager to oversee the move to the new coding system.

Two of his staff members attended TMA's ICD-10 Now! How and Why seminar, which gave them an overview of ICD-10, explained how the transition will affect the practice, and walked them through implementing a successful transition. The seminar is now available as an on-demand webinar. He also purchased the Simple Solutions ICD-10 Transition Software from TMA to speed up the process of converting from ICD-9 to ICD-10. (See "Get ICD-10 Tools and Help From TMA.")

"We've relied on TMA for our ICD-10 roadmap. TMA was the first place we went for guidance on the process, and I feel good knowing that we have some direction," Dr. Spencer said.

At press time, Dr. Spencer and his colleagues were ramping up ICD-10 training and talking to their electronic health record (EHR) vendor to determine necessary system upgrades and next steps.

Justin Barnes, vice president of government and industry affairs for Georgia-based EHR vendor Greenway Medical Technologies, says you should demand transparency from your EHR vendors in the lead-up to the ICD-10 implementation deadline.

"If they haven't already, physicians need to ask their EHR vendors right now to share the strategies they're undertaking to prepare for ICD-10 and for the timelines that indicate when the tools to achieve the transition will be delivered and installed," Mr. Barnes said.

He adds that you should rely on EHR vendors for resources for the transition and to educate you and your staff on the functionality and clinical and reimbursement benefits associated with the new coding set. He says the new codes are "a way to better manage patients and improve reimbursements" while providing clinical flexibility.

"The move to ICD-10 … is meant to accommodate performance-based measures and quality reporting while also improving the depth of clinical diagnosis and care. Physicians will benefit from the flexibility within ICD-10 coding. The new code set gives them the ability to use a single code to report a disease and its current manifestation, for example," Mr. Barnes said. 

"We Don't Love Everything About ICD-10"

TMA delegates convinced the American Medical Association House of Delegates in November 2011 to go on record opposing ICD-10. At TMA's insistence, AMA approved a resolution urging CMS not to adopt ICD-10 because of its "bureaucratic and financial burden on physicians." The resolution also warned ICD-10 would force many small practices out of business.

But CMS delayed implementation for only one year; thus, barring some unforeseen circumstances, ICD-10 will become a reality next October.

AMA and TMA are not giving up, though. At the AMA House of Delegates meeting in June, delegates directed AMA to support federal legislation to "stop the implementation of ICD-10 and remain with ICD-9 until ICD-11 can be properly evaluated."

TMA and AMA also sent letters to Rep. Ted Poe (R-Texas) in April to support HR 1701, known as the Cutting Costly Codes Act of 2013. The resolution prohibits the secretary of Health and Human Services from replacing ICD-9 with ICD-10.

"TMA is greatly concerned that adoption of the ICD-10 data code sets would introduce great cost in disruption and practice implementation without a corresponding benefit. TMA has urged the Department of Health and Human Services to forego adopting ICD-10 and instead implement ICD-11, when that becomes appropriate and possible," wrote then-TMA President Michael Speer, MD.

At press time, HR 1701 had been referred to the House Energy and Commerce Committee's Subcommittee on Health.

Although TMA opposes the transition to ICD-10, it is committed to helping you get ready for the new coding system, should CMS persist in its current trajectory. TMA, AMA, and coding experts recommend you plan now, as ICD-10 promises to affect every aspect of your practice. (See "Prepare for ICD-10 Now.")

Mr. Barnes says Greenway doesn't anticipate CMS will push back the ICD-10 implementation deadline again.

"We've made it clear to our customers that the Oct. 1, 2014, transition date is very solid and is not anticipated to be extended any further. Our customer base understands that having the conversion in place about six to nine months out is an industry best-practice goal we're meeting," he said.

Dr. Spencer says the ICD-10 conversion represents a "difficult and cumbersome management process for practices," but he recognizes the need to get ready now.

"We don't love everything about ICD-10. We're embracing ICD-10 for survivability and sustainability, not because we think it's a great thing. Physicians need to get ahead of this and not fall behind it," he said. 

It's Not Too Late

Medical Group Management Association (MGMA) research suggests the health care industry's overall readiness to meet the Oct. 1, 2014, ICD-10 compliance date is still slow. The greatest concern is the lack of communication and critical coordination between physician practices and their essential trading partners (such as claims clearinghouses, EHR vendors, and practice management system vendors) regarding software updates and testing, which have not yet occurred.

Only 4.8 percent of practices reported making significant progress when rating their overall readiness for ICD-10 implementation. The research includes responses from more than 1,200 medical groups where more than 55,000 physicians practice.

