Are Wound Care Providers & Their Clinics Prepared for ICD-10-CM?

The information and opinions shared within this article are derived from a recent survey conducted by readers of Today’s Wound Clinic. All opinions are those of the authors, not necessarily of the publishers. In some cases, respondents’ comments have been paraphrased. All information regarding coding, coverage, and payment is provided as a service to readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.

Despite years of warning, comprehensive educational efforts, future effective local coverage determinations, and even a yearlong delay in the actual implementation deadline, it appears that only a small percentage of wound care professionals have adequately begun to prepare themselves and their businesses for the conversion to ICD-10-CM that is scheduled for Oct. 1. A state of lethargy within the industry has been confirmed by a recent ICD-10 Preparation Survey offered to readers of Today’s Wound Clinic. As implementation looms, the following major tasks should already be in place at all outpatient wound care centers in order to be compliant with the new coding procedures by the effective start date:

• creating a plan of action to reach implementation;
• providing proper training to the wound care team;
• updating documentation and coding processes;
• engaging vendors and payers in conversation about proper implementation; and
• testing systems and processes to ensure successful implementation by the deadline.

To assist providers who are still behind schedule in sorting out the ICD-10 changes pertinent to wound care, this article will provide crucial insight and recommendations regarding coding and reimbursement from the authors that stem from an analysis of the ICD-10 Preparation Survey results. An overwhelming majority of respondents (79.2%) reported they currently work in a wound clinic. Other demographics of survey respondents in terms of workplace setting include:

• physician offices;
• acute care hospitals;
• skilled nursing facilities; and
• other settings such as durable medical equipment suppliers and home health.

Following is a review of some particularly suggestive survey results followed by commentary related to coding by Donna Cartwright (DC) and reimbursement by Kathleen Schaum (KS).

Question: Have you purchased ICD-10 books? Results: Yes — 30.6%; No — 69.4%

DC: It is essential that the ICD-10 books be purchased or that your encoder has been updated with the ICD-10 codes through your vendor. KS: For nearly 20 years I have been teaching wound care professionals that they should purchase new coding books (Healthcare Common Procedure Coding System, Current Procedural Terminology, and ICD-9/ICD-10) each calendar year. For several years, both ICD-9 and ICD-10 books have been available so that wound care professionals can slowly and methodically learn the differences between the two diagnosis coding systems. In fact, the ICD-9 and ICD-10 book chapters can be downloaded for free here. In the year that ICD-10 is being implemented, all wound care professionals should purchase or download both books. Because diagnosis codes are the first screen of medical claims, the lack of understanding of documentation requirements can seriously affect wound care professionals’ reimbursement.

Question: Have you identified the major diagnosis codes in ICD-9 that represent your patients’ primary, secondary, and comorbid conditions; and have you researched the ICD-10 codes that describe those conditions? Results: ICD-9 identifying — 63.9%, Yes; 36.1%, No. ICD-10 research — 33.3%, Yes; 66.7%, No.

DC: I am glad to see many respondents have identified their primary, secondary, and comorbidity codes in ICD-9. That is great news because those of you who have done this exercise simply have to convert these conditions to their ICD-10 equivalents. For those who have not run these types of reports for their centers, now is the right time! This exercise will ensure you have prepared for your highest volume of conditions. In addition, this exercise will identify the types of charts needing review for prioritization of clinical documentation improvement. The risks of not identifying your top primary, secondary, and comorbid conditions in ICD-10 are many. If you have not looked at the new code set, you may be surprised at the sheer increase in volume of codes from ICD-9 to ICD-10. Many codes that were previously not very specific in ICD-9 have become ultra-specific in ICD-10. Many of the conversions of these codes are from one code to numerous codes. For example, many wound codes now identify specific anatomic locations, complications (such as foreign bodies), and laterality (right, left, or bilateral). Another ICD-10 improvement in ulcer coding is including the depth of the ulcer in diagnosis codes. Wound care professionals who participate in clinical trials know how difficult it is to identify cases that have exposed muscle, tendon, and bone in the ICD-9 procedure coding system. Now you will be able to identify those cases specifically with the ICD-10 diagnosis codes. KS: I am concerned that wound care professionals may not be giving enough thought and may not be placing adequate value into understanding the descriptions of the diagnosis codes. By this time in the ICD-10 preparation timeline, wound care professionals should have created a list of the ICD-9 codes that describe the main primary, secondary, and comorbid conditions of their patient population and then have created a similar list of the ICD-10 codes and their more specific descriptions for the same patient population.

