It may feel as though we have been perpetually counting down to ICD-10—the International Classification of Diseases, Tenth Revision—but the clock is finally running out. After the initial 2009 decision to switch and two year-long delays, Oct. 1, 2015 now marks the official “go live” date for the significantly revised and expanded coding language. By the time this issue of ENTtoday goes to press, the clock will read less than 30 days.
As with any major process change, ICD-10 comes with both benefits and challenges. On the plus side, it carries the potential for increased international collaboration, the collection of more detailed health data, and more precise documentation of the patient experience. Ultimately, this should lead to better analysis of disease and its progression, facilitate better quality of care, and improve treatment outcomes. It’s also expected to contribute to epidemiological research and population health management.
“One of the greatest benefits of ICD-10 is that there are improved descriptions of patient illnesses,” said James C. Denneny III, MD, executive vice president and CEO of the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) and the AAO-HNS Foundation (AAO-HNSF). “Better descriptions mean better data to help physicians treat patients more effectively. ICD-10 codes extend beyond the classification of diseases and injuries to include risk factors, too. The codes have been updated for the clinical practices of today, and the structure of ICD-10 allows for greater expansion of codes in the future.”
On the flip side, the challenges inherent in the switch include the significantly increased scope, technical difficulties, training needs, and financial risks, and these issues are projected to be unevenly experienced by physicians who work in hospital systems, multispecialty groups, and smaller private practices. An additional complication is the potential for varying levels of specificity required by CMS compared with third-party payers as a result of the 12-month implementation period that was announced in July. Despite the varying level of complications, one truth is clear: The switch is not optional, and now is the time to make sure everything’s in place when the clock runs out in October.
The Current View
ICD-10 codes must be used on all HIPAA transactions, including both outpatient claims with dates of service and inpatient claims with dates of discharge of Oct. 1, 2015, and beyond. Claims and other transactions with outdated codes may be rejected and need to be resubmitted, which could result in delays and affect reimbursements.
According to CMS, the transition to ICD-10 is occurring because ICD-9 produces limited data about patients’ medical conditions and hospital inpatient procedures; the data set is 30 years old, has outdated terms, and is inconsistent with current medical practice; and the structure of ICD-9 limits the number of new codes that can be created. ICD-10 contains significantly more codes than the previous iteration of the data set, and the codes are longer.
In ICD-9, there are approximately 14,000 diagnosis codes and 3,800 procedure codes, totaling about 17,800. By comparison, ICD-10 has nearly 70,000 diagnosis codes and nearly 72,000 procedure codes, for a total of almost 142,000 codes.
In addition to the increased quantity of codes, the code structure is different. Although there are some similarities (e.g., the hierarchal structure, the meanings of the symbols, and the criteria for code assignment of the principal diagnosis code), some differences will take getting used to. The most significant difference is the code structure: ICD-9 codes contain three to five characters, while ICD-10 codes contain up to seven alphanumeric characters. Furthermore, the “V” and “E” codes from ICD-9 are being discontinued, and the sixth digit in ICD-10 will mainly be numeric and will identify laterality and drug poisoning.
Because there’s frequently not a one-to-one conversion, single codes in ICD-9 may translate to multiple possibilities in ICD-10. Cerumen (wax) impaction is an example, said Richard Waguespack, MD, clinical professor in the department of surgery, division of otolaryngology at the University of Alabama at Birmingham (UAB). The ICD-9 code is 380.4. “Under ICD-10, there will be additional and more specific codes, one of which should not be used (H61.20 impacted cerumen unspecified ear): H61.21 impacted cerumen right ear, H61.22 impacted cerumen left ear, and H61.23 impacted cerumen bilateral (both) ears,” he explained.
The AAO-HNS has provided numerous resources to try to mitigate the burden of ICD-10 implementation on physicians, including workshops, webinars, and online resources. One example is the AAO-HNS partnership with the American Association of Professional Coders (AAPC) to provide special access to “ICD-10 Documentation Training for Physicians” and “ICD-10-CM Specialty Code Set for Otolaryngology,” as well as other AAPC online training tools and courses.
Legislatively, efforts have been made to stall or adapt the switch to ICD-10. H.R. 2247, the ICD-TEN ACT, which was introduced by Rep. Black (R-Tenn.) in May 2015, includes an 18-month safe harbor period. H.R. 3018, the Code-FLEX Act of 2015, was introduced by Rep. Blackburn (R-Tenn.) in July and included a stipulation that ICD-9 codes continue to be accepted in parallel with ICD-10 codes for six months after the switch. Both bills were still in committee as of early August.
Although AAO-HNS stayed up to date on legislative activities, “the Academy’s recent efforts have been focused on CMS, the regulatory implementation, and preparing members for the ICD-10 transition,” Dr. Denneny said. However, he added, AAO-HNS “did sign on to AMA [American Medical Association] letters urging CMS to publish further data on ICD-10 testing results, EHR [electronic health record] vendor readiness, details on avoiding adverse impacts on quality measurement, risk mitigation plans, and more. We were pleased to see the July announcement from CMS and the AMA about efforts to limit ICD-10-related burdens on physicians.”
