ICD-10-CM Insight

By Kathy Rowland, CPC, CEMC, CPC-I, CHC

You have heard from many qualified, trained professionals in ICD-10-CM over the last several months, with some very informative articles on varying ICD-10-CM topics. As you prepare for the ICD-10-CM transition and implementation in your practice, you may benefit from hearing other health professionals speak on the topic of ICD-10-CM. I asked several individuals in key positions at different practices the question, “What is your biggest concern with ICD-10-CM implementation?”
Their responses can offer you helpful insight as you continue to prepare for the transition to ICD-10-CM.
Medical Director
“My main concern is that one of the stated advantages of ICD-10 is, ‘Specificity improves coding accuracy and depth of data for analysis.’ I say, ‘Garbage in, garbage out.’ For providers who are currently not using the specificity that exists with ICD-9, ICD-10 gives them more ‘garbage’ to choose from or to ignore. Also, as you know, you can only code what is documented in the record. I think lack of specificity will remain more often the problem, rather than miscoding a specific diagnosis.”
Kenneth W. Patric, MD, chief medical officer, The Little Clinic
One of the largest impacted areas will be the clinical documentation. Auditors and coders already struggle with this issue, and documentation may become even more problematic with ICD-10-CM because it is data driven. If only unspecified codes are used in ICD-10-CM, we are no further in capturing the specific clinical picture of the patient. In time, payers may not reimburse for unspecified codes when the documentation supports a more specific code.
Solution: The best way to confront this issue is through monitoring and education. If you are not already performing documentation audits, begin now. Incorporate an ICD-10-CM readiness section in your audits or conduct a separate ICD-10-CM readiness review as a benchmark. Run a frequency report of the top diagnosis codes being used by the practice. Pull a sample of documentation for each provider who represents these top codes. The auditor will assess the documentation and determine:

  1. Does the documentation support the diagnoses reported?
  2. Will the documentation support an ICD-10-CM code?

The auditor must be familiar with the ICD-10-CM guidelines and codes to make this determination. After the audit has been conducted and analyzed, the practice will have a good assessment of documentation deficiencies and can develop a priority list of diagnoses requiring more detail. The audit will also identify providers who will benefit from focused ICD-10-CM training.
Implement a documentation improvement program within the practice and monitor the documentation on an ongoing basis. This will ensure improvement and identify areas where providers are deficient and those who need more assistance and training. These audits should be conducted periodically to validate ICD-10-CM compliance. As with any audit, submit a report to senior management and the provider.
If you do not have a trained Certified Professional Coder (CPC®) on staff to perform these audits, contact AAPC Physician Services to schedule a “ICD-10-CM Assessment: Documentation Readiness Evaluation”.  Do not skip this step! This is a critical element as you begin the preparation and implementation process.
“My biggest concern is the additional amount of time it will take me to look up codes. I am expecting that to really eat into my patient time. If you multiply an extra 30 to 60 seconds per patient, times 25 patients a day, you have effectively eliminated a 15 minute exam slot!”
Stephen C. Spain, MD, FAAFP, CPC, CEO Doc-U-Chart
There will be a learning curve for physicians, as well as for coders.
Solution: Consider developing a cheat sheet of the top 50 ICD-9-CM codes used in your practice. Have a trained CPC® convert the ICD-9 options to ICD-10. If you do not have anyone on staff that is trained to make the conversions, or just don’t have the time, AAPC offers laminated double-sided cards by specialty to make it easy. AAPC lists the Fast Forward Top 50 ICD-9 Codes Crosswalked to ICD-10 (by specialty) for $14.95 for members (www.aapc.com/icd-10/crosswalks/index.aspx).
Be resourceful and begin talking with your information technology (IT) system staff/vendor to evaluate what tools will be available. Codes provided by a system may be crosswalked to unspecified codes via a matrix or general equivalency mappings (GEMs) file. Do not select the final code for the visit without validating it is the most specific diagnosis code supported by the documentation.
An “ICD-10-CM Assessment: Documentation Readiness Evaluation” will help in this area, as well, by providing specific documentation feedback and education, and familiarizing everyone with the most frequently used codes in your practice.
“My biggest concerns are electronic implementation and making sure we do not lose revenue by missing things or ‘miscoding.’”
Marianna D. Forsythe, MBA, chief operating officer/Vice President of administraton, The Heart & Vascular Center of West Tenn./Delta Convenient Care, PC
Solution: To address a possible short-term, adverse impact on revenue stream, consider increasing your practice’s cash reserve and/or securing an increased line of credit. This will ensure the practice can continue to meet its expenses should there be any delays in reimbursement.
Strategic planning and anticipation of productivity issues can help a practice minimize any hurdles. Begin by developing an ICD-10-CM steering committee or implementation committee that will help identify any areas of impact for the practice. This may be a committee of one or two staff members in a smaller practice or a cross-section of billers, coders, IT staff, managers, physicians, administrators, etc. in a larger practice.
Get representation for each area of the practice and be sure every affected area is identified and explored. Involve physicians early on so they understand the importance of preparation as the migration to ICD-10-CM occurs. The team should meet initially to identify the elements necessary for a smooth transition, and then analyze what areas will be affected. The resulting information should be shared with providers and management.
Set boundaries for this committee to avoid “project creep.” Keep a priority list of identifying what will be addressed, including anticipated deadlines, to keep the efforts focused and on track. Any issues that do not directly affect the implementation can be put on another action list for follow up after priorities involving the ICD-10 transition are addressed.
This planning effort will not only identify areas affected by the transition, but also how communication will be handled, training needs and education plans, as well as coordination with vendors, business partners, and other providers.
Billing Manager
“How do we ensure that currently certified coders are trained on ICD-10? Will this be a separate certification? Will they be tested? How long will it take someone to learn ICD-10? And, since this will be new to everyone, is the industry really ready for this?”
Deanna Allen, A/R consultant
Second only to system upgrades, training will be the biggest expense for the practice.
Solution: Develop a separate education plan specifically for ICD-10-CM. Do the training in phases, beginning with the background and history, rationale for change, and final rule highlights, and continue through guidelines and code set training. Measure the retention of what you learn by conducting post testing.
As you begin to evaluate the training needs of the practice, ask yourself:
Who must receive training on the ICD-10 code set?
All areas of your practice will need some degree of training in ICD-10 CM. On average, it is estimated that:

