Physician Education

Physician Education (9)

On Nov. 15, 2011 the American Medical Association (AMA) House of Delegates did a major disservice to its members and to the quality of healthcare in the United States.

The delegates voted to recommend stopping the implementation of ICD-10, a concept inconsistent with quality medicine and beyond the scope of their authority. According to AMA President Peter Carmel, “The implementation of ICD-10 will create significant burdens on the practice of medicine with no direct benefit to patients’ care.” But ICD-9 is being replaced because it is 35 years old, because its terminology and classification of some conditions is outdated and obsolete, and because such outdated codes produce inaccurate and limited data. Furthermore, ICD-9 lacks specificity (such as laterality), the benefits of the EHR cannot be fully realized without ICD-10, and comparison of domestic and international data is grossly limited in the absence of the new code set. Consider first the issue of specificity.

The American Medical Association likes to think that healthcare in the United States ranks among the best in the world, yet we already lag 18 years behind the United Kingdom and 12 years behind Canada in implementing was is viewed worldwide as a markedly ideal coding system. The vote of the AMA House of Delegates is much more than a misdirected policy statement; again, it constitutes a gross disservice to its own membership.

The vote was followed by a letter from AMA CEO James Madera, MD, to John Boehner, R-Ohio, Speaker of the U.S. House of Representatives. That letter echoed the spirit of the AMA vote, not requesting a delay in ICD-10 implementation, but rather recommending stopping the implementation altogether.

The final rule calling for the implementation of ICD-10 was published on Jan. 16, 2009.  Despite the passage of more than three years since that time, many physicians have delayed planning for ICD-10 compliance. The AMA’s widely published demand may suggest to many physicians that the organization has the authority or political clout to stop the implementation of ICD-10. It does not. However, the demand to stop ICD-10 may increase complacency among practitioners who don’t understand the scope of the conversion as it pertains to their private offices. Estimates are that as many as 50 percent of billers and coders nationwide may retire or change jobs upon implementation. ICD-10 is essentially a new language. Physicians should be working with their billers now to retrain their staff. Additionally, they will need appropriate billing systems to manage the complexity and detail necessary under ICD-10. Many physician offices are or will be transitioning to electronic medical records, which should be ICD-10-compliant.

The AMA’s vote to recommend a halt to the implementation of ICD-10 is likely to fail to produce results for a number of reasons. Insurers, hospitals and many physicians across the country already have made substantial investments with an eye on achieving compliance with the new regulations. Many coders have already undergone training for the new system. Where were the AMA’s comments back when the rule was published? To change course now would penalize those entities and individuals currently committed to compliance with the published rule – to the benefit of those who have done nothing.

The time from the publication of the final rule to the ICD-10 implementation date measures a total of 1,719 days. To choose a specific date, on March 1,2012, 1,140 days will have passed, or about two-thirds of the available time to prepare.

The Centers for Medicare & Medicaid Services (CMS) has indicated that it maintains that providers have been given sufficient time to prepare for the ICD-10 transition. Following the AMA’s vote, a CMS spokesperson stated that CMS “will continue to work with the healthcare community to ensure successful compliance.”

The societal argument supporting ICD-10 implementation is strong. The system is necessary to improve accuracy of severity adjustment, a necessary component of emerging policies supporting payment for quality, not just quantity, of medical services provided. It also will improve the quality of diagnostic and procedural information, enabling broad application of claims-based research to improve quality of care.

The AMA should consider the impact of its policy statement on physicians who now may delay training their staff and fail to provide the necessary infrastructure to support the implementation of ICD-10 while they wait to see how Congress will respond. Again, the AMA has done a gross disservice to member- and non-member physicians alike, who now may be unprepared for Oct. 1, 2013, and subsequently may face significant economic penalties.

About the Author

Paul Weygandt is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Dr. Weygandt is vice president of physician services for J.A. Thomas & Associates and is a partner in the firm.

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If you have not glanced at the ICD-10-PCS Operations Table and reviewed the 31 root operations listed there for the coding system's Medical and Surgical section, you might wonder what the word “extirpation” has to do with coding. The term is not one most of us see often in documentation of surgical procedures.

In fact, when I Googled "extirpation," the first definition I found, on the Wikipedia website, was “local extinction of a species or other taxon: the condition where a species ceases to exist in a geographic area in which it had previously existed but continues to exist elsewhere.” The next definition, found in Merriam-Webster online, was “complete excision or surgical destruction of a body part.” That definition brings us a little closer to the ICD-10-PCS definition, but it is still not exact for coding purposes. For those purposes, extirpation is defined and explained as follows:

Extirpation

Root Operation Value - C

 

Definition

Taking or cutting out solid matter from a body part

Explanation

The solid matter may be an abnormal product of a biological function or a foreign body; it may be imbedded in a body part or the lumen of a tubular body part. The solid matter may or may not have been previously broken into pieces.

