Medical Practices Should Add ICD-10 to their Compliance Plans

October 2, 2013
Alicia Shickle, CHC, CPC, CPCO, CPPM

With ICD-10 only a year away, your medical practice needs to build ICD-10 into its compliance plans for 2014 and beyond.

The Oct. 1, 2014, ICD-10 implementation date is quickly approaching. The number of providers who have yet to start preparing is staggering considering the number of changes practices will endure.

To ensure your practice is thoroughly prepared for the transition, it's important to build ICD-10 into your 2014 and beyond compliance plans. This plan should include conducting ICD-10 risk assessments, auditing and monitoring, training, encouraging open lines of communication, and ensuring incident management.

Here's more on what each of these areas should entail:

Risk assessments. Understanding the potential vulnerabilities to your practice and identifying how they will affect work flow and revenue integrity will be crucial to maintaining compliance, avoiding potential fraud and abuse allegations, and minimizing the effects to the bottom line. Conducting an initial practice work flow or impact assessment is the first step.

Consider all the different areas that may be affected by the transition:
• Management will need to develop new policies and procedures, vendor and payer contracts will need review and revision, budgets will have to be developed, and training plans will need to be developed and implemented.
• Clinical areas will have to understand changes to patient coverage and make the necessary revisions to superbills (which may prove impossible), as well as other forms, including Advanced Beneficiary Notices (ABNs).
• Physicians will face major changes to documentation requirements as the need for specificity will increase. They will also need code training.
• Nurses will face documentation requirement changes, orders that look different, and more complex prior authorizations.
• Lab orders will need to be updated to incorporate the increased level of specificity, and health plans may have new requirements for ordering and reporting services.
• Practices will need new billing and coding policies and procedures manuals, as all payer policies may be revised.
• Front-office staff will need to understand how the changes will affect them and patients. HIPAA privacy policies may need to be revised and staff will need to educate patients.
• Systems will likely need updates and work flow may change for managing patient encounters.
• Coders and billers will need code set training and updates on policy and payer contract changes to ensure payments are timely and accurate. Understanding contractual agreements may help to identify incorrect payments early and minimize the need for possible self-disclosures.

Auditing. Conducting a baseline audit on your documentation will help you determine the level of training physicians will need to bring their documentation up to par for ICD-10.

Ten records per provider are usually sufficient to determine if documentation meets the requirements for ICD-10. Note: Reviews to date show that in many cases documentation does not even meet the requirements for ICD-9.

Auditing documentation will help mitigate risk to revenue integrity and potential false claims issues. Ensure everyone in your practice understands the importance of the clinical record documentation and that it must match the coding.  Audit claim submissions both before and after payment to identify and address incorrect coding issues.

Training. Implement training based on the audit findings. The more familiar physicians are with the new documentation requirements, the easier it will be when the transition takes effect.

Coders and billers are going to need code set training, and all staff will need training to understand how their responsibilities will change and what will be required and expected from them.

Open lines of communication. Strong communication between leadership and staff will help identify potential issues. Ensure everyone knows what changes are necessary and encourage them to report concerns immediately so that corrective action can begin swiftly.

Routine staff meetings may provide additional opportunities to engage everyone in overall implementation progress and address issues.

Incident management. Set the stage that noncompliance will not be tolerated. When areas of potential noncompliance are reported or identified, keep appropriate documentation of the incident and any investigations, and swiftly implement a plan of corrective action.

Additional training, follow-up, and thorough records will ensure no further compliance issues arise. Do not hesitate to seek assistance from an experienced health law attorney, if needed.

Alicia Shickle has over 27 years of clinical and administrative healthcare experience. Prior to joining AAPC as director of compliance product development, she worked for the law firm of Hodgson Russ on the business litigation and health law practices fraud and abuse intervention teams. She also worked as a senior healthcare consultant for RSM McGladrey in revenue cycle integrity, work flow, operations, and compliance. She was a medical practice consultant for primary care, physician office laboratories, FQHC, DT&C clinics, and other provider categories. She was a primary-care practice administrator for over ten years. She also taught medical billing and coding courses, including anatomy and physiology, medical terminology, and third-party reimbursement structure.