October 1, 2013 will mark a momentous, system-wide change for physicians in practices throughout the United States. That is the day the International Classification of Diseases, 10th Revision (ICD-10) code sets go into effect. Everyone covered by the Health Insurance Portability and Accountability Act (HIPAA)—not just those who see Medicare and Medicaid patients—will begin using the new code set.
“ICD-10 codes are more specific and therefore more numerous,” said Rudy Molina, MD, chair of the Insurance Subcommittee for the ACR. There were around 14,000 available codes under ICD-9; this will increase to 68,000 codes with ICD-10.
Moreover, the effects will be felt throughout the practice. “The change will impact the person greeting patients at the front desk, through the physicians, and all the way to the back office,” says Antanya Chung, CPC, CPC-1, CRHC, CCP, and director of practice management at the ACR. “Patient charts have to be updated, there will be changes to the superbill, physicians will document in greater detail, major changes will be made in computer systems, and there are probably going to be disruptions in practice as people are trained and new programs installed.”
Start with Working Groups
The first thing practices should do to prepare for the change is set up a working group to begin planning.
The group should look at current systems and work processes using ICD-9 codes. This includes clinical documentation, encounter forms/superbills, practice management systems, electronic health record systems, contracts, public health, and quality reports. Wherever ICD-9 codes appear, ICD-10 codes will take their place. Doing this focuses the transition group on what needs to change and the personnel involved making those changes happen.
“Identify as much educational and operational information as you can for free,” said Robert Tennant, MA, senior policy advisor for the Medical Group Management Association (MGMA) in Washington, D.C. “Use resources offered by the MGMA, ACR, AMA [American Medical Association], or any other group you belong to.”
In ICD-10, the level of specificity is much greater than in ICD-9. Many coders don’t have the knowledge of anatomy and physiology needed in the more clinically driven ICD-10.
—Deborah Grider, CPC
Look for Help
There are many places to go to get suggestions on how to best implement the changes needed. Most of the involved organizations are offering information on their websites for members and others (see “For More Information,” p. 34).
“The ACR will have extensive information available through the website, at the annual meeting, and in some major cities,” says Chung. “The American Medical Association has suggested timelines and budgets for members, as does the MGMA and the AAPC. The Centers for Medicare and Medicaid Services [CMS] is also a major provider of helpful hints.”
Speed Is of the Essence
“Many practices think this is just a software upgrade with no urgency in getting ready,” said Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, president and CEO of AAPC. “The ICD is used in many areas of the practice including financial, practice management, and electronic health records. Many think this is a 48–62-month transition, which means some are already way behind.”
An early contact every practice should make is with their information management vendors. “Practices need to be proactive in reaching out to their vendors,” Tennant says. “Get them on the record about when they will be providing updates to computer programs and when you can expect to begin testing. Nail down what it will cost so that budgeting can begin.”
Ask if they will be upgrading the current version of your software or if you need a different program. Will your current computers work?
How our payors are going to implement the changeover is another possible financial impact. With a more specific coding system, will they pay the same amount as before or will they decide to cut payments for less severe cases?
—Rudy Molina, MD
Look closely at the maintenance contracts you have. They may require the vendor to update your systems at their expense. Find out if this also covers training expenses.
Don’t forget to include vendors for other practice management and reporting systems. Programs for financial management, bill tracking, statistical reporting, and even electronic health records will have to be able to talk to one another.
Next, talk to your clearinghouse or billing service. Ask them when they will be ready for testing. Will their programs be able to support both ICD-9 and ICD-10 codes, or will billings before October 1, 2013, have to be handled on a separate system?
Talk to Your Payors
“The third-group providers need to be actively involved with is their payors,” Tennant says. “Stay in touch with your payor’s provider service contact to find out when each of your major plans will begin accepting test claims. Will they be using the ICD-9 to ICD-10 crosswalks from CMS or proprietary versions? Will there be a specific individual or help desk available to work with as problems arise?”
There will be differences in how various sizes of practices address these issues. The practice with one or two physicians will probably see a larger percentage of the practitioner’s time taken up than the bigger operations.
“Much of this is being taken care of at the corporate or regional level,” says Raymond Hong, MD, MBA, chief of rheumatology at the Ohio Permanente Medical Group in Parma. “There are currently clinical representatives included; the people on the front lines will be involved later.”
