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Waffling seems to be the norm these days…

At a macro level, HHS/CMS is waffling on the already-pushed-out-once implementation date for ICD-10, causing a lot of confusion and unrest among participants in ICD-10 remediation programs. Concurrently, and not necessarily in relation to recent governmental machinations, we’ve been seeing some waffling in the ICD-10 strategy of some of our clients as well.

In short, we’re seeing significant shifts from lofty, idealistic “remediate everything” strategies to more conservative approaches.

A few quick explanations:

When working with our clients on defining their ICD-10 strategies, we find that there are three overarching approaches:

  • Full Transition - Transition to accommodate both ICD-9 and ICD-10 on Oct. 1, 2013 and during the “dual processing” period. Internal processes and systems will operate only in native ICD-10 after the dual processing period is over, when the organization becomes “fluent” in ICD-10 and stops speaking ICD-9 entirely.
  • Partial Transition - Transition to accommodate both ICD-9 and ICD-10 on Oct. 1, 2013 and after the dual processing period. Some processes, systems or external partners remain in ICD-9 for an extended period. The organization utilizes both coding sets and can accommodate “late” trading partners.
  • Insulation - ICD-10 codes do not penetrate the organization’s gateways. Business processes and technical systems are insulated or “wrapped” and continue to process in ICD-9. Step up/down capabilities are implemented to insulate the enterprise from external ICD-10-friendly trading partners.

A few years ago, the rhetoric from most organizations in the early phases of establishing their strategies was to adopt a “full transition” philosophy and fall back to partial transition for “end of life” systems or select processes/systems. The rhetoric about a year ago shifted to the prevailing wisdom of partial transition. Lately, however, we’re seeing some of our clients shift from that mode to insulation.

It’s worth noting that these shifts have nothing to do with CMS’s recent announcement that it will initiate a rulemaking process to explore changing the currently mandated date for transition to ICD-10. Rather, the shifts were in place before the announcement from CMS and this change in philosophy is due to other factors, such as:

  • Business Operational Risk – Most early ICD-10 programs were IT-centric; in many organizations it was difficult to get the business side focused on ICD-10 until fairly recently. As more business-side practitioners entered the debate, the risk focus changed from technology implementation risk to operational risk (cash flow, productivity, enablement, etc.). Technology risk is generally easier to accept than operational risk, and this is driving a shift towards more conservative approaches from a business change management perspective.
  • Budgets – It was generally accepted that 2012 and 2013 were to be the years of significant remediation investment for ICD-10 program spending. As CFOs and COOs started to comprehend the magnitude of investment, however, they became more involved in seeking opportunities to reduce or delay that spending.
  • Benefit Timing – There is much debate about magnitude, likelihood and timing as they pertain to U.S. healthcare entities achieving tangible and meaningful benefit from the increased specificity in ICD-10. The magnitude and likelihood of achievement are topics for a future article. However, it is generally agreed that the timing of benefit achievement will not be short-term. The benefits will accrue in the mid- to long-term. As such, some of our clients are seeking to smooth out their investments over a longer period to align more closely with the benefit stream.
  • Contingency Planning – As the window for transition completion narrows (though it remains subject to change for some healthcare entities if the CMS rulemaking process alters the implementation date), the level of trust of external vendors and internal IT groups to complete their respective remediation missions varies. Executive management is becoming more interested in contingency plans, and insulation is the ultimate contingency plan.

About the Author

John Wollman is the Executive Vice President of Healthcare for HighPoint Solutions, a Management and Information Technology consulting firm focused on Healthcare and Life Sciences.  John is responsible for HighPoint’s Healthcare industry group, catering to Payers and Providers.  John is a recognized expert in several healthcare business domains (Reform, HIPAA 5010, ICD-10, Platform Strategy) and technical domains (Master Data Management, Analytics).  Since graduating from Duke University, John has held executive level positions at consulting and technology companies over his 25 years in business.

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Like most people past middle age, I have certain hobbies that remind me of my childhood. I ride a Schwinn mountain bike (one of the first, and carefully maintained) and the black Harley Trike I’ve mentioned before. I also listen to classical/rock/pop/adult contemporary/country music, and play four instruments, none very well. And I am into miniature trains … “N-scale,” specifically.

Trains can be interesting metaphors for so many things:

  • The weakest link (car) can determine the success or failure of the entire train.
  • Someone/something (engine) strong enough to do the job must lead the train and follow a path laid out by those who came before.
  • The course the train follows (tracks) must be well-planned and well-executed. It is, perhaps, the ultimate strategic plan, since it is virtually unchangeable once completed, and where it leads, almost everyone goes.

Now let’s sit back and take a few moments to consider this train metaphor in the context of the entire Congress/HIPAA Transaction Rule/HHS-OCR-CMS/5010.D0/ICD-10/provider/payer/clearinghouse/consumer/beneficiary/patient” train on which we now find ourselves.