MGMA research highlights the following ICD-10 readiness findings: 

  • More than 52 percent indicated they had not heard from their practice management system vendor about when software changes would be available. Almost 50 percent had not heard from their EHR vendor.
  • Only 5.9 percent reported that internal software testing has begun or is complete with their practice management software vendor and 4.7 percent with their EHR vendor.
  • Just 11.9 percent said external testing with their clearinghouse has started or is complete. Almost 60 percent said they have not even heard from their clearinghouse regarding a testing date. Only 8.6 percent have started or completed testing with their major health plans, with a worrisome 70 percent saying they have not heard from insurers.
  • Nearly 60 percent said they are "slightly" or "not at all confident" their major health plans will be ready to meet the Oct.1, 2014, deadline.
  • Among a number of implementation concerns, 88 percent are concerned or very concerned about the expected changes to clinical documentation; 87.5 percent are concerned or very concerned about the loss of clinician productivity after implementation; and 81.1 percent indicated they are concerned or very concerned with the overall cost of switching to ICD-10.
  • Only 32.5 percent report that their vendor will cover the cost to upgrade or replace their practice management system software. Only 37 percent say their vendor will cover the cost to upgrade or replace their EHR.
  • For those organizations that must cover the costs themselves, the average cost for a 10-physician practice to upgrade or replace their practice management system and EHR software to accommodate ICD-10 is $201,690. 

John Burns, a National Alliance of Medical Accreditation Services instructor and American Health Information Management Association (AHIMA) ICD-10 trainer, says you and your staff should be immersed in ICD-10 training by now.

"ICD-10 implementation will impact all aspects of the revenue cycle. It starts with patient registration and doesn't stop until the payment has been processed," he said.

You should inquire about ICD-10 training opportunities from your EHR vendors, as well. Greenway Medical Technologies, for example, trained customers through ongoing regional and online educational sessions. The EHR vendor also held a customer conference in August to bring clients up to speed on ICD-10.

Physicians who haven't started preparing for ICD-10 shouldn't panic. Mr. Burns says it's not too late to get started.

"Physicians should start by working with their staff to run a utilization report of the 50 to 100 most frequently used ICD-9 codes. They should then cross-reference those codes with the ICD-10-Clinical Modification manual to see how the structure of the codes differs," he said.

He encourages you to jump on the ICD-10 bandwagon to begin managing training and implementation processes internally. (See "CMS Impact Assessment Checklist.")

"Practices that have done nothing before the implementation deadline next year won't get paid. That could result in their financial ruin, so it's important for physicians to take this seriously," Mr. Burns said. 

Challenges, "Potential Glory"

Eric Weidmann, MD, an Austin family physician and a member of the TMA Council on Practice Management Services, believes ICD-10 will yield public health and safety benefits down the road.

"The potential glory in using a more specific code set is the ability for us to have research data that can be tracked and used to improve policies and guidelines that affect certain patient populations," he said.

For example, he says data collected through ICD-10 on facial contusions from automobile collisions could result in improved guidelines for airbags and other safety features. That said, he's well aware of the administrative burden ICD-10 denotes. Like many physicians, Dr. Weidmann envisions financial hassles with payers when the ICD-10 switch occurs next October.

"We're expecting some cash flow hiccups next year. It's on my radar to ensure we have a line of credit available to handle the blow to the practice's finances," he said.

Mr. Burns suggests practices plan ahead and take appropriate measures in case of financial disruption next fall. He says payers and practice management system vendors will likely have some technological bugs to sort out that could delay payments to practices.

"If some payers are unable to process claims or recognize the new codes, it will lead to a spike in claim denials for practices. Physicians should have a well-established line of credit with their lenders to ensure they can make payroll, cover overhead, and keep the business running," Mr. Burns said.

Dr. Spencer anticipates ICD-10 training will cost the practice in terms of staff time spent learning a new system. AHIMA estimates coders should devote an average of 16 hours of training on ICD-10 diagnosis coding and 10 hours on additional practice.

Dr. Spencer has concerns about the changeover to a new coding system and its impact on his business.

"We've operated without a high-level professional coder, but we may need to allocate resources to hire one full-time. We have to ensure we're correctly submitting clean claims or else the practice will suffer financially," he said. 

Crystal Zuzek can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.


CMS Impact Assessment Checklist

David Nilasena, MD, Region 6 chief medical officer for the Centers for Medicare & Medicaid Services (CMS), has some advice for physicians who have yet to prepare for ICD-10.

