Featured Articles: ICD-10

ICD-10… Just tell me what I need to know

Monday, September 14, 2015   (0 Comments)
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Ray Jorgensen, CEO, PMG, Inc.

Editor’s note: This author will be presenting at our Fall Primary Care Conference in October.

If like me you've heard enough about ICD-10, let’s raise a toast to the fact that October 1, 2015 is just around the corner. The delays are over and we can finally get down to it. Here are some quick thoughts to ponder. Whether you are wildly well prepared or woefully worried of the unknown impact of ICD-10, these topics are intentionally brief and pragmatic.


More of the same. When you boil it down, ICD-9 and ICD-10 are more similar than different. Yes, the documentation is more detailed. Yes, we go from 14,500 ICD-9 codes to more than 68,000 ICD-10 options. And, yes, we have no idea what the payers will do in terms of finding new reasons not to pay us. However, document what you did and pick the corresponding code remains the modus operandi. The more training we do on ICD-10, the more I wonder why all the hoopla. ICD-10 has more codes and some idiosyncratic nomenclature, but the process is more of the same.


Medicare Grace Period.  The delay of ICD-10 implementation is largely the result of a major “fear factor” diatribe spread largely by “well intentioned” national doctor (provider) advocacy groups, intimidating management consultants, and other zealots fearful of change. As a result, CMS afforded some room to grow and learn.[1] During the first year of ICD-10 (i.e., October 2015 through September 2016) Medicare will not deny claims due to lack of ICD-10 specificity. In other words, select a code within the appropriate “family” of codes, even if the fourth-to-seventh character specificity is suspect, and you still get paid. That is in the fee-for-service (FFS) world. CMS even went as far as to avert any payment penalty for misreporting payment quality initiatives such as PQRS and Meaningful Use.  They want this to work and are being flexible to help make it happen without undue financial burden.


Public Health Imperative.  As I’ve written and stated publicly for years, the United States is way behind the rest of the world in capturing, reporting, and analyzing public health data simply because our historic use of ICD-9 was inadequate. Since 2002, the U.S.A. is the only industrialized nation in the world not using ICD-10. The move from ICD-9 finally affords the National Center for Vital Health Statistics (NCVHS) and our public health officials opportunity for meaningful dialogue and expanded data analytics with colleagues from nations around the globe.[2]


Unprecedented Opportunity.  With so many new codes, providers should be hard-pressed to complain about not finding the right code. In fact, with so many options, how do you ensure optimal and consistent coding outcomes? A good example is the  UDS required delineation of asthma status (e.g., mild, persistent, etc.). ICD-10 has definitions, but are your providers capturing info in consensus? Regular dialogue between your revenue cycle (a.k.a., billing) team and your doctors, NPs, PAs, and other providers affords the chance for your CHC to really “get it right” AND, many argue, actually see a boost vs. a drop in income.[3] Again, no one knows what will happen as of October 1 in terms of making more or less money. However, control what you can control. Getting your providers to consistently and optimally capture ICD-10 codes is doable. You need a plan and commitment from your staff. Sometimes, financial incentives help too!


Financial Challenges. While I have never been a scare tactic consultant, be forewarned that two items may negatively impact revenue at your CHC. First, provider productivity will almost inevitably slow as providers get used to the new ICD-10 codes. Plan a short drop in volume with a planned/staged step-up process to get them back to desired levels of production. Second, we don’t know what issues payers will encounter. Real or fictitious denials as a result of ICD-10 are to be expected. Lest one think I am being an alarmist regarding this latter item, please know I began my career at Blue Cross Blue Shield and United HealthCare Corporation. From those 4+ years, I just know things. Bottom line: They make money (i.e., retain premiums) only by not paying providers. Slice it any way you want but governmental and commercial payers have fiscal targets and margins to hit just like everyone else. Find out today if they offer estimated payments in the event of trouble or whether you can elevate a line of credit or donor dollars, even short term. Best be prepared than caught short while trying to make payroll.


Audit & Learn. Billing and coding audits should be commonplace at all CHCs. However, many CHCs forgo these reviews, thinking them an unnecessary luxury vs.  a business necessity. Audits mitigate risk, educate your team, and find you money. Budget for audits to evaluate accuracy of coding, maximization of income, and potential liabilities as result of business practices about which your leadership team is not expert. There is no shame in not knowing. Don’t allow misplaced hubris or indifference to limit potential for your CHC.


Transition to Risk Adjusted Compensation. With payment reform, by 2018 CMS is mandated to have 50% of all fee-for-service (FFS) payments made via alternative payment methodologies. CHCs across the country are seeing payments diverted or withheld in the name of risk management.  Providers in an expanding number of states, including CHCs,  are paid not just based on visit, procedural, or diagnostic study volume but on quality outcomes and optimal patient management. The specificity of ICD-10 coding will play a significant part in communication between providers and payers. Whether compensation is linked to individual patient or larger population health status, mastering ICD-10 coding will elevate and stabilize CHC payments historically immune to such scrutiny.



 ICD-10 Training… It Ain’t Over, Ever.  Guess what. No one will be an ICD-10 expert by October 1, 2015. ICD-9 training has been happening for decades, and ICD-9 was published in the 1970s.  PMG and other firms will continue educating clients around ICD-10 for the foreseeable future.  Coding training is a part of all providers’ lives, and CHCs are no different.  Whether utilizing internal or external resources, be certain your CHC maximizes the opportunity ICD-10 presents.


Again, prepared but not scared. So, remember, this “new” coding system is very similar to the old, yet the expanded universe of data and specificity afford unprecedented data capture opportunity. Short-term provider productivity challenges are expected.  However, your electronic medical record through Intelligent Medical Objects (IMO) and/or Systematized NOmenclature of MEDicine (SNOMED) will allow your providers to quickly search and document ICD codes within the Assessment and/or Plan of the SOAP note. They need some time (weeks) to get used to the new process. The new challenge will be consistency of ICD-10 coding across all your providers. And, don't forget about money. Have access to capital. Most importantly, expect and feel OK about change. It is the only constant. You can rest easy… ICD-11 is just around the corner.

[1] https://www.cms.gov/Medicare/Coding/ICD10/Downloads/MedicareProviderICD-10.pdf

[2] http://www.cdc.gov/nchs/icd/data/CDC_ICD-10_Transition_FactSheet_12_2013.pdf

[3] http://www.fortherecordmag.com/archives/0914p8.shtml




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