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ICD-10: Why You Shouldn't Wait


With so much else changing in healthcare, it's understandable that you'd want to avoid thinking about transitioning to the coming ICD-10 code set. But the longer you wait to start, the tougher it will be to make the switch, and the more likely you are to lose money. Here's what you need to know to avoid claims denials and ensure a smooth conversion.

When it comes to ICD-10, the new code set that takes effect Oct. 1, 2013*, what worries Jerra Allen is not the two additional digits or the reams of new disease and diagnosis codes compared with the current ICD-9. Allen, an insurance claims specialist at Miss.-based Hattiesburg G.I. Associates, PLCC, says the biggest challenge will be obtaining the additional information from patients needed to meet the higher level of diagnostic specificity that ICD-10 requires to process claims. "I'm pretty sure a lot of doctors' offices will have that same issue," she says.

(Editor's Note: At the time of publication, CMS had not finalized a one-year delay for ICD-10 implementation. The new effective date is Oct. 1, 2014.)

For Jacque Konzelman, practice manager at Sussex County Medical Associates in Newton, N.J., the timing of the switch to ICD-10 - in an era of financial and regulatory pressures - is the big stressor. "The problem with all of this is the ability to meet these requirements financially when reimbursement is going down," says Konzelman.

Many practices share these concerns. Yet, given the magnitude of changes practices will have to make - from the way they conduct patient exams to how they process claims - it's alarming that only 36 percent of 722 physician practices in our 2011 Technology Survey told us their technology is ready for the coming transition to the ICD-10 code set, which will require practices to start using more than 100,000 new alphanumeric procedure and diagnosis codes. What's more, 22 percent of respondents told us they're not sure whether their current system will ever be upgraded to handle ICD-10 codes.

Here's another kicker: Although Oct. 1, 2013, the deadline to start using ICD-10 codes, might seem far away, healthcare organizations will have to take their first step in the transition as soon as Jan. 1, 2012: using Version 5010 of the Electronic Data Transaction standard, which is necessary to transmit the new codes.

"It's amazing how many people don't even know about the upcoming transition at all, let alone how big it's going to be," says Glen Stream, president-elect of the American Academy of Family Physicians, who runs the IT management system for a 230-provider, multispecialty healthcare clinic in Spokane, Wash. "The general lack of knowledge is concerning to me."

Translation: You need to make ICD-10 a priority, even though you won't have to start using the new codes for two years. Therefore, the sooner you start, the more likely you'll be able to work out training kinks and avoid claim denials.

Here's a start on what you need to know to stay on target for the next 24 months.

ICD-10 codes: how they'll change your life

With all the focus on EHRs and meaningful use, many practices haven't even begun to think about ICD-10. And while the change to ICD-10 is touted by CMS for its benefits (supporting interoperability, accuracy, and quality of data), the magnitude of the conversion is daunting.

"This ICD-10 thing is just one more change people have to deal with," says Stream. "There's so much going on I think people are saying 'Enough! I'll deal with this later!'"

While the desire to procrastinate is understandable, the longer you wait the more difficult the transition will be, regardless of whether your physicians code their own charges or your practice uses a seasoned, certified coder.

The consequences of not being ready for the changeover to ICD-10 include losing thousands of dollars in claim denials and time spent resubmitting claims. It's even possible your practice could be liable in a malpractice lawsuit if a diagnosis is coded incorrectly and a patient therefore receives inappropriate treatment, says Raemarie Jimenez, director of education for the American Academy of Professional Coders (AAPC).

The change from ICD-9 will be a gigantic one: The new ICD-10 CM (clinical modification) codes and ICD-10 PCS (inpatient procedure) codes will replace the existing ICD-9 numerical codes (which are more than 30 years old) with more than five times as many new alphanumeric codes that are longer and more specific. According to the American Health Information Management Association (AHIMA), ICD-10 consists of more than 68,000 codes, compared to approximately 13,000 ICD-9-CM codes.

What's more, ICD-10 codes are longer - ranging between three and seven characters - than their three- to five-digit predecessors.

This shift will ultimately create more-specific patient data, and contribute to a greater knowledge base about patient diseases and best practices, according to Patricia (Pati) Hildebrand, a consultant with AHIMA who works with practices.

Hildebrand offers the example of applying a code to a patient with hypertension, which represents one of the most common diagnoses in primary care:

Currently, hypertension is coded as a single code, with multiple additional codes to describe related illnesses (effects from hypertension on the heart, kidneys, and eyes for example) or complicating illnesses (diabetes, congestive heart failure).