The CMS/AMA joint announcement came out on July 6 announcing an implementation period for ICD-10 that is intended to create some flexibility while everyone gets used to the new code set. The CMS guidance states that “for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family of codes.” (“Family of codes” refers to the ICD-10 three-character category headings.)
“This means that Medicare will not deny payment for these unintentional errors as practices become accustomed to ICD-10 coding,” wrote AMA President Steven J. Stack, MD, in an AMA Viewpoints post. “In addition, Medicare claims will not be audited based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes. This transition period will give physicians and their practice teams time to get up to speed on the more complicated code set.”
Time will be needed, given expectations for a relatively steep learning curve as physicians and staff adapt to the dramatically expanded code set. With the significant differences between ICD-9 and ICD-10, plans for testing the system in advance were a key topic of conversation in the medical community and on Capitol Hill. March 3-7, 2014, marked the initial testing week. During this acknowledgment testing, testers submitted more than 127,000 claims and were able to receive acknowledgments that the claims were accepted. The initial testing period was considered insufficient by many, because it did not represent true end-to-end testing.
In response to urging from the medical community, CMS announced three end-to-end testing periods in 2015, to involve a total of 2,550 volunteers. The testing periods included the submission of test claims to Medicare and then a subsequent response, called a remittance advice (RA), explaining the adjudication of the claims. With the testing periods, CMS intended to demonstrate that providers could successfully submit claims through Medicare, that software changes made at CMS to support ICD-10 result in appropriately adjudicated claims (based on the pricing data used for testing purposes), and that accurate RA documents are produced.
CMS has since publicized the results of two of the three testing periods. Testing held Jan. 26-30 resulted in an 81% acceptance rate among 661 participants, and testing held April 27-May 1 resulted in an 88% acceptance rate among 875 participants. A third testing period was held July 20-24, 2015.
Members of the AAO-HNS “were involved in the end-to-end testing for otolaryngology, and over time we saw improved results,” Dr. Denneny said. “We had members participate in both the January end-to-end testing week and in April. Participants were able to successfully submit ICD-10 test claims and have them processed through Medicare billing systems.”
Another aspect of the technical challenge is that Oct. 1, 2015, happens to be a Thursday, which means that claims submitted on Wednesday that week will need to be handled differently than those submitted on Thursday. One of the biggest challenges is that “we are having literally the entire medical system turn on a dime on Oct. 1,” Dr. Waguespack said. Additional challenges, he said, include documenting to the appropriate level of specificity and learning to report comorbidities—such as how an injury occurred or whether a patient is a smoker—as part of the new code sets.
Further, there will be a period of time in which claims need to be processed in both formats, depending on dates of service. Billing professionals will have to be extra vigilant and watch service dates for a while to ensure that claims are processed correctly.
Despite the newly introduced flexibility with ICD-10, the switch off of ICD-9 will be a hard stop. Although some have called for a dual use period, CMS stated in both a July 7 letter to providers and a July 24 list of “clarifying questions and answers” that ICD-9 will not be accepted as of Oct. 1. CMS also has been clear that although Medicare is allowing an implementation period, third-party payers are not held to the same requirement. The guidance will be adopted by the Medicare administrative contractors, the recovery audit contractors, the zone program integrity contractors, and the supplemental medical review contractor.
Similarly, the guidance does not change the coding specificity required by the local coverage determinations (LCDs) or national coverage determinations (NCDs), and claims may be denied because the ICD-10 code is not consistent with an applicable LCD or NCD policy.
Learning the New Code
One especially important way to be prepared for the go live is to provide staff training ahead of time. Staff training will be key for ensuring a smooth transition to the new coding set and for keeping the day-to-day practice of documenting and billing on track. To help ensure that staff members are successful after ICD-10 goes live and that there are minimal disruptions to practice, categorize the staff members who need to receive training and at what levels, coordinate the timeline for training and working with the team on completion, identify the training format that works best for the team (e.g., classroom, online, conference), decide on the amount of downtime for the office during training, and identify the additional resources staff members will need after training is completed.
In particular, three groups and levels are integral to ensuring proper staff training:
- Administrative staff (e.g., schedulers, receptionist)—overview and general understanding of the new ICD-10 code structure;
- Clinical staff (e.g., physician assistants, nurses, nurse practitioners)—clinical concepts and level of detail in ICD-10 for documentation purposes; and
- Physicians and coders—clear understanding of the new code structure, coding guidelines, and conventions related to specificity.
In addition to receiving in-depth training on ICD-10, coders who hold a coding membership from the AAPC will need to complete a proficiency assessment by Dec. 31, 2015, to satisfy their certification maintenance requirement.