The Tracks

Back in the dark ages of healthcare management (1996, to be precise), Congress passed and the president signed the Health Insurance Portability and Accountability Act. It happened very quickly, and most senators and representatives who were queried admitted to approving it solely on the recommendation of staff – and not necessarily their own staff. That was 16 years ago, and there are aspects of HIPAA that still have not been (and probably never will be) implemented (the Payer Identification Number and the Beneficiary or Patient Identification Number come to mind). At the moment we have only four components of HIPAA in place:

  • The Transaction Rule;
  • The Privacy Rule;
  • The Security Rule; and
  • The National Provider Identifier (NPI) Rule.

For the sake of this article, let’s call HIPAA and its rules the “track.” With this in place, we are supposed to know where we’re going and how we’ll get there. On to the train itself!

The Train

The U.S. Department of Health and Human Services (HHS) has multiple subunits, two of which are the Office for Civil Rights (OCR) and the Centers for Medicare & Medicaid Services (CMS). In its infinite wisdom, HHS management decided that HIPAA and its rules could be managed by existing entities, so the Privacy and Security rules now are enforced by OCR while the Transaction and NPI rules are enforced by CMS (don’t waste time trying to understand the rationale behind these assignments; just accept them for what they are). Let’s agree that CMS is the engine for our train, which I suppose makes Dr. Berwick and Ms. Tavenner our two most recent engineers. And yes, it’s a steam engine, so there is a tender (coal car).


Our first cars after the tender are that big boxcar labeled “5010” and the flatcar labeled “D.0.” 5010 is a transaction standard; it specifies the code sets that can be used for various transactions in the healthcare revenue cycle:

  • ICD-9/10 diagnosis codes are required for all claims.
  • ICD-9/10 procedure codes may be used on inpatient claims only.
  • CPT (or “HCPCS Level 1,” if you prefer) codes may be used on outpatient claims only (a requirement that goes a long way toward filling the corporate coffers of the AMA).
  • HCPCS (or “HCPCS Level 2”) codes, copyrighted by HHS, can be used on any claims, but on a very limited basis on inpatient claims.

So, what’s that “D.0” flatcar, you ask? Well, that’s the pharmacy coding requirements. Think of it as a big exception for a relatively powerful segment of the economy that is so fragmented it renders the CPT/HCPCS/ICD systems unusable.

But wait … what’s this? It’s another box car, even bigger than the first, and it has a big sign on the side that reads “ICD-10-CM and ICD-10-PCS.” To quote Dorothy from The Wizard of Oz: “Oh, my!” It’s bad enough that this car is part of the train at all, but apparently it’s going to be shunted onto a spur for a while in deference to the AMA and others who think it rolls too fast (and just when we all were having so much fun getting it into use).

Finally, we come to the three tank cars, so named because the involved parties are “tanking” just trying to keep up with everything the HIPAA rules and CMS keep doing! First are the two provider tankers; these are institutions and medical professionals. Then we have the clearinghouse tanker, which holds all those companies that make “dirty” claims clean. And finally we come to the payer tanker: insurance companies, Medicaid programs, workers’ compensation, and – Yes! What’s this? – CMS! Believe it or not, the engine is actually one of the cars too. It appears that our train can only run in a circle, going nowhere and accomplishing nothing. We don’t run off the track; we just run in circles, and our engineers call that “progress.”

But wait – we aren’t quite finished. What of the consumer/beneficiary/patient? You see that caboose sitting on the siding? That’s us. If our train wasn’t forever chasing its own tail, our caboose would bring up the rear and the voyage would be complete. But the other cars in the train – especially the engine and that last tank car – are so busy pursuing their own agenda (and unilaterally deciding what’s best for us in the caboose) that we can only sit wondering when it all will end.

Next Stop

So there we have it: a train with a bureaucracy in control, we providers and vendors caught in the middle, and that same bureaucracy bringing up the rear for the majority of healthcare expenditures – while few question why we don’t get anywhere. The HIPAA track was supposed to go somewhere – protecting patients as they change jobs and simplifying the administrative burdens of claim filing, processing and paying – but regrettably, and in true D.C. fashion, a new track was laid next to the HIPAA track. The new track goes nowhere, costs a fortune to run and gives the illusion of accomplishing good on behalf of we consumers/beneficiaries/patients who are sitting in that ratty caboose, just wishing something meaningful would happen.

I don’t know about you, but if I could figure out how to get out of here, head to the station and catch another train, I would.

About the Author

Billy K. Richburg, M.S., FHFMA is HFMA-Certified in Accounting and Finance, Patient Accounting and Managed Care. Bill graduated from the U. of Alaska, Anchorage and earned his M.S. in Health Care Administration from Trinity University, San Antonio, TX. Over a career spanning more than 40 years, Bill has held positions including CEO, COO, CFO, and CIO in hospitals ranging from 75 beds to over 300 beds, and in home health agencies, DME stores, and a home infusion company. Bill is a Board Member of the Lone Star Chapter, HFMA, and is Director of Government Programs for the Revenue Cycle Technologies business segment of MedAssets, Inc. His office is in Plano, Texas.