But starting Oct. 1, 2013, coders will have several hundred codes to choose from. Under ICD-10 - except in rare cases of essential hypertension with no known cause or related organ changes or concomitant disease - a "combined" code must be chosen from several pages worth of codes in the manual (codes I10-I15), such as "hypertension plus kidney disease" or "hypertension plus kidney disease plus cardiac disease."

Because codes are more specific, patients will ultimately require more attention and time per visit in order to input the correct diagnosis and treatment.

"Because the coding system will have combination codes, and there are multiple permutations of combinations, the sheer number of possible codes has skyrocketed," says Hildebrand. "This is going to make creating a superbill/encounter form or coding cheat sheet very difficult, not to mention the additional codes that will need to be added to any pull down menu, any memorized code list, or any frequently used code list in electronic documentation."

Ready to start training? Circle Jan. 1, 2012 on your calendar. That's the date practices are expected to start using Version 5010 of the Electronic Data Transactions standard.

The upgrade to 5010

Before you can transmit the seven-digit ICD-10 codes, you'll need software that can accommodate the extra digits. Enter Version 5010 of the Electronic Data Transactions standard. On January 1, 2012, as mandated by HIPAA, healthcare organizations must swap standards for electronic health care transactions from Version 4010/4010A1 to Version 5010.

Unlike the current Version 4010/4010A1, Version 5010 accommodates the ICD-10 codes, and must be in place before you can start using ICD-10. But 5010 is necessary for more than just ICD-10 codes. The technology, which is incorporated into practice management systems, EHRs, and any other technology system used to transmit patient data, is necessary for claims, eligibility inquiries, and remittance advice - which means any vendor or payer your practice does business with will also need to upgrade within the next few months. In addition to upgrading, healthcare providers are expected to complete Level 1 and Level 2 5010 EDI testing by the end of this year. Level 1 compliance ensures that a practice can "create and receive compliant transactions," meaning it can send and receive information, including claims. Achieving Level 2 compliance means that a practice has completed end-to-end 5010 testing with each of its trading partners (insurance companies, software vendors, etc.) and is ready to go.

"If you don't comply with 5010, it's going to hurt you," says Richard Temple, an executive consultant with Beacon Partners, at a recent virtual conference sponsored by HIMSS. "It's going to take you a lot of work to rework transactions, your cash flow is going to be negatively impacted, and there's also a fine of up to $50,000 per year [through HIPAA] if you don't comply."

But while the looming Jan. 1, 2012, deadline has put pressure on practices to adopt and test 5010, it's also shed light on the challenge of waiting for vendors to provide the correct software upgrades -whether yours is a small, independent practice or part of a larger healthcare delivery network.

A survey conducted by the Medical Group Management Association in June revealed that 30 percent of practices had not received any communication from their practice management software vendors regarding the change to Version 5010. What's more, 45 percent of respondents had not started their implementation of Version 5010; 46 percent said they have partially completed implementation; 2 percent said they had completed implementation.

Sharp Healthcare, a San Diego-based system of hospitals, group practices, and a health plan, began its transition to ICD-10 in June 2009. Yet two years later it finds itself waiting for many of its vendors and trading partners to get themselves ready for 5010 testing. "It's moving very slow, we're seeing, so I'm concerned we're going to get hit all at once with everybody knocking on the door saying 'OK, we're ready to test,'" says Debbie Coates, Sharp's IT director responsible for Revenue Cycle Management systems. "I think that's what's kind of scary. You don't know who's going to be ready when."

Practices that haven't received notice from their vendors need to inquire about the vendor's timeline for making the switch. Your next step will be based on their responses. If any vendor has no transition plan that it can share with you, says Temple, "run away, seriously."

During his presentation, Temple suggested several questions you can ask vendors and trading partners to assess their 5010 readiness, including:

1. Will you upgrade your systems to accommodate 5010?
2. What is your timeframe?
3. Will you support 4010A1 and 5010 concurrently?
4. Will there be a charge for the upgrade?
5. When will the upgrades be available?
6. Will there be a sufficient lead time to test new software prior to the Jan. 1, 2012 compliance date?

In addition to asking questions, Hildebrand suggested practices make sure they have updated, written business-associate agreements with their partners that state they "will uphold HIPAA" and "will be ready for 5010 and ICD-10 transactions."{C}

Train now before the rush

Whether you've started, completed, or are in the midst of testing 5010 transactions with your business partners, it's not too early to start making the most of your time while you wait, by starting on other aspects of ICD-10 training. Because the code change is a lot to digest, here are the actions suggested by coding experts and savvy practices:

Assess the Situation. The training required for ICD-10 will vary at different practices based on the size of the staff and who does coding. "The small practice needs to look internally," says Hildebrand. "They need to talk to anyone who has any involvement with the ICD-10 coding. It's not just the clinicians who need to know the diagnosis coding. It's the back-office staff, it's anyone who gives referrals, it's anyone who has anything to do with their billing." As part of its "Assessment Phase," Hildebrand suggests practices ask themselves: "Who is going to need training?" and "What kind of budget do we have for it?"

