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ICD-10: Can physician groups stave off or delay implementation?


With the ICD-10 deadline looming, will physician groups actually be able to keep implementation from happening?

The government isn’t backing off its mandate to implement the International Classification of Diseases, 10th Revision (ICD-10), despite calls from a coalition of physician groups to push back the October 1, 2014, deadline.

The most recent salvos occurred late last year. In November, the American Medical Association’s (AMA) House of Delegates approved a policy stating that the organization would work to stop implementation of ICD-10. The following month, the AMA, the American Academy of Family Physicians (AAFP), the American College of Osteopathic Family Physicians, and the American Osteopathic Association, along with 39 other specialty associations and 42 state medical societies, wrote to Marilyn Tavenner, acting administrator of the Centers for Medicare and Medicaid Services (CMS) requesting elimination of the ICD-10 mandate.

At press time, a CMS spokesman said the agency is drafting a response to the letter. So far, however, it has shown no signs of further delaying the implementation deadline.

First developed in the late 1980s, the 10th revision of the ICD codes has been in use in nearly all other industrialized countries since the 1990s. They replaced the ICD-9 code set that came into use in 1979 and that is still used in the United States. (See “ICD-10: A timeline.”)

ICD-10’s use in the United States was first mandated in January 2009, when the U.S. Department of Health and Human Services (HHS) published a final rule adopting the use of the ICD-10-CM (clinical management) and ICD-10-Procedure Coding System (PCS) coding sets as standards under the Health Insurance Portability and Accountability Act. The implementation deadline was set for October 1, 2013. In August 2012, HHS extended the deadline by 1 year.


Probably the biggest difference between ICD-9 and ICD-10 is in their level of specificity. Kathryn DeVault, RHIA, CCS, director of health information management solutions for the American Health Information Management Association (AHIMA), cites as an example the coding for treatment of a fractured finger. ICD-9 has eight coding options, whereas ICD-10 has about 64.

“You can’t just say it’s a finger,” she says. “Which finger is it, and which hand? Is it the proximal portion of the finger or the distal? Is it the first visit or a follow-up? That’s the level of detail that needs to be addressed.”

The greater level of specificity in the codes leads to more of them-about 68,000 in ICD-10-CM compared with 14,000 in ICD-9. But that increase shouldn’t be a reason for panic, experts say. Most primary care practices routin

ely will use only a small fraction of those.


Although third-party payers, electronic health record (EHR) system vendors, and other groups affected by ICD-10 have begun preparing for the change, many physicians oppose it.

In their letter to CMS’ Tanner, the physicians’ groups called ICD-10 “a massive administrative and financial undertaking for physicians.” Citing a 2008 study from the consulting group Nachimson Advisors LLC, the letter said that implementation costs will range from $83,290 to more than $2.7 million, depending on the size of the practice, and will force many small practices to go out of business. (See “ICD-10 implementation costs.”)

The groups also noted that ICD-10 comes at a time when many doctors are implementing EHRs and are facing other new mandates, including meaningful use, e-prescribing, the Physician Quality Reporting System, and the use of value-based modifiers. The financial, technological, and operational pressures on doctors could make it more difficult for them to participate in new healthcare delivery and payment reform models.


Although no data exist on the number of physicians who have begun preparing for ICD-10, anecdotal evidence suggests that

the number is still very small. When Debra Seyfried, MBA, CMPC, coding and compliance strategist for the AAFP, conducted a seminar on ICD-10 at the group’s annual meeting this past September, she asked how many of the approximately 175 attendees had begun preparations. “There was only a smattering of hands,” she recalls.

“We’ve talked with the state [AAFP] chapters as well,

“I think this will be a do-or-die year for a lot of people. If they’re not preparing now, they’d better start.”
- Kathryn DeVault, RHIA, CCS, Director of Health Information Management Systems, American Health Information Management Association

and from what I understand, unless you’re an employed physician in a large hospital system, then you probably haven’t started anything,” she says.

Doctors usually cite two reasons for not planning for ICD-10, Seyfried says. Either they think the deadline will be pushed back again or the mandate will be removed altogether, or they believe that their EHR vendor will take care of the coding changes. Her response to the first group is, “I would be totally shocked if they [CMS] delayed this again. There are too many large organizations that are already preparing for ICD-10.”

To doctors relying on their EHR vendors to handle the transition, Seyfried says, “That’s like getting into a car and saying ‘I know how to drive’ without knowing the rules of the road.” She points out, for instance, that ICD-10 will have 166 codes covering diabetes, compared with 23 codes in ICD-9. “Are you going to scroll through all 166 to find the one that’s right?” she says.

AHIMA’s DeVault says the changeover to ICD-10 has the potential for being “a huge train wreck.”

“Here we are in early 2013 and people are coming out of the woodwork saying, ‘Now I need to panic.’ We started to see the same thing at the end of 2011, but when CMS changed the deadline, they took their finger off the panic button. But now it’s revving back up. I think this will be a do-or-die year for a lot of people. If they’re not preparing now, they’d better start.”


Not everyone thinks doctors will be unprepared for ICD-10 when the implementation deadline arrives, however. The American College of Physicians (ACP) did not sign the letter of opposition sent to CMS. Shari M. Erickson, MPH, vice president of governmental and regulatory affairs for the ACP, said the organization has shifted its focus from opposition to helping its members prepare for the changeover.

