10 physician documentation, billing considerations for ICD-10 impelmentation

While CMS announced the new effective go-live date for ICD-10 is Oct. 1, 2015, it's important providers not put off the training and other preparations require to prepare their organizations for the ICD-10.

In April, the HHS announced that it was delaying CMS' implementation of ICD-10. Oct. 1, 2014 was no longer the "go live" date.  DightonPackardHeadshot

The delay came as a surprise to many in the healthcare community. Providers and payers had already invested millions of dollars in software updates and staff training to be ready for Oct. 1. Now what?

Before answering this question, it's important to consider why ICD-10 is being implemented in the first place. Andy Weiss, EmCare's vice president of pre-billing operations, explains that the International Classification of Diseases coding methodology was adopted worldwide in order to provide an apples-to-apples platform for aggregating and analyzing disease data.

"The U.S. healthcare industry has been using the ICD-9 code set since 1970 while most other countries in the world have already migrated to ICD-10," he says. "ICD-9 is old and outdated with many of the coding terms inconsistent with current medical practice. The ICD-10 expanded coding set allows healthcare providers to stay on top of emerging diagnosis, enabling public health experts to more precisely track and monitor multiple co-morbidities and diseases and injuries."

Having more specific codes will, however, be beneficial to healthcare providers. "ICD-10 is not going to change the way we practice medicine, but it will change the way we document in medical records," says Daria Starosta, MD, director of practice improvement for EmCare. "A silver lining to the more complex coding system may be that with more specificity, a hospital's case mix index may change, resulting in a more complete picture of the patient population being treated by the hospital and potentially more appropriate reimbursement."

While CMS announced the new effective go-live date for ICD-10 is Oct. 1, 2015, it's important providers not put off the training and other preparations require to prepare their organizations for the ICD-10.

Why is there so much pushback in the U.S.?
One reason may be the complexity of the ICD-10 coding set. ICD-9 has about 14,000 individual codes, while ICD-10 encompasses approximately 69,000 individual codes. More codes allow for better specificity. Codes jump from up to five digits in ICD-9 to as many as seven digits in ICD-10. The new codes include category, etiology, anatomic site, severity and extension — much more detailed, specific information about a particular disease or health issue.

Take, for example, a finger laceration. Currently under ICD-9, there are three codes for this diagnosis. ICD-10 has 153 potential codes for finger laceration with the correct code depending on which finger, nail involvement, presence of a foreign body, detailed type of injury and whether this was initial, subsequent or sequela.

"There is no denying that ICD-10 will have a broad impact on the healthcare industry," says Mr.Weiss. "Coders, CDI staff, providers, patient access professionals, case management, IT and data analytics, patient financial services, nearly all sectors of healthcare will feel the changes that ICD-10 will bring. That's because everything from staffing and workflow to education, productivity, documentation, policies and procedures, finance and compliance will be affected."

One of the biggest unknowns about ICD-10 is its potential financial impact on providers and payers. A February report by the American Hospital Association
estimated the costs for complying with the ICD-10 change to be between $56,639 and $226,105 for small practices. However, average practice spending to date has fallen short of this.

Additionally, Many analysts have advised providers to set aside cash reserves in case payers aren't ready to accept ICD-10 claims.

Mr. Weiss offers a helpful equation: Inadequate documentation = unspecified coding = lack of medical necessity = denied claims. Or, in the words of Dennis Winkler, director of technical program management for Blue Cross Blue Shield of Michigan, "Physicians may be ICD-10 compliant, but if they abuse the 'other' or 'unspecified' codes, payment will not occur if a more specific alternative exists."

7 clinician considerations
To ensure clinicians are prepared for the new documentation changes ICD-10 will require,Dr. Starosta highlighted these key points that physicians should keep in mind about ICD-10:

1. Severity of illness indicates the acuity of pathophysiologic changes that have occurred and provides a basis for evaluating resource consumption and the amount of patient care provided. One example is coding for aspiration pneumonia versus pneumonia.

2. One of the biggest coding challenges for the emergency department is syncopy as there are many unspecified syncopy codes because the underlying cause is unknown at the time of diagnosis.

3. When documenting multiple final diagnoses, the order of the diagnosis is important. The first diagnosis listed should be the principal one that addresses the primary reason for the patient visit. Other conditions that are not the primary reason for the visit should be addressed after the principal diagnosis. In cases where the diagnosis is unclear, using signs and symptoms for the final diagnosis is still acceptable under ICD-10.

4. The inclusion of laterality is important – left, right, bi-lateral – because it comprises up to 35 percent of the ICD-10 code sets.

5. ICD-10 requires much more precise anatomic description of the injury or condition. Remember, location, location, location!

6. Sprain and strain mean two different things in ICD-10. A sprain usually involves tendons and ligaments, while a strain usually involves muscle, especially in the lower back and ankle.

7. Many EMR vendors have not updated their software to accommodate ICD-10. One upside to the delayed implementation is it will give these vendors more time to fix ICD-10 related issues that many hospitals are currently experiencing.

Billing considerations
On the billing side, Mr. Weiss shares some recommendations for billing and coding preparations ahead of ICD-10 implementation:

1. A dual code entry methodology has been developed to minimize coder productivity losses. Coders will have two ways to assure they are using the correct ICD-10 code – cascading entry and key word look up. If a coder knows the general code for a specific disease, for example S52 for fracture of the forearm, the system will guide him or her to build the complete correct code.

2. Keyword look up enables coders to enter key words from the chart to drill down to the complete correct code. EmCare coders using the company’s proprietary system will be trained to avoid using unspecified codes as much as possible. The EmCare system will also prohibit the entry of codes that mismatch a patient’s gender or age.

3. Also built into the system is the knowledge that certain ICD-10 codes must always be primary. The internal system is being revamped to generate an ICD-10 to ICD-9 crosswalk to help coders transition exclusively to ICD-10.

Dr. Dighton Packard has practiced emergency medicine for more than 35 years. In addition to his duties as CMO for EmCare, Dr. Packard also serves as CMO of Envision Healthcare, the parent company of EmCare. He is chairman of the Department of Emergency Medicine at Baylor University Medical Center in Dallas and is a member and vice chair of the board of trustees for Baylor University Medical Center. He currently serves as chairman of the board of managers for the Baylor Quality Alliance; Baylor Healthcare Systems’ accountable care organization. He has served as vice president for the board of directors of the American College of Emergency Physicians and in 1997 received the James D. Mills Award for outstanding contribution to emergency medicine. He is currently the past chair of the Emergency Department Physician Management Association and serves on the board of directors. He is past chairman of the board of the MedicAlert Foundation International. He received his BS from Baylor University in Waco, Texas, and his MD from the University of Texas Medical School at San Antonio.

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