Is Your Practice Ready For ICD-10?

The latest deadline for ICD-10 conversion, October 1, 2015, is closer than you think. If you find yourself slightly behind on your implementation process, it is likely that you are not alone. Recent polls published by many physician organizations showed that 60 percent of physicians state they have not yet prepared or feel that they will not meet the deadline.¹

Concepts that are new to ICD-10 are not new to clinicians, who are already documenting on a patient’s chart. With ICD-10, they will be able to document more clinical information regarding the patient’s health condition than ICD-9 would allow them to capture. Some of the added information they can now capture includes:
• Initial encounter, subsequent encounter or sequelae
• Acute or chronic
• Right or left limb
• Normal healing, delayed healing, nonunion or malunion

Many ICD-10 codes — more than one-third — are identical to ICD-9 codes in description except for indicating laterality or whether the right or left side of the body is affected.

Some advantages of ICD-10 codes are that they enable clinicians to capture laterality and other concepts in a standardized way that supports data exchange. The more expansive ICD-10 system will also help us track data more effectively in order to measure the quality and safety of care, and process claims for reimbursement. Given the future of reimbursement trending toward payment based on outcomes, the use of ICD-10 codes should theoretically provide better support for reimbursement through the assessment and documentation of outcomes from care/treatment and products. This occurs through data capture using claims data without the need for the lengthy process of chart reviews

A Closer Look At Perfecting Your Documentation
While ICD-10 should not require providers to change documentation practices, reviewing documentation will help you understand how ICD-10 will affect your practice. This will provide opportunities to improve current documentation standards to meet medical necessity and specificity requirements. Understanding the scope of the ICD-10 transition will reduce the likelihood that you will overlook areas that need updates for ICD-10. From documentation all the way through communication and billing services, testing ICD-10 is vital to make sure you have worked out any snags in the process before the Oct. 1, 2015 transition date. Doing so can potentially prevent delays in claim processing and subsequent adverse effects on practice income.

Most major hospital systems will require their practitioners to obtain ICD-10 education as part of the credentialing process to hold or maintain active privileges. It is important for practitioners to understand that our documentation in the hospital can substantiate not only what we bill for our professional services, but that the hospital depends on this documentation to support the patient’s hospital admission to the payer(s). When we leave out even words that seem insignificant to us, this could mean the loss of thousands of dollars to the hospital system.

Hospitals are paid by the diagnosis-related group (DRG) codes. For example, consider a patient admitted for an infection. Upon admission, let us say that all we documented was the infection, either forgetting at the initial admission or not updating the notes to reflect that the patient has uncontrolled type 2 diabetes, vascular disease and comorbidities that add to the potential for complications. Then during the stay, there is surgical intervention for the patient and cultures show that the patient has methicillin resistant Staphylococcus aureus (MRSA). However, we do not update our notes with the findings of the organism and its resistance to standard antibiotics. Then the insurance payer may find the instillation of a peripherally inserted central catheter (PICC) line and ongoing debridements and interventions were not medically necessary. This could mean the loss of $3,000 to $5,000 for this particular admission for the hospital.

I understand that we may be focused on our own bottom line and that of our offices rather than the hospital. However, how thorough we are with documentation is a habit we have developed since we were in medical school. Since it is a habit, we tend to document the same way regardless of the location.  

Since working on ICD-10, I have focused my attention on perfecting my documentation. Most people may think that focusing on the codes themselves, memorizing them or learning all the new codes that we may use should be our focus. I think we need to keep doing what we naturally do, which is documenting the encounter. Since many of us have adopted an electronic medical record (EMR), using my chosen EMR system will help me capture information that will reflect the patient encounter more accurately. I will also be able to collect the information in an efficient manner so office workflow and ultimately income will not be adversely impacted as of October 1, 2015. I have worked on formatting a couple of common templates (such as a new patient encounter and a follow-up encounter) regardless of the presenting problem. I can use these two templates to document over 90 percent of the conditions I see. These two templates also capture the meaningful use information necessary to continue meeting this requirement.

Getting Proficient With The New Codes
Are you ready to start performing self-audits to see if you will be able to code ICD-10 from current documentation? Could you discover opportunities for improvement in your coding? At left, you will find a table (“A Guide To The Most Common ICD-10 Diagnosis Codes”) of some of the most common ICD-10 diagnosis codes I use daily with generally equivalent mapping to help you start on your road to converting to ICD-10. I have left a few codes unmapped so you can practice finding these codes. Go to the American Podiatric Medical Association’s Coding Resource Center (www.APMAcodingrc.org ). Go to the ICD-9 tab, find the code you use most often and in brackets, you will see the ICD-10 code or equivalent mapping location code with a dash. This indicates that this ICD-10 code needs further extension(s).

The last two codes are 826.0 and 826.1. The code will be based on the following factors: the toe that is fractured; whether it is an initial or subsequent encounter for that condition; and if there is normal, delayed healing or other complications to the healing. If it is a sequential encounter, there is a dash to indicate to you that further information is necessary in order to choose the correct code.

After working with ICD-10 codes for the past two years, I have reached the conclusion that I will learn and remember these codes just like I recall the ICD-9 codes almost without thinking. Just as the ICD-9 codes took time over years to learn through daily use, one to two years of daily use will make the ICD-10 codes just as natural and effortless to recall. I suggest we all take a deep breath and stop obsessing about having to know these codes immediately. The resources available on the APMA’s Coding Resource Center make learning and finding the codes that much easier. I have used the site to quickly look up the ICD-10 equivalent codes while performing self audits, when preparing for lectures, while researching to write articles and during the two not so well attended ICD-10 meetings I have offered to my colleagues in Tucson to help them prepare their offices. I have also used the site to start looking up the most common diagnoses I use on a daily basis using my current superbill as the foundation to start mapping the codes I use most often.

After working on fine-tuning the templates I use daily, my next step is working on an electronic superbill or charge ticket. Some EMRs have a practice management module, which will help suggest the CPT codes for the procedures one performs. That is wonderful but it has come to mind that the EMR needs to help pare down the choices of ICD-10 codes I can submit based on the documentation. I have been working with my EMR vendor to come up with an electronic superbill that will capture the CPT and, perhaps more importantly, pare down my choices of ICD-10 codes so I will not need to have nine cheat sheets of ICD-10 codes to look through for every encounter.

This will complete the day’s transaction the same day I render services and my billing/coding staff will just need to review the note and claim to make sure they add the correct modifiers if necessary, and that the documentation supports the claim they are submitting. The billing staff will be able to send the claim out within the same hour or day, and this should minimize the risk of superbills getting lost in a pile or not being submitted in a timely manner.

In Conclusion
I may have a more positive outlook on ICD-10 than others may have but preparing over the past one and a half years and very slowly moving through my checklist of items to accomplish has allowed me to feel confident that we will be ready to meet the challenge without missing a breath. It is not too late for anyone. If you have not prepared your practice, you will just need to intensify your efforts on working to streamline your process but it is doable.

Dr. Aung is in private practice in Tucson, Ariz. She is a member of the American Academy of Professional Coders as a Certified Professional Medical Auditor. She is also a panel doctor at Carondelet St. Mary’s Advanced Wound and Hyperbaric Center in Tucson. Dr. Aung serves on the Examination Committees for both the American Board of Wound Management and the American Board of Podiatric Orthopedics and Primary Podiatric Medicine.

Reference
1. McCann E. Outlook grim for docs’ ICD-10 readiness. Healthcare IT News. Available at https://www.healthcareitnews.com/news/grim-outlook-docs-icd-10-readiness . Published Dec. 19, 2013. Accessed Sept. 4, 2014.