Beginning December 31, 2011, rheumatology practices will begin to see significant changes in how medical diagnoses are reported. The Centers for Medicare and Medicaid Services (CMS) has mandated that hospitals and medical practices adopt the International Classifications of Diseases, Tenth Revision (ICD-10) by October 1, 2013. The transition may provide many benefits, but also could be very expensive and time consuming for rheumatology practices.
“ICD-10 has been in use around the world outside of the United States since 1994,” says Jonathan Kay, MD, professor of medicine at the University of Massachusetts Medical School in Worcester. “The adoption of ICD-10 will bring the U.S. into conformity with the rest of the world and allow us all to speak the same language when describing diseases. After this change, the most significant advantage will be that data from American patients will be able to be captured using the same terminology as elsewhere in the world and can then be merged with data from other countries to better see patterns and burdens of disease.”
The World Health Organization (WHO) promulgates the ICD system as a consensus document. The WHO generally releases a set of codes as a baseline. Each country takes this document and creates its own version based on its needs.
ICD-10 has two different parts. The ICD-10PCS (or Procedural Coding System) is mostly used by hospitals to code for inpatient procedures. Individual practices of all sizes will be required to use ICD-10CM (Clinical Modifications).
New System More Robust
The new classification system is much more robust than the previous version. Currently, ICD-9-CM contains more than 17,000 codes while ICD-10 contains more than 141,000 codes and accommodates a host of new diagnoses and procedures. ICD-10 increases the number of digits that can be used from five to seven, allowing for much greater specificity when describing a diagnosis. (See “A New Era of Coding for Rheumatology Practices” on page 20 for more information on the new coding system.)
Unlike ICD-9, ICD-10 is structured more toward body systems. Most rheumatology codes will be in the musculoskeletal section. Codes will also be alphanumerical, instead of the current use of mainly numbers.
ICD-11 Revision in the Works
With all the attention being given to the ICD-10 changeover, it may be disconcerting to learn that the WHO is beginning work on the 11th edition of the system. However, most of the experts interviewed here don’t think that this will lead to another major change any time soon in the United States.
“As good as ICD-10 is, we are already beginning to make major revisions in ICD-10 to make it even better,” says Dr. Kay, who is chair of the Rheumatology Working Group of the Internal Medicine Topic Advisory Group for the Revision of ICD-11 at the WHO. “Currently, we are on schedule to release ICD-11 in 2015.”
However, release of the new version by the WHO is just the first step. The baseline revision is then given to the various countries, which make changes to fit their specific needs. This, too, takes time. Finally, after the U.S.–specific standards are published, CMS has to decide if it wants to make the change and, if it does, go through the entire rulemaking process.
“ICD-11 is the least of our worries,” says Tennant. “At the earliest, adoption of ICD-11, if it even happens, is five to seven years away.”
Rude Awakening Ahead?
“The changeover is something that is of the utmost importance to all practices,” says Antanya Chung, CPC, CPC-1, CRHC, CCP, and director of practice management at the ACR. “If appropriate changes are not made by the various deadlines, practices will be in for a very rude awakening as flow of payments will come to an abrupt halt. CMS has been adamant that there would be no grace periods.”
Denise Buenning, MsM, director of the Administrative Simplification Group (ASG) in CMS’ Office of E-Health Standards and Services, strongly reinforces that message.
“In the final rule, we extended the proposed compliance date from October 1, 2011, to October 1, 2013, to accommodate industry feedback that more time would be needed for systems and business process transitions to ICD-10, and there is stakeholder support for CMS adhering to that timeline. Because ICD-10 is foundational to many other healthcare initiatives, including reducing fraud and abuse, providing more robust patient care quality data, and supporting problem lists in electronic health records, we do not anticipate changes to the compliance deadlines for either the Version 5010 or ICD-10.”
There are two major deadlines that practices should prepare for. The first is January 1, 2012, when CMS has mandated all computer billing must be updated to use Version 5010 of the electronic standards for health transactions. The standards are required by the Health Insurance Portability and Accountability Act (HIPAA) for all transactions and not just for those submitted to government programs.
“The Version 5010 allows rheumatology practices to send and receive electronic transactions with their health plans and others,” says Robert M. Tennant, MA, senior policy advisor for the Medical Group Management Association in Washington, D.C. “This lets the practice run patient eligibility verifications, submit claims, and several other critical financial transactions.”
