It still seems to be a long way off—the changeover to the International Statistical Classification of Disease, 10th Revision (ICD-10) doesn’t become mandatory until October 1, 2013. But when you consider that practices need to look at computer systems, billing methods, and even patient welcome packets, that date is a lot closer than many think.
“There is no silver bullet that will get a practice through the implementation of ICD-10, preparation is the key” says Antanya Chung, CPC, CPC-I, CRHC, CCP, director of practice management at the ACR. “If you thought it was crazy trying to work through Y2K, implementation of the new coding systems may surpass that. Policies, information systems, even the patient’s welcome packet will need updating.”
Until now, much of the focus has been on the first deadline when Version 5010 comes active. This is how various computer systems correspond with each other using standards for electronic health information exchange. Since this has to be live by January 1, 2012, all practices should be in the final stages of implementation.
Lynette Byrnes is the practice administrator for three Rheumatology Associates of Long Island facilities located in Suffolk County, N.Y She is currently involved in getting Version 5010 ready to go before the deadline. She is hoping that her experiences are not a prelude to what happens in 2013.
“Early testing of Version 5010 is not going well,” she says. “I am not sure if our batches are getting to our clearinghouse and then to our payers. Once I get 5010 running smoothly and I know I can get paid promptly, then I can turn more of my attention to the problem of ICD-10.”
The practice is a beta site for both their clearinghouse and software vendor. Although being the guinea pig probably added extra time and effort, Byrnes thinks it was worth it because she knows for certain that Version 5010 will work with her particular computer and software system.
Now most of the focus turns towards ICD-10 itself. While much of this seems to be pointed toward the office staff and coders, Chung stresses there is need for the physicians in the practice to stay closely involved as the process unfolds.
What Physicians Need to Know
“Physicians need to immediately educate themselves in the nuances of ICD-10,” says Chung. “There will be major impacts on both the clinical and business sides of the practice that the physicians will have to work on. They need to look at the financial aspects of changing or upgrading systems, training, and to budget for operating capital if there are problems and they don’t get paid for a while in 2013. The other side is the level of detail involved in documentation and billing, which may decrease productivity and reimbursement.
“This change in the system will not be as easy as turning on a light switch and you are good to go,” continues Chung. “Physicians will need to take a look a big picture view of the practice and ask, Where do I start on this process?”
The Centers for Medicare and Medicaid Services, American Academy of Professional Coders, American Health Information Management Association, and Medical Group Management Association all have active programs to help guide practices through the maze of information. In addition, Chung heads up the ACR’s endeavors in providing resources for its members.
“We are the rheumatologists’ first-line source for specialty-related information,” says Chung. “We have information on the website [www.rheumatology.org/practice], and will sponsor a series of ICD-10 webcasts, as well as having ICD-10–specific seminars available at the ACR annual meetings and symposiums over the next few years.”
Early in 2012, the ACR will have an ICD-10 rheumatology code translator available on the website to help the transition of specialty-specific codes. The ACR is also working toward developing a suggested Superbill to help ease that burden on practices.
Information is what most practices are looking for at this time.
Byrnes’ practice started the information quest around the first of this year as she began acquiring books, participating in webinars, and attending workshops. Candice Brazeale, CPC, CRHC, an internal auditor and coder at Piedmont Arthritis Clinic PA in Greenville, S.C., has been doing much the same thing at her practice.
“Preparedness so far has been in training the trainer,” says Brazeale. “If we have any problems with 5010, it will not slow down our ICD-10 training and we will continue on as planned.”
Both groups are beginning to also look at how the instruction can be accomplished in a way that minimizes disruptions. Should it be a couple hours at a time over a few weeks? Would it be better to just close down for a day and do all the training at once? How much can be done in-house and how much has to be done either off-site or with an outside consultant? Where is the money for this coming from?
“They make it sound so simple; all you need to do is to download the new codes to your electronic medical record [EMR] system,” says Byrnes. “What is not so simple is getting those codes linked with the proper documentation, and sent to your clearinghouse and your payer. That is something that you want to start working on right away.”
How this linkage is done will vary greatly depending on how the individual practice is set up.
“Our practice is looking at our major diagnoses and grouping them on a new Superbill so it will be easier for the physicians,” says Brazeale. “We don’t want the doctors to have to sort through a thousand different codes to get the ones they need.”
