Whether or not you perform your own diagnosis and procedure coding, you are likely to have been exposed to the controversy surrounding ICD – 10. Physicians characterize it by the five times more diagnosis codes, nineteen times more procedure codes, the high level of specificity, and the unusual “new” codes. It is amusing to focus on the “Struck by turtle”, W59.22, “Water skis on fire” V91.07, or “Space craft collision” V95.43 codes. What is not amusing is the amount of time and effort needed to incorporate the new system into your practice. Far worse is the lack of preparation across the country, especially among family physicians. A survey conducted by American Health Information Management Association (AHIMA) in June 2015 indicates 50% of hospitals and 17% of physician practices conducted ICD 10 diagnosis and procedure code testing; however, only 6% were family physicians. Medicare data on 800,000 active physicians, seeing on average 10-15 patients per day, only managed to test 1,000 bills/day over a 2-week period in June of this year. The lack of preparedness reflects inadequate buy-in from physicians. Physicians seem to believe the transition to ICD-10 will result in the collection of large volumes of data that will eventually be used against them. (Healthcare Informatics 4/15) Either that or physicians they are all putting their faith in computer systems that will somehow rise to the occasion and support their revenue flow. Two things are clear. First, ICD-10 is here to stay. It is scheduled to become the rule of law on Oct 1, 2015. Second, a lack understanding as to the why, what, when, how to, and what to do now is leading to resistance of the new system.
Data collection in healthcare has been around for a long time. Letters and numbers are assigned to disease states and procedures every day. ICD-9, the diagnosis code system used today, was implemented in 1977 by the World Health Organization and is based on 1970s medicine. It was never designed to be a reimbursement tool. The ICD-9 system has been shown to be poorly organized and not specific enough for the myriad number of diagnoses and procedures performed in today’s healthcare environment. Foe instance, laparoscopy gets lumped in with open surgery and there is no distinction between excision, freezing, laser and cauterization of treating a skin lesion.
ICD – 10 brings with it a host of new codes and vast potential for data collection. As physicians, we all realize the value of date driven decision-making. Those new codes and their higher specificity will increase payment efficiency through quicker payments; higher payments for sicker patients, less rejected claims, and reduced fraud. Patient care plans will be directed to the right patient at the right time. Physicians will be alerted to public health threats and informed of the effectiveness of new procedures. The coding system is not meant to hinder physicians; rather its goals lie in improving the care delivered to patients.
Outpatient encounters use ICD-10 for diagnosis and CPT for procedures. Hospitals will use ICD- 10 for both diagnosis and procedure coding. There are 7 digit spaces in an ICD-10 code. That doesn’t mean all codes have seven digits. The first three digits designate which of the 22 categories the diagnosis falls. The next three give information on severity, etiology and laterality. The seventh digit, an extension code, may or may not be present. The key is to produce a billable code. C61 is a billable code for prostate carcinoma. J00 codes the common cold and it also is billable. N50 is the code for breast cancer and is not billable; it needs more specificity. Billable codes must have at least three digits, but can have up to seven. If your codes do not contain the proper level of specificity; they are rejected. There are unspecified codes used when the information needed to achieve appropriate specificity was not documented in the patient’s record. There are codes for signs and symptoms when the diagnosis in unknown and codes for under dosing and noncompliance. There are even external causes codes in case a patient’s water ski catches on fire. ICD-10 contains a clear method of organization to the codes. Following a code from the three-digit category through to its proper level of specificity actually makes sense in a way that ICD-9 coding never did.
ICD-10 codes will be accepted on bills submitted to payers beginning on Oct. 1, 2015. If a bill is submitted on Oct. 1 with ICD-9 code, it will be rejected. The AMA and CMS have reached an agreement on phasing in the transition. For a period of time, codes that lack the proper level of specificity but are at least in the “same family” will be accepted. Unfortunately, “same family” has yet to be defined. Allowances will be made for both provider and payer systems that produce coding mistakes. Those allowances will only be made for systems producing ICD-10 billing codes. There are two bills in Congress that are attempting to allow a period of either/or coding. However, the AMA/CMS agreement makes an extension a moot issue.
The lack of specificity of ICD-9 diagnosis codes allowed most physicians to use a “cheat sheet” of their most common diagnoses. It seemed that 90% of codes were the same dozen or so. This required only an occasional referral to the ICD-9 book to look up a diagnosis. Say goodbye to that process. With ICD-10, there are just too many codes and the level of specificity required may make listing the same code a rare occurrence. The new coding process will and must involve computers and software. Keyword searching for ICD – 10 codes will be the new normal. It is not much different than initiating a Google or Bing search. The quality and specificity of keywords will characterize the accuracy of the search. Each EHR or mobile app has a different process by which keywords will be used to identify the appropriate ICD-10 code. Sorry to say, this process begins with trial and error and proceeds along a learning curve that is influenced by the chosen EHR or mobile app. One thing is clear, training and practice are of the upmost importance. Physicians should be testing their practice’s ability to submit ICD-10 codes. Although end-to-end testing is no longer available, Medicare will accept Acknowledgement Tests until Sept. 30. Coding an identical “test” bill with ICD-10 coding and following the Acknowledgement Testing procedure will return a rapid reply of acceptance or not. The overall 90% acceptance rate of Acknowledgement tests by Medicare, down from 97% for ICD-9 codes, may signify an overall lack of practice and preparedness among those submitting tests, and those practices actually engaged enough to perform testing. A much lower acceptance rate must be anticipated for those practices not involved in testing.
What to do
“If you didn’t document it, you didn’t do it,” is a familiar phrase for all physicians since the first note written in medical school. ICD-9 was very forgiving in order to streamline documentation issues. ICD- 10 is not! If you code, it is essential to ignore all but what is recorded in the record. What you remember as relevant to the coding should also appear in the record. If you have others coding your work, the record will speak for itself. If the level of specificity does not appear, that encounter bill will not be paid. That record will then come back to you for re-coding and who needs more work to do at the end of the day when all you want to do is go home to your family.
So, find software that works for you and practice with it. If your EHR’s keyword search engine is not working for you find another. There are several very inexpensive mobile apps. Know that each one works differently and that each has its own keyword search functionality. Don’t expect it to jump into your hand and magically find codes. A little practice goes a long way to increase your efficiency and decrease your frustration level.
Train your coders, make them practice, and test them. Professional coders vary widely in their efficiency using ICD-10 based on the level of training and practice. Practice had two features. The first is to gain a level of efficiency in producing codes. The second is determining if your codes are acceptable to Medicare through participation in Acknowledgement Testing. No one wants a 50% acceptance rate on Oct 2.
ICD- 10 will be the only billable coding system beginning on Oct. 1. The time for resistance is past. The systems that process payments are ready. Luckily, there are tools to guide providers to the right codes, computers to send them to payers, and a system to test them and inform you on how well you are doing. It is not too late to embrace the change and get ready. Patients depend on a practice infrastructure that is healthy and available. One of the most important features of practice infrastructure and worthy of protection is your revenue cycle.
David Joyce M.D. M.B.A. Director of Educational Programs, Essential Seminars for Physicians LLC.
Paul Gurny M.B.A. M.S. Managing Director, Essential Seminars for Physicians LLC., Senior Professional Instructor, Johns Hopkins Carey Business School