  • Providers will require 8-16 hours
  • Nurses will require 6-10 hours
  • Ancillary staff will require 6-10 hours
  • Coders will require 20-40 hours, not counting  recommended A&P courses

What options are available to train staff?
Look into training options such as onsite, vendor training, community courses, webinars, and certification courses. Check out AAPC’s plan for training on www.AAPC.com.
Which training format(s) will work best for your staff?
Consider classroom training, web-based training, or self-guided materials to meet your staff needs.
How much will the training cost?
Develop a budget once your methods are determined.
What resources will staff need after training to resolve questions as they arise?
Resources could include any available tools, manuals, or frequently asked questions (FAQ) lists.
Will this be a separate certification?
A separate certification will not be required for coders; however, to ensure certified coders maintain their ability to accurately code the code sets, AAPC certified members will have two years to pass an open-book, online, unproctored assessment. Due to the clinical nature of ICD-10-CM, a strong understanding of anatomy and pathophysiology (A&P) is recommended. AAPC offers “ICD-10 Anatomy and Pathophysiology Training” that covers all body systems in 14 modules (www.aapc.com/ICD-10/anatomy-pathophysiology.aspx). The curriculum blends online multimedia presentations (www.aapc.com/ICD-10/sample/sample.html) with downloadable manuals (http://static.aapc.com/ppdf/sample1.pdf) and evaluation quizzes to ensure your comprehension of the material. At minimum, a refreshers course in A&P will be necessary to code using ICD-10-CM.
Is the industry really ready for this? 
The ICD-9-CM system is more than 30 years old. Think of how much medicine has changed in 30 years. The ICD-9-CM categories are full and do not represent contemporary medicine. Although the extended proposed implementation date (Oct. 1, 2014) provides more time to prepare, you should begin now.
Create a list of your practice’s electronic systems and work flow processes using ICD-9 codes, both clinical and administrative—including payers, contractors, clearing houses and vendors. If you’re not sure if your circle of vendors, contractors, payers, clearing houses, and billing companies are ready, ask.
Begin by communicating to all of your vendors and contracted payers to get an idea of where they are in regard to ICD-10 readiness. Determine which existing vendors will be affected by the ICD-10 transition. Define requirements you will need from vendors to support your ICD-10 implementation. Determine if systems vendors and/or clearinghouses/billing services will support changes to systems, supply a timeline and cost estimate for implementation changes, and identify when testing will occur. Determine the anticipated testing time and a schedule. Put everything in writing.
Begin testing four to six months before the live date to assess glitches that may affect payment. Identify crosswalk capabilities with your system for operating in ICD-9-CM and ICD-10-CM. Workers compensation carriers are not considered covered entities under Health Insurance Portability and Accountability Act (HIPAA) and are not required to make the transition to ICD-10-CM. If you are contracted with these carriers, contact them and ask them if they will be converting to the ICD-10-CM system.
Explore “Plan B” options in case your vendor does not progress fast enough, including operational workarounds and vendor replacement alternatives.
“My main concern is getting clinical staff – especially doctors – on board for the transition. I do not see doctors changing their habits to become more specific. Coding will take twice as long, if not longer, by having to dissect every word into pulling out the perfect diagnosis when the doctor or provider could have provided the needed information all along.”
Coding Staff of Calypso Enterprises, LLC
Unspecified diagnoses will affect the revenue cycle, as well as the possibility of increased denials, because of incomplete or inaccurate translations of existing policies, benefits, and payment rules in payer systems as they attempt to transfer these rules to ICD-10-CM.
Payments delays due to challenges in claim processing in the ICD-10 environment will include:

Medical coding books

  • Can the system maintain both ICD-9-CM and ICD-10 CM for a time?
  • Can the database support so many codes?
  • Can it distinguish ICD-9-CM and ICD-10-CM code?
  • How will the code set updates be managed?

Solution: Explore these areas with your staff, vendors, and clearing houses. Planning and implementing ICD-10-CM must include communication and significant collaboration on IT, finance, education, and problem solving.
Knowing whether clinician documentation is specific enough can be determined using the aforementioned AAPC Physician Services “ICD-10-CM Assessment: Documentation Readiness Evaluation.”
Regardless of the size of your practice, steps toward implementation must begin now. As Winston Churchill said, “He who fails to plan is planning to fail.”
Kathy Rowland, CPC, CPC-I, CEMC, CHC, of Integrity Compliance, LLC, has over 25 years in the areas of health care administration and management. Nine years were spent specifically in the development and implementation of practice-based compliance plans, auditing documentation, and litigation support. She holds certifications in evaluation and management coding, compliance, and as an AAPC instructor.  Ms. Rowland is also an ICD-10 trainer for AAPC.

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