In many cases, physicians are relying on their electronic medical record vendor or their institution for training or to ensure a smooth transition.
“There’s going to be a tremendous amount of variability,” Dr. Waguespack says. “For example, in large academic institutions like the one I am in, a lot of the groundwork will have been done by their institutions. The challenge is to make sure it trickles down to individual practitioners and that the tools people need to report correctly are factored into EHRs and are otherwise available to them.”
Budgeting and Financial Considerations
Staff training time and resources are important, although this constitutes a financial consideration in the transition. Training time, software upgrades, and other considerations are all rolled into recent projections on the cost of implementing ICD-10 across the U.S. The total cost is projected to be significant.
The Nachimson Advisors, a Baltimore-based health IT consulting firm, released a revision to the 2008 study on the costs of ICD-10 implementation that projects higher costs than originally estimated for practices of all sizes. The practice definitions were small practice (i.e., three physicians and two administrative staff), medium (i.e., 10 physicians, one full-time coder, and six administrative staff), and large (i.e., 100 physicians, 64 coding staff, 10 full-time coders, and 54 medical records staff). The updated projections from 2008–2014 include the following:
- Small practice: $83,290 vs. $56,639–226,105;
- Medium practice: $285,195 vs. $213,364–824,735; and
- Large practice: $2,728,780 vs. $2,017,151–8,018,364.
The revised projections are the results of adding in tasks that were not considered “critical” in the 2008 study, which includes testing as well as projections for payment disruptions.
It is generally expected that there will be an increase in denied claims and delays in reimbursements as the country gets used to ICD-10. AMA predicts, “You will have disruptions in your transactions being processed and receipt of your payments. Physicians are urged to set up a line of credit to mitigate any cash flow interruptions that may occur.” Planning ahead and having cash reserves on hand to keep business moving while these difficulties are sorted out could make the difference.
Although there is continued contention about whether the switch to ICD-10 is the right move for the U.S., the reality is that ICD-10 is coming, and the clock is running out. Many hospital systems, multispecialty groups, and physicians’ offices have begun implementation efforts and training for their staff. Those who have not are encouraged to get started quickly.
The AMA recommends several steps to prepare for converting to ICD-10:
- Talk to your practice management or software vendor about whether the needed software updates will be installed with upgrades and when;
- Talk to your clearinghouses, billing service, and payers to determine when they will have their ICD-10 upgrades completed and when you can begin testing with them;
- Identify the changes that you need to make in your practice to convert to the ICD-10 code set (e.g., diagnosis coding tools, super bills, public health reporting tools);
- Identify staff training needs, and complete the necessary training;
- Conduct testing internally to ensure transactions with ICD-10 codes can be generated; and
- Conduct testing externally with clearinghouses and payers to make sure transactions with ICD-10 codes can be sent and received.
“Otolaryngologists should also look into the resources available to them through the specialty societies,” Dr. Denneny said. “For example, the Academy offers ICD-10 ENT super bills for AAO-HNS members to use. One version lists over 120 additional ICD-10 codes relevant to otolaryngology, and another lists ICD-10 codes by anatomic/disease area. Other things to do include communicating with payers and vendors, improving documentation practices, assessing claims for mapping risks, and testing claims under ICD-10.”
After the steps have been taken to lay the groundwork for the go live, another consideration is what to communicate with patients. The code switch will take some getting used to for healthcare providers across the country, and that carries with it the risk that the physician will lose overall productivity.
“I think the important message for patients about ICD-10 is that more descriptive codes for their illnesses will improve data and ultimately lead to better patient care,” Dr. Denneny said. “Should the transition to ICD-10 impact a practice’s patient flow, an explanation of why there are delays might be appreciated.”
Dr. Waguespack noted that patients may need to be made aware of issues with reimbursements. “In the event there’s a monkey wrench in the reimbursement process, staff might need to take time to investigate where the problem is and, if necessary, engage the patient and allow the system to work out the kinks,” he said. “Which is why, hopefully, this one-year Medicare allowance to report in the family [of codes] without a reimbursement penalty will be really helpful. This is meant to help practices transition into the new system, not defer implementation.”
Ultimately, the switch is coming without further delay, and the changeover has the potential to cause considerable upheaval for day-to-day medical practice. The only way to mitigate that is to be prepared and educated about what using ICD-10 in day-to-day practice means.
“There seems to be such a giant number of codes in ICD-10, but if the otolaryngology community realizes the need is to focus on diagnoses encountered most often and know those codes, we probably will do just fine, or at least make it through the transition and get up on the learning curve,” Dr. Waguespack said. “Hopefully, this will turn out to be like Y2K, where it looked like there was the potential for impending doom and end of civilization as we know it, but it turned out to not be anything of the sort for most of us.”
Kimberly J. Retzlaff is a medical journalist based in Denver.
Adapted with the permission of The American College of Rheumatology from an article in the July 2015 issue of The Rheumatologist.