According to Buenning, all vendors of billing services and programs should have already concluded internal testing and be ready to start external dry runs between the provider, clearinghouse (if used), and payor. CMS’ Medicare Fee for Service Program began to accept test claims with the basic Version 5010 standards as of January 1 and will continue to pay claims submitted using the current Version 4010/4010A standards until December 31, 2011. CMS expects to accept claims in production using the errata Version 5010 standard in April of 2011.
Testing Should Start Now
The experts interviewed here suggest that practices immediately contact their practice-management system software vendor to find out when and if they will be updating their software to allow the practice to use Version 5010 standards in external testing with their health plans. Depending on how a specific practice is structured, they may also need to check with other vendors such as its electronic health record company to address compatibility issues.
The experts also strongly suggest that practices start sending test transactions to health plans and clearinghouses as early this year as possible so that there is adequate time to iron out problems before the end of 2011. Otherwise, there is a risk that the practice will not get paid until their systems are in compliance with the Version 5010 mandate.
“The transition to Version 5010 will have a large impact on information technology staff throughout 2011,” says Kim Reid, CPC, CEMC, CPC-I, and ICD-10 expert for the American Academy of Professional Coders. “The operations of the practice (documentation, coding, and billing) will not feel the effects of ICD-10 until the end of 2011. This is when training on the new system should begin to make it a smooth process.”
ICD-10 change-over websites
ACR
www.rheumatology.org/practice/office/coding/icd10.asp
Centers for Medicare and Medicaid Services
www.cms.gov/ICD10
American Academy of Professional Coders
www.aapc.com/ICD-10
America’s Health Insurance Plans
www.ahip.org/content/default.aspx?docid=31192
World Health Organization
www.who.int/classifications/icd/en/index.html
Centers for Disease Control and Prevention
www.cdc.gov/nchs/icd/icd10cm.htm
Heavy Lifting Ahead
The really heavy lifting for the practice has to be completed by October 1, 2013, the deadline CMS has set for implementation of ICD-10. “ICD-10 is much more invasive to the practice,” says Tennant. “It will impact all areas of the practice starting virtually when the patient first comes in the door. We have never gone through a change before where nearly every physician, nonphysician provider, coder, and even administrative staff must be brought up to speed in a hurry.”
As with the change to Version 5010, one of the major concerns will be in the IT area. Not only will the expanded ICD-10 code set need to be added to the computer systems, but different programs may be required to communicate with each other for statistical or management reasons.
Updating the payment system is stressed due to the fact that the ICD-10 code sets far exceed those of ICD-9. ICD-10 coding of diseases includes health related conditions and provides a higher specificity at the sixth-digit level with the extension of a seventh digit. The use of these additional codes will not be optional.
Other less technological parts of the practice will also be affected. For example, a practice’s billing sheet or superbill will have to be changed, and probably expanded, to include many more diagnostic possibilities.
After the initial learning phase, users may find the new system is actually easier to use. “ICD-10 is much more versatile than ICD-9,” says Dr. Kay. “Once we get used to using it, it will be a much easier classification system to use since similar types of diseases are grouped together. It is a much more precise comprehensive system of classifying disease.”
Resources Available
The ACR will be very active in helping rheumatologists and their staff prepare for both Version 5010 and ICD-10 implementation.
“The practice management section of the website (www.rheumatology.org) will have frequently updated links to Version 5010 and ICD-10 resources,” says Chung. “That is only a part of what will be available through the College.”
Through its practice management office, ACR will also be sponsoring webinars and other training classes. For at least the next three years, this will be a subject of presentations at the ACR/ ARHP Annual Scientific Meeting. The ACR website will also include links to outside sources, such as CMS and other related associations.
“This is not something that practices are going to be able to download from the Internet and install on their computers the day before,” says Chung. “Physicians and their practices will need extensive training to be ready for the transition and should stay in touch with ACR and attend courses. This is not one of those changes where individuals will be able to play catch up—this will shake the core of rheumatology practices because services will not be paid if the coding and billing systems do not meet the necessary criteria!”
Kurt Ullman is a freelance journalist based in Indiana.