Armed with this definition and explanation, it is our job as coders to determine what the current procedural terminology is for procedures that will be coded as extirpation. The Operations Table provides two examples: thrombectomy and choledocholithotomy. These are both examples of an abnormal product of a biological function (blood clot, calculus, etc.) contained within the lumen of a tubular body part (blood vessel, bile duct, etc.). Also included in the scope of extirpation are procedures involving the removal of a foreign body in the lumen of a tubular body part, such as removal of an aspirated peanut from the trachea or removal of a substance from other tissues or other sites (for example, removal of a metal fragment from the sclera or loose cartilage of a knee joint).

Related Procedures

There are a number of helpful tables in ICD-10-PCS that define terms (such as the Operations and Approaches table), and one that groups similar procedures together. Extirpation is grouped with two other procedures (drainage and fragmentation) that take out or eliminate solid matter, fluids or gases from a body part. The table below compares and contrasts the three procedures.

Table 1: Procedures That Take Out Or Eliminate Solid Matter, Fluids, Or Gases From A Body Part

Operation

Action

Target

Clarification

Example

Drainage

Taking or letting out

Fluids and/or gases from a body part

Without taking out any of the body part

Incision and drainage

Extirpation

Taking or cutting out

Solid matter in a body part

Without taking out any of the body part

Thrombectomy

Fragmentation

Breaking down

Solid matter in a body part

Without taking out any of the body part or any solid matter

Lithotripsy of gallstones

 


 

While drainage is easily distinguishable from extirpation, fragmentation and extirpation procedures have the potential to be confused with one another. The key difference between extirpation and fragmentation is that in extirpation the solid matter is removed, while in fragmentation it is not removed but rather eliminated or absorbed through normal biological functions. So, lithotripsy of a ureteral calculus without removal would be reported as fragmentation while lithotripsy of the calculus with removal would be reported as extirpation.

Coding Examples – Extirpation

Example 1: Open choledocholithotomy

0FC90ZZ

0

Section – Medical and Surgical

F

Body System – Hepatobiliary system and pancreas

C

Root Operation – Extirpation

9

Body Part – Common bile duct

0

Approach – Open

Z

Device – No Device

Z

Qualifier – No Qualifier

 

Example 2: Tracheoscopy with extraction of peanut lodged in and partially obstructing trachea

0BC18ZZ

0

Section – Medical and Surgical

B

Body System – Respiratory

C

Root Operation – Extirpation

1

Body Part – Trachea

8

Approach – Via Natural or Artificial Opening Endoscopic

Z

Device – No Device

Z

Qualifier – No Qualifier

 


 

Example 3: Exploration of right eye with removal of BB gun pellet from sclera.

08C6XZZ

0

Section – Medical and Surgical

8

Body System – Eye

C

Root Operation – Extirpation

6

Body Part – Right Sclera

X

Approach – External

Z

Device – No Device

Z

Qualifier – No Qualifier

 

About the Author

Lauri Gray, RHIT, CPC, is the clinical technical editor of coding and reimbursement print and electronic products for Contexo Media. She has worked in the health information management field for 30 years and began her career as a health records supervisor in a multi-specialty clinic. Following that she worked in the managed care industry as a contracting and coding specialist for a major HMO. Lauri has also taught medical coding at the College of Eastern Utah.  She is a member of the American Academy of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA).

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Most organizations by now have realized the impact of ICD-10 implementation. Many currently are undergoing global readiness assessments, looking at not only the obvious coding, information systems and infrastructure issues, but also more tangential issues such as contract renegotiation, claims tracking, analytics and reporting. A question heard more and more throughout the industry is “do physicians understand the impact, and can we get them ready?” For hospitals to succeed under ICD-10, physician cooperation and collaboration will be essential. So what are the “physician-related” critical success factors for ICD-10?

1. Early Awareness

Physicians generally look at ICD-10 implementation as another relatively unnecessary intrusion by the legal and regulatory spheres of influence into the practice of medicine. This notion is reinforced by the cost of conversion, which will be a direct out-of-pocket expense for physicians. If hospitals, through their actions or inactions, allow opposition to ICD-10 to build, the impact on operations (especially revenue cycle function) will be impacted severely. Let’s translate this risk into an actionable strategy.

ICD-10 makes clinical sense. Physicians should be approached now, through educational presentations, to build recognition of the value of ICD-10 to the profession of medicine. It is a far better clinical system than ICD-9, which is more than 35 years old and rife with outdated clinical terminology, inconsistent language and global lack of specificity (we can’t even indicate laterality in it). We are also far behind the global healthcare community, as evidenced by Great Britain’s adoption of ICD-10 in 1995 as well as adoption by our Canadian neighbors to the north in 2001.

2. Early Collaboration

Where is your medical executive leadership as it relates to ICD-10? Is your CMO/ VPMA/chief of staff integrally involved in ICD-10 planning? If not, you are risking engendering unnecessary resistance in the medical staff. The medical staff should be made aware that medical leadership is working in collaboration with hospital leadership to do as much as possible to limit the negative impact of ICD-10 on the day-to-day practice of medicine. Transition timetables should be discussed with physicians. Educational planning should be laid out thoroughly within the next few months. Solutions to potential problems should be discussed at the leadership level and shared with the medical staff.