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Don’t wait for the Centers for Medicare & Medicaid Services (CMS) to make its decision about the implementation date for ICD-10, advises David Sayen, a CMS regulatory director.  “Even if I-10 is delayed, keep on course,” he said, and make sure things are functioning properly. That’s the advice Sayen offers to providers and payers during this time of uncertainty.

EDITOR’S NOTE: This is the fourth in a series of articles addressing the definitions and differences between the Medical and Surgical Root Operations of ICD-10.

This is the fourth in a series of articles addressing the definitions of, and differences between, the Medical and Surgical Root Operations of ICD-10-PCS. Let’s review what we covered so far: in the Medical and Surgical section (first character 0) there are 31 root operations using standardized terminology with no procedure names, no diagnostic information and no eponyms. You won’t find an appendectomy in ICD-10-PCS, but you will need to know that the cutting out or off, without replacement, of all of a body part is a “resection.” Since an appendectomy typically means the total removal of the appendix, resection is the correct root operation in this case. This is the type of translation coders must make to ensure accurate code assignment.

Coders will find this information in Appendices A and B of the ICD-10-PCS book. The PCS appendices are rich with helpful information meant to assist the coder in the translation of medicine to PCS. That is for future discussion, however, as today we are focused on procedures that alter the diameter or route of a tubular body part. Per the ICD-10-PCS book, we will review the definition, explanation and some examples of each. We also will introduce the applicable coding guidelines. The character listed after each root operation below represents the third character in the PCS code.


Restriction (V) Definition: Partially closing an orifice or the lumen of a tubular body part.
Explanation: The orifice can be a natural or an artificially created orifice.
Examples: Esophagogastric fundoplication; cervical cerclage; craniotomy with clipping of cerebral aneurysm.

Coding Guideline Occlusion vs. Restriction for vessel embolization procedures (B3.12)

If the objective of an embolization procedure is to close a vessel completely, the root operation "occlusion" is coded. If the objective of an embolization procedure is to narrow the lumen vessel, the root operation "restriction" is coded.

Examples: Tumor embolization is coded to the root operation of occlusion because the objective of the procedure is to cut off blood supply to the vessel.

Embolization of a cerebral aneurysm is coded to the root operation of restriction because the objective of the procedure is not to close off the vessel entirely, but to narrow the lumen of the vessel at the site of the aneurysm where it is abnormally wide.

Occlusion (L) Definition: Completely closing an orifice or the lumen of a tubular body part.
Explanation: The orifice can be a natural or anartificially created orifice.
Examples: Fallopian tube ligation; ligation of inferior vena cava.
Coding Guideline (see above, B3.12)



Dilation (7) Definition: Expanding an orifice or the lumen of a tubular body part.
Explanation: The orifice can be a natural or an artificially created orifice. This procedure is accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the orifice or wall of the tubular body part.
Examples: Percutaneous transluminal angioplasty (PTA); percutaneous transluminal coronary angioplasty (PTCA); esophageal dilation.

Coding Guideline Coronary arteries (B4.4)

The coronary arteries are classified as a single body part, further specified by number of sites treated and not by any name or number of arteries. Separate body-part values are used to specify the number of sites treated when the same procedure is performed on multiple sites in the coronary arteries.

Examples: Angioplasty of two distinct sites in the left anterior descending coronary artery with placement of two stents is coded as Dilation of Coronary Arteries, Two Sites, with Intraluminal Device.

Angioplasty of two distinct sites in the left anterior descending coronary artery, one with a stent placed and one without, is coded separately as Dilation of Coronary Artery, One Site with Intraluminal Device, and Dilation of Coronary Artery, One Site with No Device.

Coding Guideline Procedures following delivery or abortion (C2)

Procedures performed following a delivery or abortion for curettage of the endometrium or evacuation of retained products of conception are all coded in the obstetrics section, to the root operation of “extraction” and the body part “products of conception, retained.” Diagnostic or therapeutic dilation and curettage performed during times other than the postpartum or post-abortion period are all coded in the Medical and Surgical section, to the root operation of “extraction” and the body part “endometrium.”

