ICD-10 Is Here, Ready or Not

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By Maria St. Louis-Sanchez

Ready or not, a new medical coding system is now required for all entities covered by the Health Insurance Portability and Accountability Act, and O&P practices that aren't prepared for the change may have their reimbursements denied, experts say.

On October 1, those entities were required to transition their diagnostic and procedure coding to the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). The ICD-10 codes are a complete revision of their ICD-9 counterparts, which were developed in 1979, according to the Centers for Medicare & Medicaid Services (CMS). The new codes have been expanded from three to five digits to three to seven digits and will better describe the exact diagnosis; for example, the code reflects if a fracture happens on the left or right side of the body and the precise anatomic site that is affected.

CMS has been warning medical practitioners about the change for years and even gave them an extra year to prepare. This means there is no excuse for not being ready for the transition, O&P experts say.

"[O&P practitioners] all knew it was coming," says Don Hardin, an independent O&P consultant based in Union, Kentucky, who specializes in payer relations. "If not, shame on them. God knows they've had enough warning on this."

Still, experts acknowledge there are probably practices that weren't ready for the change, or didn't realize the extent of its impact on them.

"I think there are still people who were caught off guard," says Mark Ford, president of The OPIE Choice Network, Gainesville, Florida. "If the physician groups aren't prepared, it could mean a bigger problem for O&P practices. There are still a significant number of people who haven't figured it out."

For those practices that are still working on the transition, there's a lot of advice out there. To deal with the changes, CMS recommends that all practices:

  • Test their business software and hardware
  • Train staff members
  • Update internal business policies to support the transition

O&P experts have their own suggestions as well. They suggest that O&P practitioners:

  • Start learning the new codes and train the necessary staff to use them
  • Communicate with their software providers and with the physicians they commonly work with to make sure they are prepared for the changes
  • Be especially vigilant at the beginning to ensure that any mistakes in coding are caught and corrected and staff is retrained to avoid repeating the error

In addition to the CMS recommendations for preparation, multiple media outlets have reported that CMS has appointed William Rogers, MD, as its ombudsman for the transition to ICD-10. Rogers is the director of CMS' Physicians Regulatory Issues Team. In his role as ombudsman, he will help receive and address physician and provider issues related to the transition. He can be reached at .

Start Learning

For practices that have not already started reviewing the new codes, there are ample resources to learn from, Hardin says. "There are a number of applications for computers and even iPads that have been out there for some time and explain what the codes are and how they relate to individual procedures. [Practitioners] should be looking at the procedures they refer to on a regular basis and see which ones will be affected."

CMS also provides free training, including video lectures on its website, recommendations for implementing the change, online tools for practices, and occasional conference calls to explain what practices can expect. For more CMS resources, visit www.cms.gov/medicare/coding/icd10.

Even though there is some crossover from ICD-9 codes to ICD-10, practices shouldn't assume that is the case, says Ford. "It's estimated that 30 to 40 percent of the codes will have a direct crossover, but that means that [60 to] 70 percent of ICD-9 codes will be different than ICD-10 codes." Most of the new codes won't have any bearing on O&P practices, but practices should be well-informed about the codes that they will use routinely, he says.

CMS graphic

Communication Is Key

Don't expect an easy transition in which software works perfectly from the start and physicians' offices have all of their codes correct, the experts say.

"Anything involving the federal government and Medicare can't be simple and seamless," Hardin says. "That's an oxymoron."

Ford says that O&P software companies have been working on the transition for years and appear to be prepared, but practices shouldn't rely solely on the software to make sure the changes are made correctly.

"Many practices expect software to solve all of their problems," Ford says. "It's a tool. It's not an end-all be-all." He says that practices should be communicating with their software companies so they know what to expect and what's expected of them, so their staff inputs the information correctly and the software can do its job. For example, he says, the software might have an ICD-9 code for a certain patient, but then the device isn't actually delivered until after the transition, when it would have an ICD-10 code.

"The software system isn't going to look at what's going on with the patient and know the history, and know it will automatically lead to an ICD-10," Ford says. "Your administrative staff needs to be paying attention."

O&P practices shouldn't rely on the physicians either, Ford says. Before the changeover to ICD-10, O&P practices routinely had to provide ICD-9 codes for the claims that physicians' offices may have neglected to assign, he says. The transition to ICD-10 only means that it will be even more complicated for O&P practices to figure out the necessary codes.

"There are more codes, and they are more complex, so it becomes harder for someone who is not the physician to make sure it's accurate," Ford says. "Everyone will say that it's the doctor that should make them, but that's not how the information oftentimes flows in the real world. O&P practices have to become experts quickly on the ICD-10 codes that they will use to describe their patients."

He says that larger physician groups are probably prepared, but specialty practices may take longer to get on board. "The best thing [O&P practices] can do is to go back to the physician with any questions that they may have," Ford says. "The sheer increased number of ICD-10 codes could easily result in O&P practices not getting the correct ICD-10 code if they choose the codes for themselves."

While it is important to clarify the information with the prescribing physician and strive to ensure that the correct ICD-10 codes are on all claims-and a valid ICD-10 code will be required on all claims-CMS has recognized that the move is bringing significant changes to providers and has implemented some audit flexibilities. According to guidance published on CMS' website, as long as a valid code from the right family has been used, it will not deny claims based solely on the specificity of the ICD-10 diagnosis code for the first 12 months of implementation.

Be Vigilant Right Now

Ford says this initial transition period is the most critical for O&P practices because they may have received a prescription from a physician before the October 1 change date that included ICD-9 codes, but the definitive device was not ready until the diagnosis code requirement switched to ICD-10.

"There's almost always a lag time in the O&P patient care process, and that lag time is where the problem is," he says.

The good news is that CMS has said it will allow offices that submitted ICD-9 codes after the October 1 cutoff to resubmit the claims and be reimbursed, Ford says. However, if an O&P office isn't paying attention, the number of claims that it will need to resubmit can build up and potentially affect the staff's time and the business' accounts receivable.

"I think the biggest risk for O&P practices is really in the first 90 to 120 days," Ford says. "If a third of your claims have incorrect diagnosis codes in a 60-day window, those claims will have to be resubmitted, which will then have a dramatic impact in slowing down the cash flow for your business. That's the biggest fear."

Maria St. Louis-Sanchez can be reached at .