Diagnose Your Practice’s Readiness for ICD-10-CM/PCS

By Deborah Robb, BSHA, CPC
Original story posted on: January 29, 2014

Physicians excel at thinking analytically – that is, using a step-by-step clinical decision-making process to arrive at an accurate diagnosis. This logical way of thinking will be a huge asset when it comes to ICD-10. Physicians must ask critical questions of themselves and their staff to determine their “ICD-10 prognosis.” The goal is to ensure a healthy outcome – both operationally and financially.

The following are some questions to consider when assessing your practice’s ICD-10 readiness:

Has someone been appointed to lead the ICD-10 effort? A practice manager or lead coder is a logical choice. Many practices may also decide to streamline the effort by hiring an external ICD-10 training company. Either way, the kitchen needs a chef, and you must assign one!

Is your documentation truly ready for ICD-10? Don’t try and speculate whether your documentation will be sufficient under ICD-10. Only a formal documentation audit can reveal this. Plan to review at least 25 charts per provider. Choose charts randomly, or consider auditing a particular date of service or your top 20 diagnoses. When auditing, ensure that documentation includes acuity, disease type, stage, laterality, manifestation, and site specificity. Other details may also be necessary, depending on the specialty.

How will you improve documentation? Once you’ve performed a documentation audit, focus on the diagnoses that require clinical documentation improvement. Consider these Centers for Medicare & Medicaid Services (CMS) tips to improve clinical documentation. Also read through any relevant specialty-specific chapters in the ICD-10-CM code set so you can better understand how codes and code descriptions relevant to each practice will change.

How frequently do you report unspecified codes? If your answer is “frequently,” or worse yet, “I have no idea,” then you’ve got some work to do. ICD-10 includes unspecified options; however, you shouldn’t default to them regularly. It’s currently unclear whether payors will reimburse certain unspecified codes (e.g., unspecified otitis media). Unspecified codes also may be problematic when billing higher-level E/M services.

Have you talked to your vendors lately? It’s paramount that your vendors are just as ready for ICD-10 as you are. CMS provides several tips for how to talk to your vendors about the transition. The agency also provides specific questions to ask your practice management and EHR vendors. Consider these other questions:

  • Will my systems require an upgrade or replacement for ICD-10?
  • When will new versions be ready for testing with payors?
  • How will documentation templates be updated to meet new ICD-10 documentation requirements?
  • Will systems include any computer-assisted coding or an automated component for coders?

When will you perform ICD-10 training? Everyone in a practice requires some type of ICD-10 training, depending on their role. Consider the following:

  • For coders: Begin comprehensive training in January 2014 and continue throughout the year, according to CMS. Coders working in the physician practice setting require at least six hours of specialty-specific training. After coders have undergone training, ask them to code one encounter per provider per week using ICD-10-CM to keep it fresh in their minds.
  • For physicians: Provide high-level training that focuses only on relevant specialty-specific code changes and documentation requirements.
  • For practice managers: Provide at least one hour of high-level ICD-10 training. Once trained, practice managers can monitor NCD and LCD coverage changes, answer patients’ questions about ICD-10-CM codes and what they mean, coordinate coder training and coverage, and more.

Do you know how ICD-10 will affect your workflow and operations? Consider the following:

  • Superbill changes: Due to the increased specificity inherent in ICD-10, you’ll likely need to update your superbill to accommodate a greater number of codes. How will you update this document so that it becomes a user-friendly tool?
  • Other changes: Any practice document that currently includes an ICD-9 code must be updated to include ICD-10. This includes authorizations, pre-certifications, physician orders, and more. How will your practice ensure that these forms are up-to-date?

Are you prepared for decreased productivity? When Canada transitioned to ICD-10-CA, it reported a 50 percent decrease in coder productivity. Practices must determine how they will handle such a decrease. Outsourcing companies may be able to assist coders during the transition. Determine how much this may cost and for how long your practice can employ them. Does the practice currently employ a certified coder? If not, would it be beneficial to do so? If not, how will you ensure that individuals who perform coding on a regular basis thoroughly understand ICD-10-CM?

Provider productivity also likely will take a hit. How will the practice handle this decreased productivity and potential of impact to cash flow? Can it set up a reserve fund now?

Are you ready for testing? Physician practices should already be testing ICD-10 claims both internally and externally, according to CMS timelines. Conduct a mock go-live prior to Oct. 1, 2014 that involves your practice management vendor, EHR vendor, clearinghouse, and payors.

…And the prognosis is?

If after reading these questions, you’ve already got clear answers, then you’re probably in a good spot with an excellent prognosis. If your answers are rusty, that’s OK, too, provided that you start devoting time to the effort now. If you haven’t even begun to ask the questions, there’s no time like the present. Get the ball rolling to ensure that your practice has every chance at achieving a favorable outcome.

About the Author

Deborah J. Robb, BSHA, CPA, has served TrustHCS since 2007, in that time developing the professional services department providing physician coder education related to CMS guidelines. She has also managed 34 coding staffers who provide coding services to a variety of specialty clinics nationwide. With more than 35 years in the healthcare profession, she is a frequent speaker on medical coding, including appearances at state and national American Health Information Management Association (AHIMA) conferences.

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.