Many physicians still unprepared for ICD-10

The clinic where Corrine Leistikow, MD, works in Fairbanks, Alaska, was on its way to preparing for the transition to the International Classification of Diseases-10th Revision (ICD-10). But then ICD-10 was delayed until October 2015, and that work ground to a halt in the face of the other burdens of running a medical practice, says Leistikow, the clinic’s assistant medical director for family medicine.

Now she plans to hold monthly in-service training sessions with the physicians  to study commonly-used codes. “As physicians, we haven’t been thinking about it, except to know that it is coming,” she says. “We know it is coming and needs to happen but we also know it will be painful.”

Leistikow and her colleagues have some company. With 11 months to go until the transition, half of the physicians who answered Medical Economics’ exclusive 2014 physician survey said they are not ready for ICD-10. The reasons are many, but mostly come down to cost, productivity and technology hurdles, and lack of certainty in the transition.

While many physicians are not ready, the number who are prepared is up significantly from a large-scale survey in 2013 by the Medical Group Management Association in which fewer than 5% of practices reported having had made significant progress towards ICD-10 readiness.

Acknowledging the enormous outlay of resources required to transition to ICD-10, the Centers for Medicare and Medicaid Services (CMS), through congressional action, has twice pushed back the compliance date, first from October 2013 to 2014, and then to 2015.

But physicians, health plans and electronic health record (EHR) vendors should not assume another delay. Stanley Nachimson, principal of Nachimson Advisors and an expert on ICD-10,  estimates there is a 75% chance that the ICD-10 transition will actually take place in October 2015. Most EHR vendors have already upgraded their software to reflect the new codes.

“The health plans and vendors are moving forward and getting out ahead of the providers,” he says. “It’s time for the providers to catch up. Doctors need to be somewhat assertive and start taking steps to move forward on ICD-10. I’m not sure I’d want to take a chance of my revenue getting interrupted.”

The move to ICD-10 will improve national healthcare initiatives such as meaningful use, value-based purchasing, payment reform, and quality reporting. “With ICD-9, there were serious gaps in the ability to extract important patient health information needed to support research and public health reporting, and move to a payment system based on quality and outcomes,” says Nancy Enos, FACMPE, CPC-I, an American Association of Professional Coders-certified ICD-10 instructor.

Enos says the physicians she’s been training are finding the new codes much easier to work with. “They’re able to find the code they’re looking for much more easily than with ICD-9 because they’re much more specific,” she says.

Next: ICD-10 readiness demographics

Next: ICD-9 vs. ICD-10

That specificity also can help an insurer understand a claim more easily, says Enos. “If a patient breaks their right wrist and six weeks later breaks their left wrist, there’s no code right now that differentiates between them,” she says, adding that ICD-10 codes will also help with complications.

And the fact is that ICD-9 is out of date, with much of the world already using ICD-10. For example, Nachimson says, there is no code for Ebola in ICD-9.

But the burden of the transition is great, and most of it falls on  physicians. Due to the increased number of codes, changes in the number of characters per code, and increased code specificity, the transition will require significant planning, training, software and system upgrades and/or replacements, among other investments.

“A lot of the costs and the effort falls on the providers, and they don’t necessarily get the direct benefit of the coding change,” Nachimson says. “Cost and benefits are not quite aligned.”

While CMS has characterized the new codes as a needed benefit, they are an administrative burden for physicians, and mostly benefit insurance companies, says Reid B. Blackwelder, MD, FAAFP, a family physician in Kingsport, Tennessee, and president of the American Academy of Family Physicians.

“I’m not sure there’s a clinical benefit to using them,” he says. “The reality of the codes is so much of what we document is not for patient care. It’s there to support better billing and research documentation. Whether I code asthma in a general code or more specific code doesn’t impact the care that the patient will receive that day. “The codes in and of themselves do not improve (patient) outcomes,” he adds.

A sticking point for Blackwelder is that family physicians will only use a small portion of the codes but will still have to spend the money to upgrade their EHR software for ICD-10, and get documentation training for themselves and coding training for staff.

That’s an expensive proposition. In a study updated for the American Medical Association in early 2014, Nachimson found that the costs of preparing for ICD-10 could range from $56,000 for a small practice to millions of dollars for large practices and health systems.

Each step in the preparation process involves a significant outlay of cash, says Blackwelder, and without proper testing, there’s no guarantee that by the deadline the process will be functional. Nachimson says that some health plans have begun testing, but many have delayed their efforts.

Next: Practice size and ICD-10

Practice size is a major indication of ICD-10 readiness, according to the survey. Fewer than 44% of solo and two-physician practices said they are ready for the transition.

Meanwhile, 49% of groups of three to 10 physicians, and 55% of groups of 11 to 25 doctors said they are ready. Groups with more than 50 physicians are the most prepared, the results show, with 68% ready.

Blackwelder’s practice is part of a larger system that’s linked to an academic center. Typically, larger institutions have been better prepared, because they have the resources, he notes. His practice is already conducting trial runs using ICD-10 codes.

Enos says she’s worked with many larger practices that have already turned on ICD-10. “They’re actually using the codes and turning them on and having the clearinghouses convert them back to ICD-9. It’s good practice,” she says.

But Blackwelder says it’s the small practices the AAFP represents that really need the testing.

“It’s no benefit to our members if (the coding system) works reasonably well for hospitals but not for them,” says Blackwelder. “If there are problems with the way they’re documenting, then their payments get disputed.”

Smaller practices often can’t handle a disruption to their revenue stream, says Blackwelder, and it’s for that reason that the 115,000-member AAFP pushed for both compliance date delays. The association wants CMS to conduct comprehensive, end-to-end process testing, from documentation to submission to payment, to ensure that the system is operational.

But so far, he hasn’t seen any evidence of testing, which he finds troublesome. “The whole purpose of the delay is to make sure the system works by the compliance date,” says Blackwelder. “If you don’t do any work until the deadline, (the delay) is meaningless.”

Enos agrees with a recent Workgroup for Electronic Data Exchange (WEDI) survey that found the April delay has slowed progress. She says the delay is “rewarding the procrastinators.”

“I felt very badly for the practices that had already invested time and were ready to go, and I don’t know that we’re really any further down the road,” Enos says.
Nachimson says that while the delay was unfortunate, it probably avoided catastrophe. “I firmly believe the industry would have been in chaos on October 1, 2014, if they had gone ahead,” he says.

In the meantime, Enos says, practices should already be in the training phase. Training, she notes, is available from a wide variety of sources, and much of it is free. Yet finding the time for training might be the biggest obstacle, especially for small practices that have fewer staff members with more responsibilities. But Enos says there are many no-cost training webinars offered by CMS, EHR and practice management vendors, and the clearinghouses.

One way for small practices to test documentation is to incorporate ICD-10 codes into charting audits, says Enos. Doing so exposes problems and pitfalls that could lead to claim rejections.

While the preparation requires a significant commitment of time and resources, Enos urges physicians to stay the course. “The efficiencies gained through ICD-10 will be worth the effort,” she says.