Guest Editorial: Our ICD-10-CM ‘Lessons Learned’ Edition

In my 48 years of working with medical reimbursement, only a few “bellwether” reimbursement events are indelibly stamped in my memory: the first day hospitals switched to the Medicare payment system known as diagnosis-related groups, the day the Balanced Budget Act of 1997 was signed, the day wound care hospital-based outpatient departments (HOPDs) began their prospective payment system known as ambulatory payment classification groups, the day the Medicare Physician Fee Schedule changed from a volume-based emphasis to value-based, and the day ICD-10-CM replaced ICD-9 as the diagnosis coding system for the entire country. After all the horrible predictions, such as “hospitals will close, HOPDs will come to a grinding halt, patients will die because their physicians will not be able to manage their caseloads, and Medicare’s computers will crash because they will not be capable of handling the large volume of ICD-10 codes with more digits,” Oct. 1, 2015, was just another day in the medical field. 

On Sept. 30, 2015, I was the guest speaker at the annual symposium for the program directors of a large wound management company. I was surprised to find the ballroom packed with attendees! I thought many of the directors would stay in their HOPDs to make last-minute preparations for the ICD-10 conversion. But they told me they were “ready and were not worried about the conversion.” On the morning of Oct. 1, I awoke bright and early and began monitoring the Internet for news of catastrophes. Actually, things were quiet all day. The best Internet post of the day was a picture of my colleague Andrea Rubinowitz, RHIA, CCS, COC, CPC-H, and her team of coders having a “funeral service” for ICD-9! A few days later, I spoke with Andrea and asked her if she would pay attention to any wound care-related issues that surfaced post-ICD-10 implementation and if she would share them with us in this special edition of Today’s Wound Clinic (TWC). You can read about the three wound care-related ICD-10 coding challenges that she describes in this issue of the journal. 

I also called my colleague and fellow TWC editorial board member Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA, to ask what she was hearing from her fellow coders. She also said things were “fairly quiet.” Donna and I then reflected on the fact that ICD-10 had been the biggest change in coding history and that the healthcare industry had plenty of time to prepare for the implementation. We discussed how the TWC editorial board had done its best to publish educational articles about ICD-10, including Donna’s wound care-specific ICD-10-CM Diagnosis Coding Documentation Tips published for many months prior to Oct.1. Donna and I also felt good about the four-hour and eight-hour wound care-specific ICD-10 implementation seminars that we’ve offered throughout the country. However, our internal barometers told us some wound care professionals took the time to implement all the needed ICD-10 processes and to improve their documentation one disease state at a time while others procrastinated their preparation because they kept hoping ICD-10 would simply go away. Therefore, Donna and I agreed we needed to do several things to prepare for this special TWC edition that discusses the wound clinic industry’s state of ICD-10 implementation success (and lack thereof). In order to make this issue of the journal as comprehensive as possible, we:

1. created a three-part survey to gather readers’ perceptions of their ICD-10 conversion preparations and implementation processes (Part 1 results in this journal, see page 28; results to parts 2 and 3 will publish in March and April);

2. reviewed various local coverage determinations (LCDs) to see the specific codes and documentation that Medicare Administrative Contractors (MACs) are requiring now that ICD-10 is a reality; and

3. spoke with wound care professionals about ICD-10 concerns that have surfaced and that need to be improved.

We are thrilled to see that wound care professionals who reported the most successful ICD-10 conversions have followed implementation steps that we have published in TWC and taught over several years. If you are having trouble implementing ICD-10, please read the recommendations of readers who’ve experienced successful conversions. I was fascinated to see the similarity of the implementation process among successful readers — the profile of success did not seem to be affected by where one worked or by one’s specialty. One topic is very clear: Documentation is the key to success.

Many readers report they were having difficulty using more than one code to “paint the picture” about a patient’s medical condition: With ICD-9 they did not have many specific codes from which to choose. Beginning on page 21, Donna discusses how wound care professionals can prevent becoming ICD-10 coding “minimalists.” Along this line of thinking, many readers faced challenges adjusting to the mapping from ICD-9 to ICD-10. In some instances, the codes map one-to-one. In many other instances, the codes map one-to-many. To that end, we also provide useful guidance for using General Equivalence Mappings (see page 24).  As Andrea reveals in her article, pressure ulcer coding has presented some specific issues and has emphasized the need for specific wound care documentation. To provide additional education on this topic, we also discuss some controversies in ICD-10 pressure ulcer coding (see page 14). As most readers know, I always emphasize that reimbursement is made up of three parts: coding, payment, and coverage (but the most important part is the payer’s coverage guidelines and policies). Many qualified healthcare professionals (QHPs) have told me “it is not my job to read and understand the payers’ coverage policies.” Yet, these policies are the “playbook” for understanding how the payer determines what is medically necessary and what the payer expects to find documented in the medical record. Prior to ICD-10, the need for QHPs to read their top 10-20 payers’ medical policies (that pertain to the services, procedures, and products they provide to patients) was very high. Since the implementation, the need to read those payers’ medical policies is essential. Some of the medical policies contain specific lists of covered ICD-10 codes. Due to the variety of available ICD-10 codes, QHPs may not have selected the same codes (to describe their patients’ diagnoses) as the covered codes the payers selected as covered. In some instances, the QHP’s codes are not specific enough. In other instances, the payers may have inadvertently omitted important ICD-10 codes from their list of covered codes. Most payers have been very accommodating to add ICD-10 codes to their lists if they align with the payer’s coverage criteria. In fact, many payers have released specific directions for requesting updates to the list of covered ICD-10 diagnosis codes. Note that in nearly all cases, the payers have reminded providers they do not intend on adding “not otherwise classified” codes (with few exceptions) to the list of covered codes. You will enjoy the review of some of the MACs’ LCDs that were updated on or after Oct. 1 in this issue’s Business Briefs.

I would like to thank our dedicated readers for allowing us into their wound clinics each month. In addition, I’d like to thank Donna and Andrea for their passion and dedication to educating our industry about the wound care revenue cycle. Together, we have had a long journey in preparing for and implementing ICD-10. We hope you’ll gain insight with this special journal issue, which you helped create!

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.