Choose ICD-10 Consultants Carefully
Although the ICD-10 changeover is a long way off, consultants have already begun to market their services. As with many other gold-rush scenarios, there will be vast differences in the expertise and credentials among those vying for your business. Caveat emptor.
“There are going to be a lot of consultants trying to get rich over this,” says Grider. “Practices are going to have to be very careful when spending their money.”
One red flag is an insistence that people have to already be trained in the new ICD-10 codes. The guidelines and codes are now in draft form and won’t be frozen until October 1, 2012. There is no reason to learn codes that may not even be part of the final set.
The AAPC is currently suggesting that code training not be started until about six months before the final deadline. Start much earlier and training is likely to be forgotten by the time it is needed.
Check closely any claimed certifications or similar credentials. CMS is not testing anyone or issuing certifications for ICD-10 consultants. In general, if someone claims that some group has endorsed their credentials, contact that group to confirm.
If you already have a relationship with a consultant, see if they offer ICD-10 services. If not, can they suggest someone they know and trust? Find out whom your peers recommend.
When looking for a consultant, ask questions. What is their general background and credentials? What experience have they had with in areas they are claiming expertise? Approach with caution a person who wants to discuss information technology, for example, with no background in computers.
Find out how long the consultant has been working with ICD-10. Ask them what kinds of training they have had on ICD-10 in particular. Always ask about previous clients, and then contact them for references.
Changes Will Be Costly
Although information systems are the 800-pound gorilla in the room, the financial impact weighs in at around 799 pounds. Estimates of the costs of implementing ICD-10 vary widely.
For example, Nachimson Advisors, LLC, estimates it will cost the typical small practice with three doctors and two administrative staff around $83,000 to fully implement ICD-10. For a large practice employing 100 providers and 64 staff members, the price tag could be as much as $2.7 million.
Some of these costs will be easy to quantify and plan for. After consulting with your information management vendors and looking at the maintenance contracts, the practice should have a good idea of how much to budget for new programs, new hardware, and training on that part of the changeover.
TABLE 1: Gout Codes
2011 ICD-9 Acute gout arthropathy:
ICD-10 Acute gout:
- M10. Gout
- Acute gout
- Gout attack
- Gout flare
- Gout NOS
- M10.00 Idiopathic gout, specified site
- M10.01 Idiopathic gout, shoulder
- M10.011 idiopathic gout, right shoulder
- M10.012 idiopathic gout, left shoulder
- M10.019 idiopathic gout, unspecified shoulder
- M10.02 Idiopathic gout, elbow
- M10.021 idiopathic gout, right elbow
- M10.022 idiopathic gout, left elbow
- M10.029 idiopathic gout, unspecified elbow
- M10.03 Idiopathic gout, wrist
- M10.031 idiopathic gout, right wrist
- M10.032 idiopathic gout, left wrist
- M10.039 idiopathic gout, unspecified wrist
- M10.04 Idiopathic gout, hand
- M10.041 idiopathic gout, right hand
- M10.042 idiopathic gout, left hand
- M10.049 idiopathic gout, unspecified hand
- M10.05 Idiopathic gout, hip
- M10.051 idiopathic gout, right hip
- M10.052 idiopathic gout, left hip
- M10.059 idiopathic gout, unspecified hip
- M10.06 Idiopathic gout, knee
- M10.061 idiopathic gout, right knee
- M10.062 idiopathic gout, left knee
- M10.069 idiopathic gout, unspecified knee
- M10.07 Idiopathic gout, ankle and foot
- M10.071 idiopathic gout, left ankle and foot
- M10.072 idiopathic gout, right ankle and foot
- M10.079 idiopathic gout, unspecified ankle and foot
- M10.08 Idiopathic gout, vertebrae
- M10.09 idiopathic gout, multiple sites
Other areas will require further study before a budget can be put in place. Staff competence in the software and hardware is the first step. After that comes the training of appropriate people on the actual codes.
The monetary impact will be very specific to the practice. Smaller practices may find it easier and more efficient to have their coders and other back office staff use webinars and in-office training. Others may send staff to conferences or have trainers come to the practice. In that case, you may also have to pay travel expenses.
Some experts suggest coders should receive training in anatomy and physiology, too.
In ICD-10, “the level of specificity is much greater than in ICD-9,” said Grider. “Many coders don’t have the knowledge of anatomy and physiology needed in the more clinically driven ICD-10.”