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RELATED CONTENT
ICD-10 Conversion Guide: Things to Consider Prior to Deadline!
NCDs & LCDs Released With Covered ICD-10 Codes: Will Your Documentation Support Medical Necessity?
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Question: Have you identified areas of your clinical documentation that had to be improved to meet the specificity of the new ICD-10 codes? Results: Yes — 33.3%; No — 66.7% DC: If you have not identified your most common diagnosis codes for your facility, it will be hard to do a review on your existing clinical documentation. The importance is to identify the opportunities for improvement, educate staff members, and re-evaluate as many areas as necessary so the documentation becomes second nature to the providers. Try to focus on your highest-volume cases. Implementing specific documentation practices with the new coding system will lead to better explanation of medical necessity for payment, better data for research, proper billing, better rate setting, and more attention to quality indicators, etc. KS: The small number of wound care professionals who have identified their documentation needed to be improved to meet the specificity of the ICD-10 code was surprising because the No. 1 reason wound care professionals are asked for repayments to the payers is the lack of specific documentation. Because ICD-10 code descriptors are more specific and finite than ICD-9 code descriptors, my experience has shown that wound care professionals have to spend a lot of time refining their clinical documentation and improving any documentation templates they use. I am pleased to learn those wound care professionals who have worked on improving their clinical documentation have worked on:

• diabetic ulcers; • laterality; • pressure ulcer staging; • tobacco cessation; • debridement; • training scribes; and • secondary and tertiary diagnoses.

Question: Have you made any changes to improve your clinical documentation to provide the specificity of diagnosing required by ICD-10? Results: Yes — 34.7%; No — 65.3%

KS: Of all the questions in the survey, the answers to this one worry me most. All reimbursement is based on meeting medical necessity requirements for the service/procedure/product. Medical necessity is determined by clinical documentation. Wound care professionals often complain their patients are “more complicated,” but they have no way to show that on a medical claim. ICD-10 finally provides wound care professionals the opportunity to specifically describe primary, secondary, and tertiary diagnoses as well as comorbid conditions through the codes on the medical claims. However, that level of detail must be documented in the medical record. If only one-third of wound care professionals have made any changes to improve their clinical documentation at this stage in the implementation timeline, many are going to have to spend most of their summer identifying the level of specificity they can achieve by refining their dictation and documentation and by verifying that their documentation is mapping to the ICD-10 codes for which they are aiming. Keep in mind that wound care professionals have been documenting in the same way for many years. In order to change those habits, they will have to practice. In the ICD-10 workshops we teach, we always remind wound care professionals that repetition is very important because, generally speaking:

• it takes up to 54 times for a person who hears something to commit it to memory and begin to use it; and • it takes three weeks of practice on a particular function to establish “a habit.”

Since wound care professionals care for patients with quite a few major diagnoses and it will take three weeks of practice to refine clinical documentation for each, I am worried Oct. 1 will arrive before two-thirds of our wound care professionals can learn to refine their clinical documentation. If you are one of these wound care professionals who has procrastinated, please begin to refine your documentation now.