Give a Good Overview. Training physicians to use more than 100,000 codes would waste a lot of time, as most practices won't use all available codes. At Hattiesburg G.I. Associates, Allen says the practice has already participated in hour-long ICD-10 training webinars cosponsored by its data clearinghouse vendor, Navicure, that have given staff an overview of the changes ahead. Though physicians and supporting staff will require more hands-on training in using the codes later on, taking this initial step has made the task of adopting ICD-10 a lot less daunting for the four-physician clinic. "The sessions have helped us look at the practice as a whole and helped [physicians and staff] understand how the whole practice of gastroenterology will change," says Allen.

Train, But Not Too Much, Too Soon. With two years to go until the coding changes take effect, there's no need to fret about getting your staff ready to actually use the new seven-digit ICD-10 codes just yet. Most coding experts agree that actual training on how to use the codes will come in phases, and that it will be at least another year from now before coders and physicians start trying out the new ICD-10 codes while continuing to use ICD-9. "It's human nature to forget things you haven't been using," says Hildebrand. "If you train people all at once, there are going to be people who forget." More important is to train clinicians on how to gather more specific information at the point of care (to support the more-detailed ICD-10 codes), or train coding staff on how to edit codes to ensure they're accurate before claims are processed.

Challenges ahead

The good news is that it's only 2011, so as long as you're in the process of implementing 5010, you should be on schedule. Still, there are a number of potential challenges likely to arise as the calendar creeps closer to implementation time.

Consultant John Dugan, the ICD-10 practice leader for market research firm PwC, notes the first challenge that physicians will be faced with: a new burden of accurate code submission, which will be particularly acute at family physicians' offices. While this may not be a big deal for seasoned coders who have planned for the additional training, it is a big deal for physicians who may have to tweak their clinical practices.

"You may have a current list of common diagnosis codes that's one page long, and guess what? That list will be five pages long," says Dugan. "You're going to have a certain panel of tests for [common] conditions. The difficulty is making sure they're updated."

Dugan says he anticipates a greater number of denials if documentation and procedures lack specificity.

"Ultimately that's going to come back to the physician," he says.

To help physicians get acquainted with ICD-10, a number of organizations, including the AAPC and AHIMA - which offer full-scale accredited courses to professional coders at large practices and healthcare organizations - also offer short and long coding workshops and webinars that could help physicians think critically about how they might assign the new codes to patients with common ailments.

"Even now, we're finding that providers are not picking out the most specific codes," says Jimenez. "From a payer's perspective, you should be able to tell [them] what you're treating on that patient. The average person is looking at 40 to 60 hours of training."

At Hattiesburg G.I. Associates, Allen says there will be a greater focus on asking patients the most important questions related to their G.I. condition, as well as obtaining patient information from a patient's past physicians. This will be a challenge, says Allen, as "sometimes patients don't disclose as much as they should."

Therefore, practices should expect a bit of a learning curve and decreased productivity as clinicians get used to life under the new codes. But in the end, the result will be more accurate patient data on common diseases and diagnoses, which will, CMS hopes, improve patient care and outcomes.

"The workflow of ICD-10 is not just to deal with the day-to-day billing software," says Hildebrand. "It starts with how patients are documented. It starts with the very first point of contact with that patient."

In Summary

Given the magnitude of changes practices will have to make - from the way physicians will conduct patient exams to how they process claims - it's alarming that only 36 percent of 722 physician practices in our 2011 Technology Survey told us their technology is ready for the coming transition to the ICD-10 code set. Here are some points to remember:

• On Jan. 1, 2012 healthcare organizations must swap standards for electronic healthcare transactions from Version 4010/4010A1 to Version 5010, which accommodates the ICD-10 codes.

• Version 5010, which is incorporated into practice management systems, EHRs, and any other technology system used to transmit patient data, is necessary for claims, eligibility inquiries, and remittance advices.

• Train, but not too much, too soon. It's important to train clinicians and coders on the new ICD-10 code set, but don't expect them to master the changes all at once. Introduce basic information, and revisit select training the closer you get to implementation.

From ICD-9 to ICD-10

How would some common procedures be coded differently under the ICD-10 code set? Here are some examples, courtesy of healthcare consulting firm Beacon Partners.

Marisa Torrieri is an associate editor at Physicians Practice. She can be reached at

This article originally appeared in the September 2011 issue of Physicians Practice.

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