Bypass (1) Definition: Altering the route of passage of the contents of a tubular body
Explanation: Rerouting contents of a body part to a more distant area of the normal route, either to a similar route and body part or to an abnormal route and dissimilar body part. Includes one or more anastomoses, with or without the use of a device.
Examples: Coronary artery bypass; colostomy formation; urinary diversion: ureter: using ileal conduit to skin.
Coding Guideline Bypass procedures
Bypass procedures are coded by identifying the body part bypassed “from” and the body part bypassed “to.” The fourth character, denoting body part, specifies the body part bypassed from, while the qualifier specifies the body part to which the bypass leads.
Example: For bypass from stomach to jejunum, stomach is the body part and jejunum is the qualifier.
Coronary arteries are classified by the number of distinct sites treated rather than the number of coronary arteries or any anatomic name of a coronary artery (i.e. left anterior descending). Coronary artery bypass procedures are coded differently than other bypass procedures, as described in the previous guideline. Rather than identifying the body part bypassed from, the body part identifies the number of coronary artery sites bypassed to, and the qualifier specifies the vessel from which the bypass leads.
Example: Aortocoronary artery bypass of one site on the left anterior descending coronary artery and one site on the obtuse marginal coronary artery is classified in the body-part axis of classification as two coronary artery sites. The qualifier specifies the aorta as the body part from which the bypass leads.
If multiple coronary artery sites are bypassed, a separate procedure is coded for each coronary artery site that uses a different device and/or qualifier.
Example: Aortocoronary artery bypass and internal mammary coronary artery bypass are coded separately.


Our next group of ICD-10-PCS root operations to explore includes procedures that always involve devices.

About the Author

Becky DeGrosky, RHIT, is the Product Manager for TruCode. She brings over 35 years experience in health information management.  She worked for 11 years in HIM software development for QuadraMed and MedAssets, including product management, content maintenance, implementation and training, and client support.  She is an active member of the Pennsylvania Health Information Management Association, where she has served on multiple committees including Chairman of the Education Committee and the Coding Roundtable.

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What’s Happening?

Everyone working on ICD-10 preparedness in any capacity fits into one of two groups:

  • Group 1 includes those who have thought “I will be so glad when this is done and ICD-10 is all there is!”
  • Group 2 includes those who have not thought this.

Typically, the group in which you find yourself is a direct function of how long you’ve been working on this stuff!

Yet for those in Group 1 – whether you are a provider, a payer, a clearinghouse or a business associate – the distant light of hope shines on Oct. 1, 2013, when ICD-10 becomes law.

Ready or not, here we come – and we will comply!

What Is It?

But there is one small problem … one tiny problem … one teensy-weensy problem … one microscopic, mere wisp of a problem (drum roll):

In case you haven’t heard, not everyone is converting to ICD-10.

Two groups of payers in the industry are unique because they pay claims for which neither the patient nor the patient’s family are financially responsible. Those two payer groups are workers’ compensation plans and motor vehicle liability plans.

Under the former, an employer (or their insurance) is liable for the cost of medical care, and under the latter, an “at-fault” driver (or their insurance) is liable for the cost of vehicle-related damages. And since, in the former case, neither the patient nor their family is liable, our incomparably wise Congress and CMS decided that those patients don’t have the right to privacy afforded by the HIPAA Privacy and Security Rules. Likewise, those insurers can ask for pretty much anything they want, because the HIPAA Transaction Rule doesn’t apply to them either.

Presently there are roughly 500 authorized exceptions to the HIPAA Transaction Rule. That is, CMS has permitted 500 or so variations from the so-called Transaction Rule “standard.” And the biggest exception of all was covered in the original law (drum roll No. 2):

If you are not ultimately responsible for the cost of your medical care,

you have no rights, under HIPAA, related to that care.

What Does It Do?

This part is easy: since the HIPAA Transaction Rule (and its requirement for 5010 and ICD-10) does not apply to workers’ compensation and motor vehicle liability plans, those payers have no real incentive to switch from ICD-9. After all, their historical statistics are in ICD-9; it costs $0.12 to $0.43 per member (estimated) to convert to ICD-10; and honestly, converting from ICD-9 to ICD-10 is expected to be a total pain in the derriere, which only will be exacerbated by the adoption of ICD-11 around the start of the next decade!

If I’m the big boss of California Workers’ Comp or XYZ Car Insurance, I challenge you to give me just one good business reason to go through the ICD-10 conversion hassle. Alas: it can’t be done. We may all think it’s a great idea, but if we look at it objectively, perhaps we’ve decided it’s a good idea only because we have no choice.

What Does it Mean?

Whether you are a covered entity (provider, clearinghouse or payer) or a business associate (vendor, consultant, whatever), this nonsensical situation means only one thing (drum roll No. 3):

You probably will never be fully rid of ICD-9.

Here’s the proverbial bottom line, friends:

You must maintain both systems – coding, billing and collections – because

you have no idea what will be on the next claim that comes in.

Yes, this is a sticky situation, but it’s the plain truth, and it will only get worse. Just imagine: in less than 10 years you may need an encoder that can use ICD-9, ICD-10 or ICD-11 – and you may need to use any of them for any date of service!

Oh my…

Suddenly I have a severe headache. I think I’ll go take a half-dozen aspirin and a double shot of something strong.