Question: Which activities have you had to re-evaluate in order to improve the completeness and accuracy of your documentation to meet ICD-10 specificity requirements? Results: Internal audit — 41.7%; Peer review — 18.1%; Consulting group — 8.3%; Other — 47.2%

DC: You may be surprised, but many records we think are well documented are not when it comes to levels of specificity contained in ICD-10. I see that some respondents have done internal audits of their chart documentation and others have worked with their vendors. It is important to look at problem lists on electronic outpatient records. Diagnoses are often carried over to the next encounter when, actually, the problem has been resolved. It is important to list only those conditions affecting the treatment of the current encounter. Carrying over inappropriate diagnoses may artificially inflate the complexity of your case mix. Internal auditing is a great way to review the documentation. Also, if you have a physician champion, it’s a great idea to have that physician do some peer review on the documentation. Sometimes physicians prefer to learn from their peers. Make sure you are evaluating any of your automated documents. If they make all patients look the same, the clinical documentation probably needs some modification. KS: I was so happy to see that a high percentage of respondents have increased their internal auditing to evaluate the specificity and accuracy of their documentation. I was hoping that a much higher percentage would have been mentoring each other through the peer-review process. What made me the most nervous were the comments provided by the 47.2% who reported “other.” Most of the comments said that they had not re-evaluated any activities to improve their clinical documentation.

Question: Have you reviewed your Medicare Administrative Contractor’s (MACs) published future effective local coverage determinations (LCDs) that will become active Oct. 1? Results: Yes — 16.7%; No — 83.3%

DC: Most wound care professionals should have in their possession the most current coverage policies from your MAC and other major insurances your patients have. Many of these carriers have already posted future effective LCDs that will go into effect Oct. 1. Identifying those policies for review for the types of cases you see should be a priority. Reviewing the new policies will identify which ICD-10 codes are covered for specific therapies. In addition, there may be some specifics contained within the documentation that may warrant being addressed by making sure they are captured in your coded data. For example, Novitas Solutions Inc. recently released a policy that recommends a patient receiving cellular and tissue-based products (outdated term skin substitutes) to be nonsmoking for four weeks prior and during treatment. ICD-10 has codes that describe smoking status, which you may want to visit in your internal audits. Many survey responders are not aware of the existence of these future effective policies. If you do not access them and evaluate their applicability to your wound care practice, you will already be behind. KS: The Centers for Medicare & Medicaid Services (CMS): 1) converted all National Coverage Determinations (NCDs) that included ICD-9 codes to ICD-10 codes and 2) required all MACs to convert any LCDs that included ICD-9 codes to ICD-10 codes. Those converted NCDs and LCDs are listed on the Medicare Coverage Database (MCD) as “future effective” and state Oct. 1 as their effective date. Wound care professionals would be well served to search for the NCDs and LCDs that pertain to the medical care they provide and to review the level of specificity of the ICD-10 codes covered by these coverage policies. Wound care professionals should refine their clinical documentation to include the level of detail that will map to the specific ICD-10 codes covered in the NCDs and LCDs. Follow this link to the MCD.

Question: How would you say your documentation must improve to meet the requirements of the LCDs by Oct. 1? Results: Varied. KS: The responses to this question shows that those wound care professionals who have been preparing for ICD-10 understand documentation is the key to success, and that those who have not been preparing are not aware they must refine their documentation. Following is a representative sample of responses from those in the industry who have not been preparing for ICD-10:

• “I do not know.”
• “I have not investigated this.”
• “No changes at this time.”
• “I know the ICD-10 codes are more specific, but do not yet know what I need to do to change documentation.”
• “No idea.”

NOTE: These wound care professionals should spend the greater part of their summer preparing for ICD-10. They have a lot to learn and implement before Oct.1.

Following is a representative sample of responses from wound care professionals who have been preparing for ICD-10:
• “Many forms are being tweaked and updated to meet new documentation requirements.”
• “We’re all set.”
• “The level of specificity overall needs to improve.”
• “Patient history will need to be more specific.”
• “My electronic health record (EHR) company has put in place the necessary requirements to meet this need.”
• “More inclusive of specific contributing factors to diagnosis.”
• “Clarification of wound type, location, and comorbidities.”
• “Greater detail and specificity.”

Question: How would you describe any methods of ICD-10 training you’ve received? Results: Varied.

