October 1, 2013 will mark a momentous, system-wide change for physicians in practices throughout the United States. That is the day the International Classification of Diseases, 10th Revision (ICD-10) code sets go into effect. Everyone covered by the Health Insurance Portability and Accountability Act (HIPAA)—not just those who see Medicare and Medicaid patients—will begin using the new code set.
“ICD-10 codes are more specific and therefore more numerous,” said Rudy Molina, MD, chair of the Insurance Subcommittee for the ACR. There were around 14,000 available codes under ICD-9; this will increase to 68,000 codes with ICD-10.
The group should look at current systems and work processes using ICD-9 codes. This includes clinical documentation, encounter forms/superbills, practice management systems, electronic health record systems, contracts, public health, and quality reports. Wherever ICD-9 codes appear, ICD-10 codes will take their place. Doing this focuses the transition group on what needs to change and the personnel involved making those changes happen.
“Identify as much educational and operational information as you can for free,” said Robert Tennant, MA, senior policy advisor for the Medical Group Management Association (MGMA) in Washington, D.C. “Use resources offered by the MGMA, ACR, AMA [American Medical Association], or any other group you belong to.”
In ICD-10, the level of specificity is much greater than in ICD-9. Many coders don’t have the knowledge of anatomy and physiology needed in the more clinically driven ICD-10.
—Deborah Grider, CPC
Look for Help
There are many places to go to get suggestions on how to best implement the changes needed. Most of the involved organizations are offering information on their websites for members and others (see “For More Information,” p. 34).
“The ACR will have extensive information available through the website, at the annual meeting, and in some major cities,” says Chung. “The American Medical Association has suggested timelines and budgets for members, as does the MGMA and the AAPC. The Centers for Medicare and Medicaid Services [CMS] is also a major provider of helpful hints.”
Speed Is of the Essence
“Many practices think this is just a software upgrade with no urgency in getting ready,” said Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, president and CEO of AAPC. “The ICD is used in many areas of the practice including financial, practice management, and electronic health records. Many think this is a 48–62-month transition, which means some are already way behind.”
Contact Vendors
An early contact every practice should make is with their information management vendors. “Practices need to be proactive in reaching out to their vendors,” Tennant says. “Get them on the record about when they will be providing updates to computer programs and when you can expect to begin testing. Nail down what it will cost so that budgeting can begin.”
Ask if they will be upgrading the current version of your software or if you need a different program. Will your current computers work?
How our payors are going to implement the changeover is another possible financial impact. With a more specific coding system, will they pay the same amount as before or will they decide to cut payments for less severe cases?
—Rudy Molina, MD
Look closely at the maintenance contracts you have. They may require the vendor to update your systems at their expense. Find out if this also covers training expenses.
Don’t forget to include vendors for other practice management and reporting systems. Programs for financial management, bill tracking, statistical reporting, and even electronic health records will have to be able to talk to one another.
Next, talk to your clearinghouse or billing service. Ask them when they will be ready for testing. Will their programs be able to support both ICD-9 and ICD-10 codes, or will billings before October 1, 2013, have to be handled on a separate system?
Talk to Your Payors
“The third-group providers need to be actively involved with is their payors,” Tennant says. “Stay in touch with your payor’s provider service contact to find out when each of your major plans will begin accepting test claims. Will they be using the ICD-9 to ICD-10 crosswalks from CMS or proprietary versions? Will there be a specific individual or help desk available to work with as problems arise?”
There will be differences in how various sizes of practices address these issues. The practice with one or two physicians will probably see a larger percentage of the practitioner’s time taken up than the bigger operations.
“Much of this is being taken care of at the corporate or regional level,” says Raymond Hong, MD, MBA, chief of rheumatology at the Ohio Permanente Medical Group in Parma. “There are currently clinical representatives included; the people on the front lines will be involved later.”
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Changes Will Be Costly
Although information systems are the 800-pound gorilla in the room, the financial impact weighs in at around 799 pounds. Estimates of the costs of implementing ICD-10 vary widely.