3. Operational Infrastructure

Here’s an opportunity to establish the collaboration discussed above. How are you preparing for ICD-10-PCS documentation and coding? Recall that hospitals will not be able to submit bills for inpatient services unless all procedures are coded with all seven alphanumeric characters. This will require an unprecedented level of documentation specificity for surgical procedures, cardiac catheters, interventional radiology and a vast array of other procedures. At the same time, however, physicians will continue to bill their inpatient professional services (procedures) using CPT procedural codes. Note the disconnect? So, what are your plans to ensure concurrent documentation of all seven alphanumeric digits for every procedure? I recently met with the leadership of one health system. Members of the physician leadership were discussing with HIM, IT, clinical documentation leadership and others how best to support physicians. They were looking at IT solutions, for example, that would present to the physician (based on intraoperative documentation by the circulating nurse) critical parameters for operative dictation and then, using technology, pull all the specificity necessary in an algorithmic manner. This is just one example of collaborative planning.

4. Practice Viability

Perhaps the greatest ICD-10 risk for many physicians will be the loss of practice autonomy. Many small practices, particularly in family medicine, internal medicine and pediatrics, simply will be unable to afford the practice costs of conversion to ICD-10 in light of the IT conversion costs, needs to retrain staff and loss of productivity by office staff. For many, this may be the straw that broke the camel’s back. Leadership, meanwhile, can let the chips fall where they may. The predictable result will be open hostility between physicians (whose practices will fail) and hospitals (which physicians will see as having the revenue and viability).

 


 

Would it not be a more appropriate strategy to make the medical staff aware of the risks and consider alternatives such as group practice consolidation, MSO services, group purchasing of I-10 compliant software, regional collaborative billing practices, or, ultimately, employment arrangements? Managing the knowledge gaps of the medical staff along with the inevitable changes in the practice of medicine, coupled with decreasing reimbursement and loss of professional autonomy being felt by many physicians, will challenge even the most adept medical leadership.

Many healthcare organizations are working toward a renewed sense of medical professionalism as physicians assume stronger leadership roles in collaborative hospital management. Success will require attention to all the above listed critical success factors, but at a more fundamental level it will require the ability to lead, educate, mediate, facilitate and negotiate in a professional and highly interpersonal manner.

About the Author

Paul Weygandt, MD, JD, MPH, MBA, CCS, CPE, is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Dr. Weygandt is vice president of physician services for J.A. Thomas & Associates and is a partner in the firm.

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How the heck do we begin?

Develop a project charter! Create a communication strategy template! Perform a GAP analysis! Distribute readiness surveys! List critical success factors! Draft a project management team! Schedule meetings!

For those beginning the ICD-10 transition process, taking that all-important first step seems to be the most difficult part. There is so much information out there about what needs to be done and when it needs to occur. Practices feel overwhelmed trying to sift through the many implementation strategies, action items and potential starting points. And, frankly, there exists quite a bit of misinformation and conflicting advice.

From the numerous workshops and national surveys we’ve conducted, we found good news in that the country seems to have turned the corner as it pertains to ICD-10 awareness. Most practices now understand that the ICD-10 transition is inevitable and that it most likely represents the biggest challenge in more than 20 years to how healthcare providers conduct business. The bad news is that many practices, especially small- to medium-sized practices, have no idea even how to begin the transition process. But these practices won’t need to feel resigned to failure if they can just find a way to take that first step. Here’s an easy way to do it.

Impact Analysis

Performing an ICD-10 impact analysis is a great way to kick-start implementation. Grab a notebook and take a stroll through your practice. Everywhere a diagnosis code touches the workflow, make a note. This will be an eye-opening experience for those who still feel that ICD-10 is just an IT or coding issue. There will be some obvious areas of impact, such as the superbill, but there will be many processes for which ICD-10’s future effects will not be so apparent. As you note each area of impact, keep in mind three types of issues that need to be addressed: human (Is training required? If so, how much?), technological (Software or hardware upgrades?), and budget requirements (What is this going to cost?)

As you walk the halls, this also is the perfect time to converse with any member of the staff who is affected by diagnosis codes (and by extension ICD-10-CM). At the same time, miniature training conversations inevitably will occur, and this can start getting your folks realizing that ICD-10 is coming, ICD-10 is different, and adjustments may have to be made to their day-to-day work processes.

As a road map for you to consider, here are some areas and processes that will be impacted by the ICD-10-CM transition.

Documentation Impact

This is an excellent place to start the formal ICD-10 conversation with your providers. Does current documentation, both written and in EMR template form, allow the most specific ICD-10-CM codes to be chosen? If not, procedures or services may be deemed medically unnecessary.

Superbills

With ICD-10 containing five times as many codes as its predecessor, and greater specificity required, many practices are rethinking their commitment to superbills. Obviously, if you decide to continue using them, superbills must be updated for the new codes. Any department in your practice that uses superbills for reference (billing, coding, etc.) must have updated versions and also must be trained on how to use the new tools.