Until next time…

About the Author

Billy K. Richburg, M.S., FHFMA is HFMA-Certified in Accounting and Finance, Patient Accounting and Managed Care. Bill has held positions including CEO, COO, CFO, and CIO in hospitals ranging from 75 beds to over 300 beds. Bill is a Board Member of the Lone Star Chapter, HFMA, and is Director of Government Programs for the Revenue Cycle Technologies business segment of MedAssets, Inc. His office is in Plano, Texas.

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Recently I was addressing a group of healthcare dilettantes to discuss the impending transition from ICD-9 to ICD-10 and the various processes, staff resources and impact areas expected to be affected by the changeover within the physician practice setting. One person rather abruptly raised his hand and emphatically blurted "Can you speak in English, please! This is all Greek to us!"

Ok, now I understood. Even though I had been immersed in ICD-10 for more than a year, I needed to remember that many folks are just getting started down the path to transition: a circuitous path impacting not only clinical and administrative talent directly involved in the day-to-day activities of providing services, but numerous other peripheral healthcare staff with skill sets in information technology/information systems (IT/IS), finance and accounting, staff augmentation, and sales.

So I took a step back in my presentation and started from the beginning, describing how ICD-9-CM diagnosis codes currently are generated, applied and reported by the typical physician practice, then dovetailing that information into what's anticipated for ICD-10-CM. Here's a synopsis of that "journey."


ICD-9-CM codes, representing the clinical reason(s) for an office visit, usually are generated by a face-to-face visit with a healthcare provider. The migration of the patient through the physician practice begins at the check-in desk and ends with his or her departure from the office, although the visit data continues to be handled, assessed, processed and ultimately reported for reimbursement well beyond that point. There's even an "afterlife" for this data if the initial claim is not reimbursed or is paid at a suboptimal rate due to denial, insufficient or incorrect information, or fee schedule error.

Presently, the basic office systems and internal resources involved in the generation and application of ICD-9-CM diagnosis codes are:

  • Practice management IT systems, including scheduling modules and electronic medical records, or EMRs (or manual systems for non-computerized offices);
  • Staff resources: providers, coders, billers, collections staff, data entry resources, etc.; and
  • Coding/billing IT systems for claims generation (or manual tools for non-computerized offices).

With the advent of ICD-10-CM, it is important to consider that numerous provider offices are not yet computerized. While some might have electronic laboratory ordering and lab results retrieval capabilities, this doesn't necessarily mean the office is fully or even partially computerized. And even at this stage of modernization, with government initiatives such as the Electronic Health Record Incentive Program (more commonly referred to as the "meaningful use" program because of the criteria required to obtain available federal subsidies), there are multitudes of medical practices not yet transitioned to EMRs.

On a positive note, many partially computerized practices are leaping into EMR with "meaningful use" assistance and are melding disparate practice systems or e-modules into one fluid system able to handle practice management functions (scheduling, superbill generation, patient demographics, etc.), EMR functions and coding/billing functions.



Following ICD-9-CM Code Generation for the Typical Office Visit

Step 1 - Check-in/Registration:

A patient presents for an office visit. In preparation for the visit, the practice receptionist generates an encounter form commonly referred to as a superbill or a fee ticket. This is the primary charge capture tool utilized by most physician offices. For practices on EMR, this "document" might remain in an electronic format, accessed on monitors or touch screens positioned at various service points within the practice, or by using hand-held palm pilots (or it simply might be screen-printed to paper for facile use). Using the practice management system, the superbills are generated from each provider's daily schedule of patients.

When billing or EMR modules are involved in generating the superbills, the data used for these documents may be dovetailed with data entry from the patient's prior visits, specifically demographic and clinical information already embedded in the coding/billing system. One way or another, even if done by hand, a superbill is generated. The majority of IT systems currently allow superbills to be generated with the most recent set of ICD-9-CM codes associated with a particular patient. ICD-10-CM codes, when implemented, likewise initially will be accessed at this point.

Step 2 - The Provider (SOAP) Encounter:

While in the treatment or exam room, the patient will be asked for subjective (S) information about his or her condition (information that might be coded), will be objectively (O) evaluated and provided an overall assessment (A) (which, when documented, will be punctuated by diagnostic statements that will be coded), and will be provided a care plan (P) or treatment regimen. During this process, the patient might undergo various testing and studies (glucometry, hemoccult, EKG, CXR, etc.) All of this activity is substantiated by confirmed diagnoses abstracted from the diagnostic statement(s) or by documented signs and symptoms gleaned from the chief complaint and subjective data - for example, the diagnostic statement "rule out appendicitis" in a patient with abdominal pain and vomiting will be coded using ICD-9-CM codes representing the abdominal pain and emesis only, not suspected appendicitis.

This data is required to substantiate the medical necessity of the patient encounter as well as any laboratory work or other tests or studies performed or ordered. The information subsequently is entered into the EMR superbill or onto a paper superbill. In the ICD-10 milieu, all of this activity likewise will occur.