For example, Nachimson Advisors, LLC, estimates it will cost the typical small practice with three doctors and two administrative staff around $83,000 to fully implement ICD-10. For a large practice employing 100 providers and 64 staff members, the price tag could be as much as $2.7 million.
Some of these costs will be easy to quantify and plan for. After consulting with your information management vendors and looking at the maintenance contracts, the practice should have a good idea of how much to budget for new programs, new hardware, and training on that part of the changeover.
Other areas will require further study before a budget can be put in place. Staff competence in the software and hardware is the first step. After that comes the training of appropriate people on the actual codes.
The monetary impact will be very specific to the practice. Smaller practices may find it easier and more efficient to have their coders and other back office staff use webinars and in-office training. Others may send staff to conferences or have trainers come to the practice. In that case, you may also have to pay travel expenses.
Some experts suggest coders should receive training in anatomy and physiology, too.
In ICD-10, “the level of specificity is much greater than in ICD-9,” said Grider. “Many coders don’t have the knowledge of anatomy and physiology needed in the more clinically driven ICD-10.”
For example, in ICD-9 there are 11 codes that rheumatologists can use to code for gout. In ICD-10, there are over 200 codes with more specificity to clearly define the diagnosis (see Table 1, at left).
It is also strongly suggested all physicians be included in training. As with ICD-9, one of the major determinants of payment is what the clinician puts in the chart.
“ICD-10 is much more involved with clinical aspects, terminology, and anatomical specificity,” Chung says. “The hardest thing for coders will be to reprogram their minds and refocus toward diagnosis.” [Editor’s note: Be sure to read “2013–A Whole New World” on p. 9 and “ICD-10 from a Coder’s Perspective” on p. 18 for more information on preparing your practice for ICD-10.]
Disruptions in Practice
After the practice has a handle on who needs to be trained, another thing to budget for is disruptions caused by people unavailable for regular duties. Is it best to scale back appointments for a time? Do you pay overtime to bring people in and maintain a full schedule? Does it make financial sense to shut down entirely and get everyone trained at once?
Also, plan for the early days of implementation. Will the practice cut back on patients? Will your vendors and payors have people and phone numbers dedicated to troubleshooting problems? What is the plan for providing bug fixes? How much of these costs are included with new programs or under maintenance contracts?
“For most updates, we reduce schedules by 10% to 25% for up to two weeks,” says Dr. Hong. “This gives adequate time for problem solving and additional updating if needed. We will probably do the same thing during the ICD-10 changeover.”
Following a review of the short-term costs and dislocations, the practice should begin thinking about longer-term impacts.
Productivity Concerns
Tennant suggests that physician productivity will see a decrease for the first six months following transition to ICD-10. He is also concerned that decreased productivity may be ongoing following implementation. Grider notes that the CMS foresees a productivity cut of 60% over the first year. Much of this will be related to increased clinician time for each encounter and taking longer to complete the more in-depth charting required for payment.
“How our payors are going to implement the changeover is another possible financial impact,” said Dr. Molina. “With a more specific coding system, will they pay the same amount as before or will they decide to cut payments for less severe cases? This is a big unknown from our standpoint.”
Both systems have an “unspecified” code. Will payors accept that or require more information to better use the depth of information new codes make available?
Financial contingency planning is another concern that must be addressed. Because there will be no pilot before changeover, little is known about potential problems. Experts have forecast everything from a smooth changeover to computer-directed Armageddon, and all possible scenarios in between.
“In case there is a meltdown, practices should prepare by banking reserves, establishing lines of credit, and arranging for needed loans in advance,” Tennant says. “While I don’t really expect any major problems, it is better to protect the business continuity of the practice by having these in place in case they are needed.”
The key to a successful change is careful planning that starts immediately. Otherwise, practices risk severe financial consequences, especially under current general and healthcare economic conditions. “The physician’s world is being turned upside down with healthcare reform, the Medicare/Medicaid affordability act, and mandates for electronic medical records, among others,” says Chung. “If practices are not very careful, they will find themselves overwhelmed with the transition to ICD-10, which could cause major disruptions in cash flow. Preparation is the key to success for the next generation of coding. ”
Kurt Ullman is a freelance writer based in Indiana.
