June 29, 2015

Five ICD-10 Pillars of Success for Large Physician Practices

By Kelly Whittle, MS

Regardless of size, many physician practices are struggling with ICD-10 implementation. Over the last couple of months, much of the industry focus has been on smaller practices. This makes sense, given the financial and operational limitations of these practices. However, large practices (i.e., those with 25 or more physicians, as defined by the Centers for Medicare & Medicaid Services, or CMS) also face their own unique challenges, the most fundamental of which is financial risk.

Larger practices generate far more revenue than their smaller counterparts, leaving them particularly vulnerable if documentation and coding aren’t ready and ICD-10 implementation doesn’t go smoothly.

In this article, I outline five “pillars of ICD-10 implementation” that must be on every large practice’s radar. I’ve also provided several documentation and coding tips for the top three specialties impacted by ICD-10: orthopedics, cardiology, and internal medicine.

Practices can use these strategies to prevent potential denials and ensure accurate reimbursement for services rendered in a post-ICD-10 world.

Strategy No. 1: Education

If they haven’t already, practices should build role-based educational strategies for all employees. Beyond addressing coders, practices are advised to include staff ranging from receptionists to clinicians in their ICD-10 educational efforts, using the following guidelines:  

  • Registration/schedulers should understand the specificity required for compliance and medical necessity, including the importance of obtaining a detailed diagnosis code for each referral.
  • Clinicians should recognize the granularity required within chart documentation, with a specific focus on orders, visit notes (anatomy, severity, etiology) and use of the electronic health record (EHR) to choose an appropriate ICD-10 code. Specialty-specific training for physicians is of paramount importance. Every physician doesn’t have to learn every code – only those most widely used within his/her practice. With an anticipated increase in the time physicians will spend documenting ICD-10 elements, it’s important that they be able to identify these elements efficiently.
  • Billers should organize practice-specific superbill changes required for ICD-10 and be able to coordinate revisions with the practice’s EHR, including updates to templates as well as encounter forms or cheat sheets.
  • Office managers should identify basic coding and documentation changes required for ICD-10 in order to facilitate coder/physician education as well as technology and other updates. Also, be sure to become adept at scheduling training courses to maintain day-to-day productivity and workflow.

Because large practices employ many individuals and must provide education for a wide variety of specialists, programs may be costly. However, investments in education reap great returns. The largest part of a practice’s educational investment may be the loss of productivity that occurs during training. Using a staggered approach to training helps minimize the impact on productivity and workflow.

Strategy No. 2: Technology 

Practice software vendors should already be prepared for ICD-10. Practices must communicate with their vendors to solidify upgrade timelines, determine additional costs, and begin testing systems, including interfaces and custom software code. Here are several questions to ask and issues to consider regarding ICD-10 software upgrades:

  • Upgrades are not always included in contractual arrangements. Some vendors may charge an additional fee. What is that fee, and what services are included? For example, will the vendor assist with any ICD-10 customization?
  • Customized EHR notes and templates must be adjusted to accommodate ICD-10. Many large practices tend to customize EHR notes and templates in several different ways. Although this has been helpful in ICD-9, it means they must now re-customize for ICD-10. What is the plan to accomplish this? Will your practice re-customize the EHR using internal resources, or will it outsource to a third-party vendor?

Strategy No. 3:  Denial Management 

Claims rejections and denials are expected to increase in the immediate aftermath of ICD-10, primarily for hospitals, but also for practices. Now is the time for practices to strengthen denial management processes and expand staffing. Every attempt should be made to whittle down the number of denials and delinquent accounts in advance of the Oct. 1, 2015 deadline so that all available resources can be devoted to any new claim rejections or denials that may occur. 

The good news is that large practices are more likely than smaller practices to employ a certified coder. This individual can (and should) help mitigate rejections and denials in the following ways:

  • Educate physicians on how to select a detailed and accurate diagnosis code in the EHR.
  • Provide quality assurance for physicians by validating each code that physicians select during an encounter.
  • Participate in dual coding and set up one-on-one sessions with physicians to share insights related to documentation gaps. Provide specific examples of how documentation must change to match the added specificity in ICD-10.

Strategy No. 4: Contingency Plans

Large practices must ensure access to working capital so they can continue to operate if payments are delayed or denied. The larger and busier the practice, the greater the capital required for operations. A practice that includes 15-25 physicians, for example, could generate hundreds of thousands of dollars per week. An orthopedic surgery practice could generate millions of dollars per month.

Early adopters may have been able to set aside cash to cover expenses; however, many practices may need to secure a line of credit. The unfortunate aspect of using credit is that practices also must pay interest, making it ultimately more expensive for them to conduct business.