“The feedback we’ve been getting from our members is that many of them have started to take courses and prepare their practices in a variety of ways,” Erickson says. “At the same time, we recognize that many of them will continue to struggle, so it seemed a more appropriate use of our time and resources to help them [rather] than to continue fighting the idea of implementation.”

Erickson says the ACP has held seminars on preparing for the transition at recent annual meetings and will hold a full-day “boot camp” at its 2014 annual meeting. It also has held regional meetings and Web seminars on the transition. Much of the training emphasizes the importance of focusing on how the top 50 or so codes a practice uses will differ in ICD-10 from what they are now. “That’s by no means an underwhelming task, but it’s a lot easier than 68,000 codes,” she says.


Along with the number of codes, one of doctors’ biggest concerns about ICD-10 is the more detailed level of documentation it will require. But that fear may be overblown, says Juliet A. Santos, MSN, CCRN, senior director, business-centered systems, for the Healthcare Information Management Systems Society and a family practice nurse practitioner.

“Documenting is something we learn on day one of medical school or nurse practitioner school,” she says, “But [doctors] are being paralyzed by fear. We just need to make them see they already know more [about documentation requirements] than they think they do, and unfreeze them.”

“I think by now, most payers...understand what the full [ICD-10] remediation effort involves.”
-Ray Desrochers, Excecutive Vice President, HealthEdge





Among all those affected by the ICD-10 mandate, third-party payers appear to have made the most progress in getting ready for the changeover. In a recent nationwide survey of 170 executives conducted by HealthEdge, a software developer for the healthcare payer market, 90% of respondents said their organizations will be ready to implement ICD-10, compared with 61% in July.


Ray Desrochers, executive vice president at HealthEdge, says payers began waking up to the challenges posed by ICD-10 in the spring and summer of 2011, when the implementation deadline was still set for October 2013. “I think by now most of them have confronted the challenge, have broken it down, and understand what the full remediation effort involves. And now with the extra year, they’re feeling pretty good about their ability to get there.”

A particular concern for payers, Desrochers adds, is a possible scenario in which payers are ready for ICD-10 by the deadline, but providers are not-or have been granted another extension. “We’re telling payers to prepare for both standards simultaneously, which is colossally painful. But if that should happen, the payers are going to have to support both. Otherwise, the whole healthcare system comes to a grinding halt.”

Send your feedback to medec@advanstar.com. Also engage at www.twitter.com/MedEconomics and www.facebook.com/MedicalEconomics.

 Online tool determines financial impact of ICD-10

Want to get an estimate of the cost to your practice of converting to the International Classification of Diseases, 10th Revision (ICD-10), code set? The Healthcare Information and Management Systems Society (HIMSS) has a free online tool that can help.

The ICD-10 PlayBook Financial Risk Calculator
(www.jvionhealth.com/jra/Intro.aspx), developed in conjunction with the healthcare technology company Jvion, offers a risk rating for revenues, cash flow, and operational costs, and then compares your risk with that of similar practices.

The calculator is an entryway to the ICD-10 Playbook HIMSS released in 2011, which is designed to ease the transition to the new coding system.

“The calculator provides hospitals and physician practices with a way to quickly assess the financial risk that ICD-10 poses to their organizations,” says Juliet Santos, senior director, business centered systems for HIMSS. “By simply answering a short survey, providers receive unique insight into the potential impacts of ICD-10, steps they can take to address those impacts, and ways to augment their accounts receivable even before they complete their conversion to ICD-10.”

Physicians, administrators, or other support staff can complete the survey and have results emailed in 2 to 3 days. The small practice survey has 25 questions, including those involving the practice’s location, denial rates, Medicare dependence, daily average claim acceptance, and other data. It looks at less tangible factors as well, such as how much you know about vendor performance and how recently you’ve performed a billing audit.

Preparing your practice for ICD-10

  • So you’ve decided to get your practice ready to use ICD-10 coding. Where do you begin? Maxine Lewis, president of Medical Coding & Reimbursement in Cincinnati, Ohio, recommends the following steps:

  • Put someone in charge. “Appoint one person, be it the officer manager, the coder, or the biller, to drive the process and oversee all the details,” Lewis says.

  • Develop a timeline. For instance, “ ‘This week we’re going to accomplish task A; in 2 weeks we will have accomplished task B.’ I think it’s important to put goals in front of yourself to achieve this planning,” she says.

  • Identify your codes: One of the most important elements in preparing will be identifying the codes your practice uses the most, so that you can begin learning what they will be in ICD-10, Lewis says. The easiest way to do this is to review your superbills.

  • Analyze your contracts with third-party payers: “Chances are, you have a lot of services that are carved out, or services that are automatically provided because of a certain diagnosis. So you have to find those in your contracts and make sure you’re using ICD-10 for the services you are performing, because if you don’t know what the new code is, you won’t get paid,” Lewis says.    

  • Get training in documentation: The ICD-10 codes are more granular, and thus require far more detailed documentation than do ICD-9 codes, Lewis points out. For example, treatment of a fractured tibia has six codes associated with it, and thus “you have to document the exact site of the fracture, and whether this is a first or subsequent encounter. Is it sequelae? It’s a much greater level of detail than most doctors and their staff are accustomed to providing.” (See “Differences between ICD-9 and ICD-10.”)


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