Order Entry/Requests (Lab, X-ray, PT, OT, DME)

You need a diagnosis code in order to describe what you need tested or filmed. Therefore, paper and electronic requests need to be updated in order to indicate the proper ICD-10 codes and not the old ICD-9 codes. Additionally, ICD-10 training will need to be conducted for any staff members who submit lab or radiography (X-ray, MRI, CAT, etc.) orders. This most likely will include back-office staff.




Home Health Treatment Plans Impact

If your practice prescribes a home treatment plan, you know that most of these plans are updated infrequently. If such a plan is created before the ICD-10 transition, it most likely will contain ICD-9-CM codes and therefore must be addressed once the transition occurs.

Referrals to Outside Providers

Referrals to outside providers for second opinions or specialty consideration must be updated to accommodate ICD-10 codes. You will be doing your referred providers a disservice if you continue to use ICD-9-CM codes to describe conditions for which you are seeking assistance. Likewise, the return “consultative report” must be in sync with the new code set.

Prescription/Pharmacy

In many cases a diagnosis code must be submitted as part of a prescription. This process will require an ICD-10-CM upgrade in order for pharmacies to be able to service these prescriptions (ePrescribe can help!)

Administrative Services: Insurance Pre-authorization and Surgery Scheduling

In most cases, a diagnosis code will be required in order for an insurance company to approve a desired surgery, diagnostic test, etc. In order for patients to receive the medical care they need, your insurance pre-authorization must be updated to accommodate ICD-10-CM. Both the actual request and the person submitting that request will need to be able to speak the ICD-10 language.

Denied Claims Follow-up Impact

ICD-10 represents an opportunity for insurance payers to deny your claims. Expect this to happen even if you transition perfectly. Do not allow insurance companies to take advantage of the chaos caused by the transition. Follow up on your claims denials aggressively. Beefing up your claims monitoring and appeal processes will reap great benefits when claims are denied due to reasons associated with ICD-10. The top payers (Blue Cross, Cigna, United, etc.) already have announced that they have created their own version of an ICD-9-to-ICD-10 crosswalk. Do you trust them? Do you think they are translating ICD-9 to ICD-10 equitably, or do you think they are building crosswalks that will not establish medical necessity and therefore give them the ability to deny your claims? Looking for a defense? Get a copy of GEMs and don’t let them translate your ICD-9 codes to ICD-10 codes that will not justify medical necessity.

Performance Measure Reporting Impact

Internal (clinic-specific) and external (PQRI) reports that require diagnoses codes will need to be updated for ICD-10. This process can be as generic as reporting your top 25 diagnoses in more extensive “outcomes” reports.

Retrospective Reporting Impact

Many key management reports used by your administrators are based on diagnosis codes. Starting Oct. 1, 2013, year-to-date diagnosis benchmarks based on ICD-10 being compared to the previous year’s reports based on ICD-9 may become an apples-to-oranges comparison. The impact on reporting requires that diagnoses codes be translated in order to be of any value.

Payer and Business Partner Impact

Some of your smaller insurance plans either may delay the transition to ICD-10 past Oct. 1, 2013, or they may not make the transition at all. Also remember that auto insurance and workers’ compensation plans are not subject to the HIPAA mandate and are not required to transition to ICD-10. Insurance plans that delay the transition or do not transition at all will create a substantial rippling effect on your practice. Business partners such as billing companies and clearinghouses also must make the move to ICD-10. If you use a small billing company that may be financially unable to make the change, they may not be able to submit your claims under the new system.




Staff Training Impact

Aside from possible practice management and EMR software and hardware upgrades, staff training will be your most expensive line item during the ICD-10 transition. The impact on budgeting and your bottom line will be significant. Every member of your staff who deals with diagnosis codes must be trained depending on the extent they work with them.

Budget and Productivity Impact

Budgeting for the ICD-10 transition must be given a high priority. Expendable training dollars must be allocated carefully depending on the size and needs of a practice. At a recent ICD-10 boot camp, one of the top coders in the country relayed the following:

“Under ICD-9, I can currently code between 20 and 25 charts an hour. Under ICD-10, my best efforts resulted in only being able to code between eight and 10 charts an hour.”

A decrease in productivity occurs naturally whenever staff trains using new processes. Several variables will impact productivity during the transition. Ensuring staff commitment and quality of training coupled with making adjustments to workflow in a proactive and timely manner will help mitigate this impact.

v.5010 Impact

This impact is negligible and transparent if you and your IT vendor are working together to implement and test changes. There exists serious potential impact if this upgrade is overlooked.

Practice Management Software and Hardware Impact

The impact on this vital area may involve a substantial financial commitment depending on whether your vendor is paying for an upgrade or your practice is required to shoulder the cost. During the initial transition to ICD-10, and for those payers that will continue to use ICD-9 codes, your software will be required to run both coding systems simultaneously. This will put a strain on server and workstation hardware capacity.