DC: There are numerous ICD-10 training courses available. Organizations such as the American Medical Association (AMA), American Health Information Management Association, American Academy of Procedural Coders, CMS, and a large number of consultants and consulting firms offer many types of training programs. There are in-person programs, online courses, webinars, and textbooks/workbooks that can be used to learn the ICD-10 system. Your internal health information management department should also be a resource for different ICD-10 learning opportunities. KS: I was disheartened to learn greater than 50% of respondents said they have not been trained in ICD-10. My spirits were then lifted when I read the variety of methods of training some wound care professionals have experienced. Following are responses that should help readers design a variety of training venues for wound care professionals because adults learn in different ways:

• “online training”
• “AMA’s ICD-10 training classes”
• “advanced anatomy/pathophysiology”
• “books and videos”
• “business meetings”
• “seminars”
• “handouts”
• “self-learning modules”
• “webinars”
• “eight hours of webinar training followed by four weekly in-person, eight-hour training sessions by consultant”
• “www.icdtenhelp.com”
• “shared patient cases and appropriate documentation for ICD-10”
• “discussion sessions”
• “monthly webinars that review different clinical examples”
• “one-on-one meetings with qualified healthcare professionals to discuss examples of current documentation and refinements that need to be made for ICD-10 specificity.”

Question: Have you updated all of the medical record, coding, and billing forms to accommodate ICD-10 codes? Results: Yes — 29.2%; No — 70.8%

DC: Please be sure to check all electronic forms, manual forms, and electronic records that currently contain ICD-9 codes and have a plan in place to change those codes and forms to ICD-10 effective Oct. 1. NOTE: Be extremely careful when converting forms, especially super bills. In the past, you may have had short lists of diagnosis codes, but as of Oct. 1 you will have a large number of specific ICD-10 codes. This might make it impossible to check the box on a super bill anymore. You may wish to consider having a coder review the chart instead of using a super bill. KS: The wound care professionals who have not accomplished this task should begin as soon as possible. Changing forms is usually a major undertaking and usually takes several months to accomplish. Many responders said their EHRs were ready. That is great, but many other forms contain diagnosis codes and need to be readied for ICD-10.

Question: Have you undertaken activities to ensure your software vendors are including the new ICD-10 coding capabilities within the software you use? Results: Yes — 44.4%; No — 55.6%

DC: Please be sure to test all systems such as billing, EHR, and any other services that require ICD-10 coding. It is important that you validate the changes are implemented by your vendors. Yes, vendors can make mistakes too! Select a few common scenarios and put them through a test from admission to discharge and billing for an encounter. Check that the case is assigned the appropriate ambulatory payment classification. It may be a good idea to test for LCDs that have specific coding requirements to see if they work. With all vendors, determine what the method of communication and resolution to issues will be for “go-live.” KS: Because wound care professionals use a variety of software every day, it is imperative that you speak with vendors to determine their readiness, to find out if your current hardware will handle ICD-10 and ICD-9 codes simultaneously, to find out how you will test the changes, to learn if you will incur additional charges for the implementation, and what to expect on Oct. 1. In addition, if the vendor processes your claims, ask if the system was tested with Medicare, Medicaid, and your other major payers. Some of the testing efforts revealed by survey respondents include:

• “EHR and interface are up-to-date with ICD-10”
• “dual coding (ICD-10 and ICD-9) is ongoing”
• “sent test claims to major private payers”
• “participated in Medicare end-to-end testing”
• “new software was required to handle ICD-10.”

Two of the common responses were a bit scary:
• “Probably will not test; trial by fire” and
• “Won’t test; leap of faith.”

In another survey question that asked, “Did you participate in the CMS testing of claim submission with ICD-10?” only 6.9% of respondents took part in this very important end-to-end testing while 93.1% missed this opportunity. Similarly, when asked, “Have you contacted your patients’ private payers to learn if their computer systems are ICD-10 ready?” only 11.1% of respondents reported they have contacted their major private payers while 88.9% still have to accomplish this important task.

Question: Have you assessed the workflow of your wound care business to learn if the workflow needs to be modified to accommodate new ICD-10 codes? Results: Yes — 15.3%; No — 84.7%

KS: Because diagnosis codes are involved in every step of the healthcare revenue cycle (from the time the patient makes an appointment until the claim is submitted and processed), wound care professionals will be well served to look at each step in their workflow. Personally, I believe most wound care professionals will come to the realization they will need coders dedicated to coding their wound care documentation.