Consider these tips to determine just how much money your practice may need to set aside:

  • What is your current billing turnaround time? A typical period is four days – bills are usually sent within four days of the encounter. However, in ICD-10, it may take coders/billers even longer. Many practices may not be able to send their first round of post-implementation bills until mid-October.
  • What is your typical billing cycle? Many practices operate using a 45-day cycle; however, payors may take longer to process claims in ICD-10. Cycles may expand to 60 or even 90 days. If bills aren’t sent until mid-October, practices may not receive their first ICD-10-based payments until mid-January.
  • What are your expenses (including overhead, salaries, benefits, etc.) each month?
  • Multiply the monthly expenses by three (in the event of a 90-day payment cycle). This is the minimum amount necessary for cash reserves in the event of payment/processing delays.

Strategy No. 5: Testing

In addition to internal testing and vendor testing, physician practices must test externally with clearinghouses and payors to ensure that all interfaces work correctly, claims are adjudicated properly, and receivables are reimbursed accurately. External testing is often seen as the true barometer of ICD-10 readiness, and it can help large practices identify and remediate potential problems before implementation. Identify your top payors and start there. If possible, devote one FTE (e.g., a coder or biller) to this effort.

ICD-10 Tips for Three High-Impact Specialties

ICD-10 includes a plethora of “one-to-many” ICD-9-to-ICD-10 mappings. This means that individual diagnosis codes with which coders and physicians have been familiar now will include many more options. These options will require additional details such as laterality, anatomic specificity, severity, etiology, and more.

Reach out to your professional association as well as the AAPC and American Health Information Management Association for more information about ICD-10. CMS also provides many free resources for these and other specialties:

Orthopedics: Orthopedic practices must keep the following tips in mind:

  • For fractures, document the type, pattern, etiology, episode of care, healing status (if subsequent encounter), localization, displacement, classification, and any complications.
  • For arthritis, document the type, location, and specific bones or joints affected.
  • For injuries, document the episode of care, injury site, etiology, and place of occurrence.
  • Be mindful of laterality. Many ICD-10 orthopedic codes denote left, right, or bilateral.
  • For chronic gout, document the specific site and type of gout.
  • When appropriate, document the specific region of the spine as occipito-atlanto-axial, cervical, cervicothoracic, thoracic, thoracolumbar, lumbar, lumbosacral, sacral and sacrococcygeal, or multiple sites.

Refer to the CMS ICD-10 orthopedic references for more information about these documentation requirements.

Cardiology: Cardiology practices must keep the following tips in mind:

  • ICD-10 defines an acute MI as one that occurs for a duration of four weeks or fewer, from onset.
  • ICD-10 no longer includes the concepts for “benign” or “malignant” hypertension. Instead, document the type and causal relationship.
  • For congestive heart failure, document the acuity and type.
  • Be on the lookout for cases of under-dosing in which a patient takes less of a medication than is prescribed. In these cases, document whether the under-dosing is intentional or unintentional, as well as the specific reason (e.g., financial hardship, age-related debility).
  • For atherosclerotic heart disease with angina pectoris, document the cause, stability, specific artery involved, and graft involvement.
  • For cardiomyopathy, document the type, location, and cause.
  • For heart valve disease, document the type, location, and cause.
  • For arrhythmias, document the location, type of arrhythmia, acuity, and cause.

Refer to the CMS ICD-10 cardiology references for more information about these documentation requirements.

Internal medicine: Internal medicine practices must keep the following tips in mind:

  • ICD-10 defines an acute MI as one that occurs for a duration of four weeks or fewer, from onset.
  • ICD-10 no longer includes the concepts for “benign” or “malignant” hypertension. Instead, document the type and causal relationship.
  • For asthma, document the cause, severity, and any temporal factors.
  • Be on the lookout for cases of under-dosing in which a patient takes less of a medication than is prescribed. In these cases, document whether the under-dosing is intentional or unintentional, as well as the specific reason (e.g., financial hardship, age-related debility).
  • For diabetes, document the type, complication, and treatment. The term “secondary diabetes” is no longer used – instead, document the specific cause (i.e., drug- or chemical-induced, due to an underlying condition, or gestational).
  • For abdominal pain and tenderness, document the specific location and type of pain/tenderness.

Refer to the CMS ICD-10 internal medicine references for more information about these documentation requirements.

Take Action Now

Many of the diagnosis codes in ICD-10 are expanded, providing physicians with a whole host of choices to which they are not accustomed. Without proper preparation and education, practices run the risk of significant productivity loss, both in terms of code selection for clinicians and denial management for coders.

Today’s large practices must set a plan in motion and get the ball rolling on ICD-10 compliance. The larger the practice, the more complex the implementation will be. It’s not an impossible endeavor, but it’s one that will certainly require much attention over the next few months and beyond.

About the Author

Kelly Whittle, principal of Whittle Advisors, has more than 20 years of experience in key areas of the healthcare industry. At Whittle Advisors, she specializes in developing business strategies based on data-driven evidence. Her experience consists of leadership roles in healthcare product development and program management. During her tenure with Trinity Health, she led the ICD-10 physician network program, which included the development of strategic work plans, program risk mitigation, multi-year budget and program implementation.Contact the Author:

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