Coding Staff, Resources and Tools Impact

The impact on coding staff will be significant. Twenty-year habits need to be changed and an entire new coding language needs to be learned. Coding resources such as software encoders and books need to be updated and training needs to occur in order to allow for coding under the new system. EMR templates also will need to be changed. Most importantly, coding staff will need to code both ICD-9 and ICD-10 during both the training and transition phases.

Performing a simple impact analysis that examines every area in your practice influenced by diagnosis codes is an excellent way to begin the ICD-10 conversation. Likewise, it is the perfect place to start your implementation plan. The timeliness of this activity is critical.

Do it soon. Do it now.

You’ll be glad you did.

About the Author

Dennis Flint is director of consulting and educational services for Complete Medical Solutions. Dennis formerly served as the CEO of a large, multi-specialty physician group, a full service MSO and was a certified professional coder through AAPC. He has authored or co-authored numerous “common sense” practice management books and implementation manuals. Educated at the United States Air Force Academy, he had a distinguished career as an Air Force pilot flying numerous secret and sensitive missions.

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I had the pleasure of attending both the ICD-10 Clinical Modification (CM) and Procedure Classification System (PCS) AHIMA academies in September, and I strongly urge physicians to attend a coding program designed for ICD-10.

The CM, or diagnosis, portion of ICD-10 has changed significantly, but not as significantly as the PCS, or procedure, section. The driving force behind both is the added requirement of significantly enhanced documentation and the need for increased interaction between coding staff and physicians.

Health information management professionals clearly are leading hospital preparedness initiatives for ICD-10.

There has been sufficient recent publicity about the potential economic impact on hospital operations preceding and following the implementation date of Oct. 1, 2013 to sober even the most optimistic hospital leaders. Information technology challenges of maintaining concurrent ICD-9 and ICD-10 platforms during the transition period currently are being addressed by a number of information technology vendors.

Many coders, either under the auspices of a hospital or as individuals, have begun the process of gaining the necessary expertise to code directly in ICD-10 rather than relying on GEMs or other crosswalks. While many coders will retire, the majority appear motivated to ramp up their personal skills in preparation for the transition. Revenue cycle leaders also are planning for the anticipated impact on cash flow during the transition to ICD-10 as well as budgeting for decreased coder productivity, insufficient physician documentation, the cost of maintaining parallel systems, etc.

But how are physicians progressing? We now are getting early feedback from physicians, and it is much as we anticipated: they aren’t happy, they’re getting grouchier and they’re not sure how to react. Can you blame them?

I was recently a panelist on “Talk Ten Tuesday,” a weekly podcast providing current information on the ICD-10 transition. As part of that session, attendees were asked about their hospitals’ preparations for ICD-10. Specifically, they were asked about physician preparation.  Sixty-nine percent of respondents indicated that they have done nothing to date to provide ICD-10 education to their physicians. Nineteen percent reported that they have attempted some physician education, but that those efforts were poorly attended by physicians.

So by many accounts the clock is ticking, we are counting down the months until ICD-10 implementation and those individuals directly responsible for providing necessary information for ICD-10 coding (physicians) essentially have been left out of the loop.

Physicians, however, increasingly are becoming aware of the problem even though many remain unaware of solutions. Estimates of the cost of conversion to ICD-10-compatible billing systems are coming out not only in the public press, but also from specialty societies and professional associations.

Potentially even more importantly, offices are beginning to talk to software vendors, and the sticker shock for new systems is substantial. Discussions with physician groups and individual physicians across the country have revealed that many now are beginning to view ICD-10 as the ”camel that broke the straw’s back.”   Okay, I admit that I misstated this well-known quote intentionally, but I think the adjusted analogy works better. Physicians feel like they are the straw (thin and tenuous) with yet another regulatory camel (which weigh a lot) to carry.

Options for private practices of medicine are limited:

  1. 1.  Acquire ICD-10-compliant software, run parallel systems during the transition, retrain or hire new billing staff and continue private practice if economically feasible;
  2. 2.  Obtain practice support from an entity such as a hospital, medical group or insurer;
  3. 3.  Become an employee of a hospital, medical group or insurer; or
  4. 4.  Get out of the practice of medicine.

A surprisingly large number of physicians are beginning to articulate their transition plan using the last option listed above: early retirement with or without a transition to an alternative career. Compounding private practice concerns, however, are issues related to their hospital practices. How will they be able to practice medicine efficiently in the evolving environment of inpatient ICD-10?

Let’s return to the statistics cited above. If the survey is at all representative of national trends, almost four out of five physicians (80 percent) have yet to hear meaningful information from their hospital partners about plans to support the transition to ICD-10.

 


 

Early exposure of medical staff members to the realities of ICD-10 – including benefits, costs, hospital plans to provide appropriate infrastructure for success, and most importantly, the benefits of ICD-10 for patient care – need to be addressed. This information also must be conveyed in a manner that is not perceived as self-serving to the hospital or HIM. Leadership for ICD-10 change should begin at the medical staff leadership level, where education should be provided to the entire medical staff in an enthusiastic and peer-to-peer manner.