Question: Do you plan to change your coding processes in preparation for ICD-10? Results: Yes — 47.2%; No — 52.8% DC: With regard to changing coding systems, the following issues will be important:

• Have a coder look at the medical record documentation — not a super bill. • Even if your department is not doing the coding, meet with the coding staff to make sure your specific needs are being met. Learn how to collaborate to make selection of diagnoses easier. • Get involved and be part of the change! Educate on documentation issues and specificity of codes. • Decide the appropriate workflow. If your registrar is coding for your department, will he/she really have all information needed to code effectively? • Create an internal auditing system and report on how you are doing on different topics each month. Use the audits to educate and improve systems. • Eliminate monthly serial billing and convert to per-encounter billing before Oct. 1. Otherwise, your revenue will be negatively impacted. • Have an individual responsible to check all outgoing claims to be sure he/she has the appropriate documentation and coding for medical necessity. • Do not pick a diagnosis code because “that is what the insurance will pay.” <b>KS:</b> Congratulations to those wound care professionals who have made coding process changes to prepare for ICD-10. To assist those wound care professionals who have not made progress on this project, following are some of the coding processes your peers plan to change: <p>

• “will dual coding both ICD-9 and ICD-10”
• “will conduct Internal audits”
• “will create documentation checklists for major pertinent ICD-10 codes”
• “will purchase new software” • “will update super bill”
• “will use a coder to select correct ICD-10 codes based on wound care professional’s documentation”
• “will use conversion web tool and billing software.”

Question: How would you describe any part of your ICD-10 preparation that you believe has gone well? Results: Varied.

KS: Although many responders said they have not prepared or that they thought it was “a pain,” several responders shared some very helpful responses. Following are some responses that should help all wound care professionals be ready for Oct.1:

• “availability of resources, hospital consultants”
• “extensive training in ICD-10 coding applications”
• “information technology and billing departments have been working together”
• “identifying the most accurate diagnoses and descriptions”
• “monthly discussion groups with coders and coding manager”
• “personal preparation”
• “review and handouts”
• “seminars and classes”
• “software”
• “EHR training”
• “slowly learning about ICD-10 over a one-year period”
• “the coding department helped us prepare for the original deadline”
• “now all the specific ICD-10 codes pop-up on our software.”

Question: How would you describe any part of your ICD-10 preparation that you believe has not gone well? Results: Varied.

KS: Because we can learn from others’ mistakes, the following survey results may be helpful to you:

• “We delayed physician training too long.”
• “We didn’t allow physicians to get involved to begin refining their documentation.”
• “We allowed all team members to believe ICD-10 would not be implemented.”
• “We delayed working with other departments too long.”
• “We did not understand that ICD-10 pertains to inpatients as well as outpatients.”
• “We have not adequately prepared.”
• “We waited for others (eg, health system, administration, wound management company, other departments) to tell us what to do rather than to take the initiative to prepare ourselves.”
• “We allowed our attitudes to prevent us from preparing.”
• “We did not obtain a timeline from our vendor, and they have not yet tested the software that we use.”
• “We have not practiced documenting and coding for ICD-10 on a daily basis.”

Survey Summary Hopefully these results and the commentary provided by the authors will help you create an awesome ICD-10 implementation to-do list. Time is ticking: Wound care professionals need to get started as soon as possible. Be sure your implementation team is multidisciplinary and celebrate the team’s successes as it accomplishes items on the list! Embrace the ICD-10 system as an opportunity to improve your entire system. By the time September comes around, we hope your responses to this survey’s line of questioning have all turned positive. Thanks to all those who took the time to participate in our survey! The positive feedback and suggestions should be a huge help to you and your peers!

Donna Cartwright is senior director of strategic reimbursement at Integra LifeSciences Corp., Plainsboro, NJ, and an American Health Information Management Association-approved ICD-10 trainer. She may be reached for questions at 609-936-2265 or donna.cartwright@integralife.com.

Kathleen D. Schaum, MS, is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL; and director, medical products, reimbursement, biotherapeutics at Smith & Nephew.