Step 3 - Checkout, Claims Generation and A/R Management:

At this point the patient officially signs out of the office, typically accompanied to the checkout point by the superbill. The receptionist reviews the encounter data, adds up the various services and collects the patient's co-pay, co-insurance and/or deductible amounts.

The patient departs and the receptionist, along with performing other clerical activities, initiates a quick final scan of the encircled or entered ICD-9-CM codes in or on the superbill. Internal tools such as ICD-9-CM "cheat-sheets" complete with the practice's most frequently used codes may be accessed at this juncture - often these tools likewise are used in the coding/billing department, as well as by collections staff.



Then questions, comments or concerns about superbill entries, together with the MRs, are routed back to the providers' assistants or scribes (or they are sent directly to the providers themselves for clarification). If a paper MR and hard-copy superbill are used, the finalized superbill is separated from the MR, which may be filed or sent to transcription, and the superbill then is sent to the coding/billing department. If the practice utilizes a professional billing company, the batched superbills from the day's patients will be sent to the billing company for processing.

In the coding/billing area assigned personnel perform another check of the superbill to ensure that all appropriate ICD-9-CM codes are documented for services performed (a task referred to as code linkage), and also enter the visit data into the billing system.

When coders are involved in the visit processing work, a comparison of the service and diagnosis codes against the actual MR documentation or EMR screens often is performed; just as often, however, no MR reference or final comparison with the chart notes is done at all. The superbill, then, may stand as the sole document utilized as the vehicle for accurate and appropriate coding and billing for the patient encounter.

At this juncture the ICD-9-CM code "libraries" or IT data files are accessed during input of the encounter data into the billing system by coding/billing personnel or data entry staff. Those data files currently hold the ICD-9-CM code library, but soon enough they will house ICD-10-CM data. Furthermore, there probably will be an estimated three to six months of overlap time, during which practice coders/billers may utilize ICD-9-CM and ICD-10-CM data simultaneously, reporting both sets of information to the various payers with which the practice participates.

Once the patient's encounter data is entered into the billing system - in many cases after a claims scrubber program has been run - a CMS-1500 claim form will be generated to submit to the patient's insurer (either Medicare, Medicaid, BCBS, Aetna, HMO, etc.). This can be a weekly duty, but claim generation often is performed in busy medical offices several times a week.

For practices utilizing third parties for their billing functions, i.e., claims clearinghouses, the e-files containing the pre-submission billing data are transmitted to the clearinghouses for final formatting and claims scrubbing. The claims then officially are reported to the various payers.

After the patient's reimbursement is received from the payer together with remittance advice or explanation of benefits, a review is performed to ensure that appropriate reimbursement has been received. For denied, underpaid or suspended claims (or for additional information to substantiate medical necessity), ICD-9-CM code data may be at issue.

To resolve these issues, personnel assigned to accounts receivable (A/R) management and claims follow-up are usually responsible for possessing knowledge of ICD-9-CM coding, experience in evaluating and correcting initial claims errors, and expertise in constructing correspondence with third-party payers, including federal and state payers.

These staffers will access the patient accounts, verify disparate parts of the patient encounters in question, make claims corrections if necessary, generate updated claims and resubmit the CMS-1500 claim forms or remit necessary additional MR documentation to get the services paid appropriately.




Providers and various clinical and administrative personnel working in physician practices will be affected by the transition from ICD-9-CM to ICD-10-CM, necessitating education and training (E&T), updated internal tools, and access to updated IT systems. In this short article, we have provided a high-level overview of these personnel and their internal responsibilities. In operational order, again, they are:


Medical Office Staff


ICD-10-CM Impact


Check-in and Checkout

-IT systems

-Internal tools

-ICD-10-CM E&T (functional)


Treatment areas

-IT systems

-Internal tools

-ICD-10-CM E&T (provider-level)

Ancillary Clinical Staff

-Treatment areas


-Nurses/Scribes Stations


-IT systems

-Internal tools

-ICD-10-CM E&T (provider-level or functional)

Coding/Billing Staff

Coding/Billing Department

-IT systems

-Internal tools

-ICD-10-CM E&T (in-depth)

Coding/Billing Staff

Third-Party Interface

IT systems

A/R Mgmt. & Collections

Managers and Collections

-IT systems

-ICD-10-CM E&T (in-depth)

IT/IS Interface


IT systems



Touchpoints in the physician's office anticipated to be affected by the transition to ICD-10-CM will vary, but there are sure predictions that can be made: at the very least, the above listed personnel will need to have knowledge of ICD-10-CM coding to some degree. Some staff will need in-depth knowledge of ICD-10-CM codes while others only will need operational familiarity with the new code system.