Many in hospital leadership appear to believe that we can bring physicians “into the loop” after we have all of our own systems in place. But recall other hospital initiatives through which physicians were brought in late to a process of change. It reminds me of the famous quote (though no one seems to know the original author) that insanity is doing the same thing over and over again but expecting different results.” Let’s learn from our past experiences this time.

With a change as profound as ICD-10, it is imperative to begin a dialogue with medical staff leadership now to establish that ICD-10 will improve healthcare, that preparation is being endorsed by physician leaders and that appropriate introductory education will be delivered to the medical staff within the next several months. Specialty-specific information is substantially different and should not be provided until within six to nine months prior to Oct. 1, 2013.

It is not the time to educate physicians on specific ICD-10 coding methodologies, but rather to establish a genuine interest among the medical staff in collaboratively developing the methodologies to provide the information necessary for HIM professionals to code every medical record accurately and completely.

About the Author

Paul Weygandt is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Dr. Weygandt is vice president of physician services for J.A. Thomas & Associates and is a partner in the firm.

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As hospitals begin preparations for ICD-10, it should be recognized that a parallel process will be taking place in the physician office setting. Fully integrated systems will produce the benefit of providing integrated education to physicians. In fragmented systems, physicians will be responsible for purchasing new IT systems, providing training for office billing staff and in many, many instances hiring new staff due to the anticipated attrition of professional billers as we transition to the new system.

What kind of awareness training should physicians receive now? The first step should be fostering awareness of the complexity of the system from a very high level to persuade physician leaders to begin preparations. In this article, I’ll focus on the diagnosis side of ICD-10.

Most healthcare leaders are aware that the number of diagnosis codes increases dramatically from ICD-9 to ICD-10. However, while the raw aggregate number of codes increases from approximately 13,500 to 70,000, the increase is not consistent across all categories.

Consider one localized group of fractures, those occurring in the femoral head and neck region. Under ICD-9 there are 12 available codes such as 820.02 Midcervical Femoral Neck Fracture, Closed or 820.11 Epiphyseal Fracture Transcervical, Open. These fractures are distinguished from peritrochanteric and shaft fractures.

In ICD-10-CM, Chapter XIX: Injury, poisoning and certain other consequences of external causes (including subchapter S00-T98, Injuries to the Hip and Thigh) are addressed in sections S70-S79. S72 is titled Fracture of Femur and is subdivided into S72.0 Fracture of the Neck of the Femur, S72.1 Pertrochanteric Fracture, S72.2 Subtrochanteric Fracture, S72.3 Fracture of the Shaft of the Femur, and so on.

In comparison to the 12 available codes for all femoral head and neck fractures in ICD-9, consider S72.0 Fracture of the Neck of the Femur. This appears to be a specific code, but under S72.0, using the appropriate additional digits S72.0xyz allows for markedly increased specificity.

There are, in fact, 576 subtypes of fracture within S72.0. There are 48 specific codes for Fracture of Unspecified Part of Neck of Femur, another 48 specific codes for Unspecified Intracapsular Fracture (of the femur), 96 codes for epiphyseal fractures (48 displaced, 48 undisplaced), 96 codes for mid-cervical fractures (again half displaced, half non-displaced), 96 codes for fractures of the base of the neck (same pattern), 48 codes for unspecified fractures of the head of the femur, 96 codes for articular fractures of the femoral head (displaced and non-displaced, and 48 codes for “other fractures of the head and neck of the femur.” If one considers all codes for femoral fractures from the proximal to distal aspects bilaterally, by my calculations there are 2,466 codes (though I may have missed a few).

The level of specificity required appears daunting. Can we expect coders currently using12 different codes to find the detail necessary to specify one of 576 codes? Further, do we expect orthopedic surgeons to provide all the necessary detail for this specificity? The challenge may not be as insurmountable as it initially appears.

ICD-10-CM diagnosis codes have 3-7 characters (compared to 3-5 in ICD-9) laid out in a specific format, with each character organized within any subchapter in a specific manner (see ICD-9-CM diagnoses/ICD-10-CM sidebar comparison).


 

The first three digits indicate the category. The first character is always alphabetic, the second is always numeric and the third can be either. Consider the following specific diagnosis code listed below (it’s one of the 576 codes):

S72031K Displaced midcervical fracture of right femur, subsequent encounter for closed fracture with nonunion.

The category of fracture is S72 – femoral fracture; S72.0 narrows the description to those of the head and neck. The remaining digits indicate, in this example, the subsequent encounter for a non-union in a fracture that originally was closed. This level of detail typically is included in the clinical record, though it may not be summarized succinctly by the orthopedic surgeon at this point.

By developing a collaborative educational approach for physicians as well as coders and documentation specialists, ICD-10 at least can be demystified partially. The anticipated benefits of ICD-10, according to CMS, are listed in the sidebar. Successful implementation will require peer-to-peer discussions to provide the motivation and knowledge necessary for physicians to collaborate in the inpatient ICD-10 process.

