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June 6, 2011

Time for an ICD-10 Reality Check
By Judy Sturgeon, CCS
For The Record
Vol. 23 No. 11 P. 8

Ready? Set? Go! ICD-10 might actually come to fruition in less than three years!

Pardon my cynicism, but I’ve been coding for more than 20 years and have been hearing that ICD-10 is right around the corner for a good portion of that time. My hopes of being spared from the conversion hinged on the American Medical Association (AMA) continuing to oppose any federal law that mandated its abandonment of a money-generating product such as the CPT coding system. (The AMA owns the lucrative licensing fees to CPT products.)

While everyone submitting future claims will need to switch to ICD-10 diagnosis codes and facilities will be required to submit ICD-10 procedure codes, an exception has been made to allow physician billing to continue using CPT procedure codes. As a result, even those most skeptical about ICD-10’s proposed time frame have grown more convinced it’s about to become a reality.

Typically, HIM departments are expected to head ICD-10 steering committees, but it would be a mistake for healthcare organizations to consider the transition to be nothing more than a coding issue. The Centers for Medicare & Medicaid Services (CMS) assumes that primary coding staff don’t need in-depth, hands-on training and competency in ICD-10 until six months prior to implementation. But if coding isn’t expected to weigh in early, then who should?

When deciding who should be responsible for the project, consider who stands to lose the most if the ICD-10 conversion does not go smoothly. What happens if codes and documentation are not up to par, not all information systems are compatible with the expanded data fields, interfaces stop working properly, or claims are transmitted incompletely, incorrectly, or not at all?

If the bills stop going out, the revenue cycle department can suffer financial morbidity or mortality. If the bills do go out but are incomplete or incorrect, then the entire facility can suffer a level of compliance risk that will have the region’s recovery audit contractor licking its chops.

Now that the scope of both risk and responsibility has been identified, let’s consider where to best focus evaluation and preparation. 

Information Systems Compatibility
Extensive detective work may be required to identify all systems that accept and/or transmit diagnosis and procedure codes. Coding software is an obvious item of concern, but large vendors such as 3M and QuadraMed have been prepared to meet the challenge. Have you validated your billing software? Can it be converted to accept the expanded data fields required for ICD-10 or does it need to be replaced? If so, how do you allocate funding?

Do you have custom or vendor software (scrubbers) that digitally edits claims prior to submission? Do you have department-specific software that receives or transmits codes to or from the claims system?

In some facilities, pharmacy, lab, and radiology are owners of separate software. Are there any additional internal software systems that process codes in research, audit, or denials departments that might be affected?

Coder competence in medical terminology, anatomy and physiology, and pathophysiology will become even more vital during ICD-10 implementation. Exceptional coders may need little more than a brushup, while others may need to enroll in college courses to achieve the minimum required skills. Facilities that have certified ICD-10 trainers on staff can begin mock coding challenges to identify individual weaknesses and strengths and then focus training levels based on the results.

Along with clinical documentation improvement professionals, who are likely to have the same educational needs, coders will have an extensive selection of educational resources from which to choose. Besides local colleges and universities, professional associations such at the AHIMA, AAPC, the Association of Clinical Documentation Improvement Specialists, and the AMA offer textbooks, webinars, online training, and certification programs.

In addition to these options, software focused on individual ICD-10 training is springing up like dandelions in spring—unfortunately for coders, many are about as valuable. On the Web, there are resource services and sites that will charge an annual fee for unlimited individual access or corporate contracts.

There are even iPhone and iPad apps. If one costs $19.95 and another is much more expensive, chances are you’ll get what you pay for. Price is not a guarantee of quality, though. Research the products and garner opinions from users to find something that fits both your needs and your bank account.

Physician specificity will likely continue to be an issue during ICD-10 preparations. Engaging this group in the learning process is a separate trial altogether. If consistent documentation of the cause of anemia or the type and acuity of congestive heart failure is difficult, it may be wise to find more receptive departments with whom to begin project involvement.

With the CMS in charge of rulemaking, one might expect both Medicare and Medicaid to spearhead ICD-10 compliance. While Medicare typically follows its own rules, it is important to remember that each state governs its own Medicaid program. They may not be following ICD-9 coding rules, so be prepared for possible similar issues when the new codes and rules arrive.

Unlike Canada, which had only one payer (the government) with whom to contend during implementation (and its billing still nearly ground to a halt), the United States has numerous payers that must be taken into account. Will Blue Cross/Blue Shield continue to use whatever fiscal year’s codes and diagnosis-related groups it prefers? Will boutique insurance plans be ready or able to replace processing systems and software just because Medicare expects it? Will your various fiscal intermediaries be trouble free by October 1, 2013?

If your professional options do not include imminent retirement or a drastic career change, surviving the ICD-10 conversion will require a strong foundation. The need for action is immediate—once the proverbial wave is on the horizon, it’s too late to start building a defense.

Healthcare organizations should evaluate risks and strengths now. Identify key players and establish a steering committee that maintains good lines of communication with everyone affected by the makeover. Lay out a timeline and monitor progress in critical internal departments and remember to include vendors, partners, and customers.

Build a foundation and use it to elevate systems, coder skills, and physician documentation to higher ground. Even cynics are beginning their preparation, so don’t be left trying to tread water in the whirlpool that is ICD-10.

— Judy Sturgeon, CCS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 21 years.


Some Useful ICD-10 Websites

AAPC ICD-10 FAQ: http://www.aapc.com/ICD-10/faq.aspx

AHIMA ICD-10-CM Primer: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_038084.hcsp?dDocName=bok1_038084

ICD-10-CM Official Guidelines for Coding and Reporter, 2011: http://www.cdc.gov/nchs/data/icd9/10cmguidelines2011_FINAL.pdf