Various internal tools and office systems (IT and manual) will require revision and updating in the change from ICD-9-CM to ICD-10-CM. Office efficiency in administrative operations, clinical operations, coding/billing functions and A/R management likewise will be affected until all parties are proficient in ICD-10. IT systems - including scheduling and demographic modules, coding/billing systems, third-party and clearinghouse interface(s), and practice EMR systems - will require new data files and ICD-10 functionality, updated linking (especially if ICD-9 and ICD-10 systems will be run concurrently for a time), staff training on the revised systems, and the ability to generate claims in the 5010 format versus the current 4010 format. All of these matters should be considered when contemplating what touchpoints ICD-10-CM will impact in the physician office, and to what degree.

About the Author

Michael G. Calahan, PA, MBA, is the director of physician services at KForce Healthcare, Inc. Michael has more than 25 years of experience in health care, beginning as a physician assistant with the USN. He has served as an administrator for several physician practices and has enjoyed a varied career in healthcare consulting, being affiliated with Ingenix, CGI, Navigant, PWC and Parente-Randolph. He has authored numerous industry publications and articles in physician, IP/OP/ASC, DMEPOS, ESRD, HHA, ambulance, HIPAA and in Medicare Parts C & D for Medicare Advantage.

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When an organization brings us in to talk about ICD-10-CM, someone invariably asks why "how to register for and receive EHR government Incentive money" is part of the planned agenda. Well, for one thing, talking about accessing up to $63,750 per provider is fun. Everyone wants to hear about "free money."

And, of course, a speedy, efficient EMR can ease the ICD-10 implementation. Automating data entry, documentation and coding simplifies the transition. We are clear about communicating that, at the end of the day, the responsibility for the success or failure of ICD-10 implementation rests squarely on providers' shoulders. ICD-10-CM adds coding, documentation and work process complications to an already complex system.

EMR goes a long way toward mitigating these challenges. Whether you work with your EMR vendor to create "problem" or "pick" lists - intuitive chart templates that satisfy ICD-10's voracious appetite for new and complete documentation elements - or whether you are working alone to create your own lists and templates, capturing these elements is made easier with the proper EMR setup.

These are good reasons to talk about the government EHR incentive program during an ICD-10 workshop. The BEST reason to talk about the program is simple: money (and free money, at that). The crystal ball (and those countries already using ICD-10) tells us we can expect to lose up to 40 percent of our productivity due to ICD-10. That makes sense when you consider the massive confusion introduced when you overhaul a mission-critical item. New language, new codes, training curves and habit changes surely equate to fewer patients seen.

Even CMS is recommending that practices cache a six-month operating capital "war chest" to deal with loss of productivity and revenue. Providers also are securing lines of credit or short-term loans to help weather the storm. The EHR government incentives program can help. A CNP-led FQHC in rural Louisiana just received its second set of incentives checks; to date it has received more than $400,000. Seems like a good head start on an ICD-10 "emergency reserve."

Setting up the protocols in your EMR makes the process to collect meaningful use data easy. Work with your regional extension center. Take the plunge. It's free money. When times are lean in the fourth quarter of 2013, 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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Here's a top 10 list of things to think about this coming month to get you moving in the right direction.

1.   Have a formalized plan.

If you do not have a documented project plan with assigned responsibilities, milestones, resource needs, etc., you do not have a formalized plan.

2.   Develop a project timeline for decision-making.

The longer you take to make a decision, the less time you'll have for your implementation plan. See 5010 experience for details and motivation.

3.   Don't try to boil the ocean - start with a simmer (but start now!)

Remediation for ICD-10 during the next 18 months will be a fluid process with many decisions being made and many outcomes depending on unknown variables. Don't start with perfection, work towards perfection.

4.   Strengthen ICD-9 processes.

If you have operational deficiencies in your current processes, they will only get worse with ICD-10.

5.   Prioritize impact effort (i.e. implement an education plan for physicians on documentation and meaningful use)

What is the saying again? He who fails to plan, plans to fail.

6.   Assess your resource plan and delivery capabilities.

Hoping for the best is not a feasible strategy for delivering on this initiative. Take a realistic viewpoint for your business case as it pertains to resources. If you think you can accomplish all the required tasks and activities with your existing staffing compliment, then you are grossly overstaffed - and we know that is not the case.

7.   Align your project management and team structures.

If you have the same six people on different steering committees, you probably have an opportunity to align your team members to become more effective in driving these initiatives.

8.   Evaluate your strategic project plans and coordinate your return on investment for these multiple initiatives.

Turn this into a strategic advantage and work collaboratively with overlapping initiatives such as meaningful use and EMR implementation.

9.   Recognize that ICD-10 is not a deadline - it's a beginning.

I repeat, ICD-10 is not a deadline - it's a beginning. The work does not end in October 2013. That is just when we will realize how prepared we are for the change.

10.  Understand that things will change and adapt to the changes.

Being flexible has always been and always will be a key to business success. Remind yourself of that when an unexpected situation requiring a change in direction arises. You will find the journey a smoother one if you keep this in mind.