They are also planning to do a lot of training for physicians and billing staff, since the ICD-10 codes will require a much higher level of detail. No longer will you be able to just code 714.0 for rheumatoid arthritis (RA). After the 2013 date, you will have to code for RA, for example, in a specific joint, in a specific foot, on a specific side of the body. In addition, the physician’s documentation will have to reflect that amount of detail.
There is no silver bullet that will get a practice through the implementation of ICD-10.
Other practices will have to take a close look at their computer systems and how they are structured.
“We will go through our charting templates to make sure that the appropriate check boxes are present and that they link to the right codes for billing,” says Byrnes. “I will need to incorporate all of the nuances of ICD-10 into my templates. Then we have to make sure that what is checked by the providers has the proper codes behind them to successfully populate the bills.”
All of this fine-tuning of computer programs and systems should be done carefully to avoid disruptions. Byrnes noted that, during testing for the Version 5010 changeover, the new program broke her profile and she could not get automatic deposits from Medicare for a period of time. Because of this, she suggests that all testing be done on a virtual server so that any conflicts can be worked out without crashing mission-critical computers.
Uncertainty a Big Concern
Currently, the biggest problems with the coding change are the uncertainties as to how implementation will be handled. One issue is that the codes have not been frozen, so none of the work of getting Superbills redone or EMRs programmed can begin.
Rheumatology practices can stay abreast of the latest updates through the ACR practice management department. According to Chung, there will a partial freeze of the ICD-9-CM and ICD-10-CM codes prior to the implementation of ICD-10. The last regular, annual update to both ICD-9-CM and ICD-10 code sets will be made on October 1, 2011. This is likely when work on Superbills and programming can begin.
Then, on October 1, 2012, there will be limited code updates to both the ICD-9-CM and ICD-10 code sets to capture only new technologies and diseases. To help ease the final transition, there will be a very limited code update on October 1, 2013. There will be no updates to ICD-9-CM, as it will no longer be used. On October 1, 2014, regular updates to ICD-10 will begin.
Although there is much general work that can be done, such as getting systems in place, developing budgets, reworking policies and procedures, and planning training sessions, much of the nuts-and-bolts work is frozen until the codes are fully implemented.
“While we are starting to plan for the changes in coding, we don’t want to go too far too early,” says Brazeale. “Until the codes are frozen, coders may have to ‘unlearn’ some things if there are changes. If we start working with the codes too early, all we are doing is giving people a chance to forget them when they actually need them. We’ll probably start this part of the plan around January 2013.”
One group that should consider working with the interim codes now is the physicians. Chung suggests they sit down with their current charts. “From the doctor’s standpoint, it is all about making sure that documentation is up to par,” she says. “They need to take their charts as they are now and compare them with the guidelines and conventions for ICD-10. If you can’t match them up, you are definitely not ready and have some work to do.”
The practice partners and owners should also be making financial planning decisions. Although there will be ongoing outlays for equipment, software, and training, the real danger to the viability of the practice will happen when payments will no longer be based on ICD-9 protocols.
There is little agreement on how well the switch will go. Some think it will end up like Y2K where most of the kinks are worked out successfully during the runup and the actual day of reckoning passes with little fanfare. Others suggest that prudent physicians should have as much as six months of income available through savings, loans, lines of credits, or other financial methods—especially since being ready is only one part of the equation.
“There are just so many layers to go through to get paid and they all have to work together,” says Byrnes. “Maybe I can get my batch to the clearinghouse, but if they can’t pass it along to the payer, I am still not going to see any money. I can do things perfectly, but if the others don’t do theirs, I am going to have find money real fast.”
The experts suggest that practices stay in close contact with their vendors, clearinghouses, and payers and make sure they are testing their programs. They should also demand the ability to run tests of how their specific systems work with those used by the others as early as is practical.
All the experts interviewed for this article agreed that activating Version 5010 on January 1 should give some indication of what to expect in October 2013.
“With all the changes going on in medicine today, practice management is more and more like squeezing a balloon,” says Brazeale. “You squeeze one end and the other pops out. Get one part controlled and a new concern comes up.”
Keeping an eye on the balls currently in the air is important. Don’t just focus on the one with the nearest deadline.
“Some practices have put ICD-10 on the back burner while they work through EMR or e-prescribing,” says Chung. “Like many other things in the medical world, you will need to be doing many things simultaneously.”
Kurt Ullman is a freelance journalist based in Indiana.