He offers this checklist as a guide: 

  • ICD-10 will change certain aspects of your business processes. Once you implement ICD-10, assess its impact on your processes for referrals, authorization and precertification, patient intake, physician orders, and patient encounters.
  • ICD-10 codes are more specific and detailed than ICD-9. This will yield more clinical data but involve more precise and complete documentation with each encounter, requiring:
    • Training for staff to accommodate the substantial increase and specificity in code sets added with ICD-10;
    • Increased anatomical and clinical detail;
    • Consideration of physician work flow and patient volume changes;
    • Changes to forms and documents to improve specificity for input with ICD-10;
    • Revisions to superbills and other forms to reflect new patient coverage policies and payment limitations;
    • Changes to prior authorizations; andGreater specificity in ordering and reporting lab services to health plans.    
  • ICD-10 will cause changes in payment schedules. Coordinate with payers on contract negotiations and new policies based on the expanded code set.
  • Check with your vendors to make sure they can accommodate your ICD-10 needs. Coordinate with vendors on their readiness and timelines for completing system updates:
    • Establish a tracking system and timelines for milestones.
    • Review existing and new contractual obligations with vendors.Coordinate vendor capabilities and work with your organization's needs and expectations.
    • Evaluate code set search function and vendor products' ease of use.  


Get ICD-10 Tools and Help From TMA

Medical professionals are not making the progress needed for their ICD-10 implementation, according to a recent survey by the Workgroup for Electronic Data Interchange (WEDI).

"Unless more providers move quickly forward with their implementation efforts, there will be significant disruption on Oct. 1, 2014," WEDI concluded. If you do not comply with ICD-10 by the Oct. 1, 2014, implementation date, your claims won't get paid.

Manually converting ICD-9 codes to ICD-10 can take hours, even days. The Simple Solutions ICD-10 Transition Software available from the Texas Medical Association helps reduce the conversion time frame. The software can generate a medical practice's top 50 codes in a matter of minutes. It can also create coding flash cards of most commonly used diagnoses that you can share with your staff.

The software 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. 

TMA's Complete ICD-10 Implementation Solution walks your practice through every aspect of preparation, including policies, procedures, processes, relationships with other organizations, and technology. It comes with two licenses for Simple Solutions ICD-10 Transition Software and instruction videos.

You can view a four-minute demo of the toolkit, available through the TMA Education Center. Plus, you can watch more interviews with TMA staff in TMA's ICD-10 Video Vault

In addition, 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. TMA's on-demand webinar ICD-10 Starts With Physicians targets physicians, office managers, and coders. It highlights the ICD-10 transition process, code structure, and the impact of ICD-10 on your practice. Register for the webinars here.

Be sure to bookmark TMA's ICD-10 resource page for news, tools, education, updates, and the ICD-10 Readiness Questionnaire for Vendors from the  American Health Information Management Association.

The TMA Knowledge Center alert service will also keep you up to date with the newest articles and latest developments on ICD-10 and other health care topics. TMA Knowledge Center staff have created custom searches on ICD-10 and many other topics set to run weekly. The search results are emailed directly to you or accessed via RSS feed. TMA Knowledge Center alerts provide citations and abstracts along with some full-text access. Fill out the online form to sign up.

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Prepare for ICD-10 Now   

The American Medical Association has published "ICD-10 Timeline: Meeting the Compliance Date." 

The timeline's nine critical steps take at least 22 months to complete. Ideally, medical practices should now be working on step 4 to ensure that employees, office technology, and internal operations are ready to make the switch on Oct. 1, 2014. The nine steps and the time required to complete each step are: 

  1. Conduct an impact analysis on business practices and systems to determine how the switch will affect operations. Next, inventory all systems, both electronic and manual, that use ICD-9 codes. By conducting this review as early as possible, you fully understand the scope of work ahead and can prioritize important tasks. (3 months minimum)
  2. Contact vendors about the dates, expected costs, and other details of installing the ICD-10 upgrades on computer systems. (2 months)
  3. Contact 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, let these groups know when you expect to have their upgrades installed. (2 months)
  4. Because the timing of system upgrades to a medical office depends on the readiness of the vendors serving that office, talk to vendors about upgrades early on. This also may help reduce ICD-10 transition costs. Upgrade other systems, such as quality reporting and public health reporting tools, as well. (3 months)
  5. Once the upgrades are complete, conduct internal testing to ensure the upgraded systems can generate transactions with the ICD-10 codes. Allow extra time for troubleshooting and working with vendors to address any obstacles. (2 months)
  6. Update internal processes that support coding. These include superbills, encounter forms, quality data collection forms, and public health data collection forms. Take this time to review clinical documentation to ensure it captures the necessary details of patient diagnoses. (2 months)
  7. Train every staff member. The training times should be staggered to prevent downtime 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. (2 months)
  8. Conduct external testing with clearinghouses, billing services, and payers to make sure they can properly send and receive ICD-10 codes in transactions. (6 months)
  9. Switch to ICD-10 on Oct. 1, 2014. Payers will not accept claims with ICD-10 codes before Oct. 1 and will reject transactions that use the ICD-9 codes after Oct. 1, 2014. 

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