 

 


 

 

BENEFITS OF ICD-10-CM

ICD-10-CM incorporates much greater clinical detail and specificity than ICD-9-CM. Terminology and disease classification have been updated to be consistent with current clinical practices. The modern classification system will provide much better data needed for:

- Measuring the quality, safety and efficacy of care;
- Reducing the need for attachments to explain the patient’s condition;
- Designing payment systems and processing claims for reimbursement;
- Conducting research, epidemiological studies and clinical trials;
- Setting health policy;
- Performing operational and strategic planning;
- Designing healthcare delivery systems;
- Monitoring resource utilization;
- Improving clinical, financial and administrative performance;
- Preventing and detecting healthcare fraud and abuse; and
- Tracking public health and risks.

Source: Quick Reference Information: ICD-10-CM Classification Enhancements, available at https://www.cms.gov/ICD10/Downloads/ICD-10QuickRefer.pdf

About the Author

Paul Weygandt is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Dr. Weygandt is vice president of physician services for J.A. Thomas & Associates and is a partner in the firm.

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ED. NOTE: This is the first of a two-part series on physician education as part of the transition to ICD-10.

Preparation for ICD-10 is beginning to heat up.

Hospitals, insurers, physicians and other providers need to ensure compliance with ICD-10 diagnosis and procedural coding requirements by Oct. 1, 2013. It is important, however, for those with a professional focus on I-10 to recognize that this initiative is just one of the many challenges facing organizational leaderships these days.

J. A. Thomas & Associates recently conducted a survey of client hospitals to assess the statuses of their preparations for ICD-10. The findings of that survey are interesting and informative.  Participants included representatives of the C-suite, physicians, clinical documentation specialists and HIM professionals.

Approximately 80 percent of respondents indicated that they have begun preparing for ICD-10. Approximately 50 percent of those who have not started preparations cited competing priorities as a reason. When considering hospital challenges such as capital improvements, decreasing reimbursement, competition, the newly introduced value-based purchasing program, core measures, medication reconciliation and EMR conversion, among others, those involved in I-10 preparations must recognize that such competing priorities are not inconsequential.

Among those who have launched preparations, there also appears to be a pattern. More than 70 percent have formed I-10 committees, 46 percent have implemented or expanded their CDS programs in anticipation of challenges, 53 percent already have invested in training (primarily for HIM staff) and 15 percent have purchased new technology. One of the most revealing questions, however, was “What is your greatest challenge in the move to ICD-10?”

While 13 percent reported facing challenges in getting buy-in from executive management, 39 percent had difficulty finding space in the budget and 40 percent faced challenges in upgrading EMR/technology. A whopping 75 percent listed “getting buy-in from physicians and then training physicians” as their most daunting perceived challenge. Similarly, when asked to identify what I-10-related services would benefit their hospital most, the most common response (more than 70 percent) identified education and training as where they need the most help.

Finally, when asked what types of resources their organizations intend to use to prepare for I-10, five options were available, including:

  • In-house (34 percent),
  • External/Third Party (22 percent),
  • Professional organizations (34 percent),
  • Local colleges (12 percent), and
  • A mixture of in-house and external training programs (72 percent).

Note that the sum of these selected alternatives totals 174 percent. What is indicated clearly here is that organizations are realizing that they will need different providers of services and education to meet the needs anticipated by the I-10 committees.

The Challenge of Providing Physician Training (Let Alone Getting Buy-in)

It is fairly early in the I-10 preparation cycle, but several trends already can be identified. Most organizations have begun their formal I-10 preparation processes, typically by initially forming an I-10 committee (often driven by HIM professionals who recognize the importance of preparing).


 

Providing training is clearly a challenge, and more than 70 percent of survey respondents plan to combine in-house and external training programs – likely reflecting necessary approaches to different constituencies and different levels of current competency. Perhaps most importantly, more than three-quarters of respondents identified getting buy-in from physicians and providing  training as their greatest perceived challenges.

In recent interactions with a variety of facilities, from large academic centers to small community hospitals, it has become evident that there is some reticence of hospital HIM professionals to provide in-house I-10 training for staff physicians – or even to approach physicians about I-10 at all. This is due in part to timing in that HIM departments themselves are getting an early start in the I-10 educational process.

But concerns about approaching the medical staff probably are based more on HIM wisdom than lack of knowledge. As discussed in a previous article, it is extremely unlikely that there is going to be broad, immediate physician buy-in to I-10.

Surgeons particularly are likely to react negatively when approached about ICD-10-PCS. They are likely to perceive no benefit from I-10 procedural coding (since they will continue to bill professionally using CPT procedural codes), and will be prone to viewing the requirement to provide necessary documentation to support the required seven-digit alphanumeric coding necessary for ICD-10-PCS as an additional administrative burden foisted upon them by an unsympathetic hospital administration.

ED. NOTE: Part II on physician education continues in the next edition of ICD10monitor.enews May 17, 2011.

About the Author

Paul Weygandt is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Dr. Weygandt is vice president of physician services for J.A. Thomas & Associates and is a partner in the firm.