About the Author

John Pitsikoulis, RHIA, is a Strategic Advisory Services Client Executive and ICD-10 Practice leader at CTG Health Solutions (CTGHS). John is responsible for the strategic advisory services such as ICD-10, EMR clinical documentation integration program, and Computer Assisted Documentation Services. John has over 25 years of Health Information Management (HIM), coding, and compliance consulting experience working with clients on ICD-10 services, RAC, coding, and clinical documentation improvement engagements.

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I was in a planning meeting this morning – a joyful, exuberant, bi-weekly event designed to maximize performance from developers and analysts alike – and someone raised this question:

“Is there a crosswalk we can use to price Medicaid claims?”

The inquirer was referring to an ICD-10-to-ICD-9 “back” crosswalk with the expectation that we might receive claims coded using ICD-10 while our existing software will price only ICD-9 claims.

I stated that there was no such crosswalk, and the 52 percent of people in the room who know of General Equivalency Mappings (GEMs) all inhaled simultaneously, sucking half the oxygen out of the room, fully confident in their knowledge of GEMs as a viable crosswalking system. (Incidentally, is “crosswalking” really a word?)

As you would expect, I sensed the instantly hostile tone and was compelled to backpedal a bit by addressing the obvious concern my comment had raised among team members. So I pointed out three facts to the individual who originally asked the question while the remainder of the team listened in, hanging on every word in the sincere hope that I’d make yet another faux pas as good as the last!

This is what I said:

  1. There are crosswalks, including GEMs, but they are “one-to-many” comparisons – there are ICD-10 codes that have no ICD-9 equivalent. A developer to my right chimed in, saying “Well, yeah, but there is a ‘priority’ indicator to tell which is most likely.” I conceded that he was correct but stood my ground that it really didn’t help, since we have no way of knowing which ICD-10 codes the various government payers actually will include in their new regulations.
  2. Because my team’s mission is to price certain government claims as precisely as possible, we couldn’t presume to second-guess what a Medicaid program…or Medicare…or Tricare…will do in the future. For example, if we referenced an ICD-9 code in our software and it had 16 possible ICD-10 codes to which it could map, we had no basis on which to decide how many of those ICD-10 codes actually would wind up in the payer’s payment protocol (even though we could map a billed ICD-10 code back to an ICD-9 code, in most cases). In other words, we can crosswalk back to ICD-9 fairly easily, but that is no guarantee that the ICD-10 codes billed will be correct when the payers finally publish their rules.

All of this really points to my No. 1 problem with GEMs and all other ICD crosswalks:

I don’t care to make business decisions based on best guesses and probabilities. That’s not so much business as it is structured gambling, and let’s face it: in gambling games, the odds always are in favor of the house. That is, you will lose eventually; it’s only a matter of time.

Those who have decided to count on crosswalks to do their ICD-10 grouping rather than buying an ICD-10 grouper or paying someone to do it for them have my unmitigated respect, because they are truly dedicated gamblers. They have decided to risk their future livelihood and, ultimately, their success on the probability that a particular ICD-10 code is the right choice. Relying on probabilities only makes sense in two scenarios:

  1. When the odds are statistically significantly in your favor, or
  2. When you can make conscious decisions and take actions that move the odds to your favor.

Any other time, you may as well pin all your hopes and dreams on a coin toss, because using GEMs in this manner – which CMS (to its credit) has unequivocally denounced – is equally irrational.

There is an old saying from Mother England:

“Penny wise and pound foolish.”



This means:

You may save a penny thinking it’s smart, but it might cost you a pound to fix what your cheap side embraced.

Or something to that effect…

Using a crosswalk to code claims is foolish: you simply can’t win. If you are a healthcare professional, think with your brain rather than your heart (or worse, your checkbook) and hire experts to code for you – or train the experts you have.

The money you spend doing your coding the right way will be a pittance compared to the benefit you’ll realize over time. Remember, ICD-10 is going to be with us for 10 years or so, and it will be followed by ICD-11: and then you’ll know what pain really is, especially if you don’t act now to do it right the first time.

About the Author

Billy K. Richburg, M.S., FHFMA is HFMA-Certified in Accounting and Finance, Patient Accounting and Managed Care. Bill has held positions including CEO, COO, CFO, and CIO in hospitals ranging from 75 beds to over 300 beds. Bill is a Board Member of the Lone Star Chapter, HFMA, and is Director of Government Programs for the Revenue Cycle Technologies business segment of MedAssets, Inc. His office is in Plano, Texas.

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"Nothing has changed at CMS relative to I-10 implementation... We haven't been given any clue that the implementation date will move." That was the official word provided by Denise Buenning, director of the administrative simplification group at the Centers for Medicare & Medicaid Services (CMS) Office of E-Health Standards and Services, during the roundtable discussion, “At the Crossroads: AMA’s Impact on ICD-10,” produced by ICD-10monitor on Tuesday, Dec. 13, 2011.