For example, in ICD-9 there are 11 codes that rheumatologists can use to code for gout. In ICD-10, there are over 200 codes with more specificity to clearly define the diagnosis (see Table 1, at left).
It is also strongly suggested all physicians be included in training. As with ICD-9, one of the major determinants of payment is what the clinician puts in the chart.
“ICD-10 is much more involved with clinical aspects, terminology, and anatomical specificity,” Chung says. “The hardest thing for coders will be to reprogram their minds and refocus toward diagnosis.” [Editor’s note: Be sure to read “2013–A Whole New World” on p. 9 and “ICD-10 from a Coder’s Perspective” on p. 18 for more information on preparing your practice for ICD-10.]
Disruptions in Practice
After the practice has a handle on who needs to be trained, another thing to budget for is disruptions caused by people unavailable for regular duties. Is it best to scale back appointments for a time? Do you pay overtime to bring people in and maintain a full schedule? Does it make financial sense to shut down entirely and get everyone trained at once?
Also, plan for the early days of implementation. Will the practice cut back on patients? Will your vendors and payors have people and phone numbers dedicated to troubleshooting problems? What is the plan for providing bug fixes? How much of these costs are included with new programs or under maintenance contracts?
“For most updates, we reduce schedules by 10% to 25% for up to two weeks,” says Dr. Hong. “This gives adequate time for problem solving and additional updating if needed. We will probably do the same thing during the ICD-10 changeover.”
Following a review of the short-term costs and dislocations, the practice should begin thinking about longer-term impacts.
Tennant suggests that physician productivity will see a decrease for the first six months following transition to ICD-10. He is also concerned that decreased productivity may be ongoing following implementation. Grider notes that the CMS foresees a productivity cut of 60% over the first year. Much of this will be related to increased clinician time for each encounter and taking longer to complete the more in-depth charting required for payment.
“How our payors are going to implement the changeover is another possible financial impact,” said Dr. Molina. “With a more specific coding system, will they pay the same amount as before or will they decide to cut payments for less severe cases? This is a big unknown from our standpoint.”
Both systems have an “unspecified” code. Will payors accept that or require more information to better use the depth of information new codes make available?
Financial contingency planning is another concern that must be addressed. Because there will be no pilot before changeover, little is known about potential problems. Experts have forecast everything from a smooth changeover to computer-directed Armageddon, and all possible scenarios in between.
“In case there is a meltdown, practices should prepare by banking reserves, establishing lines of credit, and arranging for needed loans in advance,” Tennant says. “While I don’t really expect any major problems, it is better to protect the business continuity of the practice by having these in place in case they are needed.”
The key to a successful change is careful planning that starts immediately. Otherwise, practices risk severe financial consequences, especially under current general and healthcare economic conditions. “The physician’s world is being turned upside down with healthcare reform, the Medicare/Medicaid affordability act, and mandates for electronic medical records, among others,” says Chung. “If practices are not very careful, they will find themselves overwhelmed with the transition to ICD-10, which could cause major disruptions in cash flow. Preparation is the key to success for the next generation of coding. ”
Kurt Ullman is a freelance writer based in Indiana.
For More Information
American College of Rheumatology:
- Currently includes information for practice management. This will also be the main area for information on webinars and seminars at the annual meeting between now and final implementation.
Healthcare Information and Management Systems Society:
- This website includes links to Excel spreadsheets for cost prediction models, vendor assessment worksheets, and various presentations on topics such as establishing time lines, contracting, training principles, and detailed questions an organization should consider as they begin work toward implementing 5010 and ICD-10 regulations.
- Includes links to information on the impacts of ICD-10 with an emphasis on coding. In addition to frequently asked questions, there are links to training sponsored by the organization and discussion groups for coders.
Centers for Medicare and Medicaid Services:
- This site has information on how ICD-10 will affect the governmental healthcare programs. In addition to implementation compliance timelines, there are links to CMS industry e-mails, agency-sponsored teleconferences, and resources for providers.
Medical Group Management Association:
- Main page for ICD-10–related information. Resources such as webinars, checklists, and vendor questionnaires are available. Some may only be accessed by member practices.
American Medical Association:
- This site has lists of AMA materials on ICD-10, including books and magazine articles published, FAQs, and links to educational resources both from the AMA and elsewhere.