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In an era of proposed Accountable Care Organizations (ACOs), bundled payment and medical homes, hospital leadership has the concurrent challenge of preparing medical leadership and staff for ICD-10.

This challenge may not be as simple as it appears on the surface, however, and in fact may alter the healthcare environment as much as health reform.

As hospital leaders are aware, medical staff’s adoption of important initiatives at times can be limited by organizational culture. Even initiatives that have no negative impact on physicians may be met with resistance. It is essential to demonstrate direct benefit to the medical staff if at all possible. There are several inherent challenges tied to the conversion to ICD-10, and organizational leadership must be aware of them.

Cool Reception

So be prepared for a less-than-enthusiastic response by your medical staff to implementation of ICD-10, let alone the next-generation HIPAA transaction standards (5010). Even in preliminary discussions I have been taken aback by physician resistance to the transition. I hear questions like “Why are they doing this now?” “Why should we have to convert to this new system?” And maybe most importantly: “Whose idea was this anyway?” It is important to be aware of physician concern, because it is only going to get worse.

As you consider how to approach ICD-10 with your medical staff, consider the additional costs they will be facing. The increases will stem from staff education and training, changes in health plan contracts, coverage determinations, increased documentation, changes to super-bills and other documents, information technology system updates (or, more likely, system changes), and interruption of normal cash flow.

Assessing the Cost of I-10

Consider the following: a recent study by Nachimson Advisors – performed on the behalf of a number of professional organizations, including the American Academies of Dermatology, Neurologic Surgeons, Orthopaedic Surgeons, the American College of Physicians, the AMA and others – estimated the “typical” cost of ICD-10 implementation for a small practice comprised of three physicians and two supporting staff to be $84,290. For a medium-sized practice of 10 physicians, one full-time coder and six impacted staff members, the estimated cost rose to $285,195. For a large group practice with 100 physicians, a coding staff of 10 full-time coders and 54 impacted medical records staff, the estimate rose to $2.7 million.

In light of the shrinking margin of individual or small group practices, a price tag of approximately $85,000 is likely to be a death knell for some of these practices.  Consider further that the deadline for implementation of ICD-10 in all clinical settings is firmly established as Oct. 1, 2013, with no flexibility offered. If physicians fail to bill correctly, using ICD-10 as of that date, they no longer will be paid by any payer. Additionally, Medicare has indicated that those failing to abide with the deadline and appropriately utilize ICD-10 additionally may be subject to substantial fines.

These financial costs likely will lead to fundamental changes in the healthcare environment.  At the same time hospitals will continue trying to assemble ACOs and medical home initiatives collaboratively, many primary-care physicians may be seeking refuge in new employment arrangements. They simply may not be able to afford ICD-10 and associated information technology conversions. And these physicians, having surrendered the private practices they have taken decades to build, may not be the most collaborative of new affiliates.

Greater Challenges

However, this may be only the leading edge of the challenge. Surgical and other procedure-based practices will face additional struggles. For professional billing purposes, physicians will be required to use ICD-10-CM for all diagnostic coding, but fortunately (for them), they still will bill procedural codes using the Current Procedural Terminology (CPT) manual as published by the AMA. Hospitals on the other hand will be required to use ICD-10-PCS (Procedural Coding System) for all hospital procedures in order to determine appropriate Diagnosis Related Group (DRG) billing.

Correct DRG assignment is also critical for severity-adjusted morbidity and mortality rates. The coding is complex. ICD-9, for example, uses three or four characters to identify a surgical procedure, whereas the specificity of ICD-10-PCS requires seven digits. ICD-9 has approximately 4,000 procedural codes, whereas ICD-10 has approximately 72,000. Physicians will be responsible for providing the appropriate level of specificity.

So, consider the challenge: at the same time many physicians will be seeking refuge with larger employment organizations, many also will be faced with the additional challenge of being required by their hospital partner or employer to provide all the specificity necessary for I-10-PCS – even though they will be using a totally different system (CPT) for their professional billing.

Being Prepared

With awareness of the challenge hospital leaders face vis-à-vis physician adoption of ICD-10 and the fundamental change in medical practice situations being forced upon physicians by economic constraints, managing this situation will be, at best, extremely challenging. It is advisable to begin a process soon to avoid unnecessary bumps in the road by providing medical staff education regarding ICD-10. However, education alone will be insufficient. It will be necessary for hospital leaders to anticipate demographic transitions not only in how physicians want to practice medicine, but also how they will be forced to practice medicine under heavy financial constraints. Additional commitments to infrastructure, both in information technology and support. such as clinical integration specialists, will be necessary to facilitate a cultural transition.

Hospital leaders will need all their facilitation, negotiation and mediation skills – and even then – don’t expect a lot of gratitude from your medical staff.

About the Author

Paul Weygandt is a Certified Physician Executive (CPE) with more than 20 combined years of experience in medical management, legal counsel and orthopedic surgery. He has served as a hospital VPMA, improving documentation across all DRG payers. Dr. Weygandt is vice president of physician services for J.A. Thomas & Associates and is a partner in the firm.

Contact the Author