June 2, 2014

ICD-10: Physician Engagement: Managing the Delays

By

On April 1, 2014, when the Protecting Access to Medicare Act of 2014 (Pub. L. No. 113-93) was enacted, most of us were caught off-guard. Along with once again patching the SGR methodology for physician payment, ICD-10 implementation was delayed at least until October 1, 2015. On May 1, CMS announced it would be publishing an interim final rule including a mandatory compliance date of October 1, 2015.

This delay has considerable impact on the issue of engaging physicians for the transition. Let’s be optimistic and start with the positives. Hospitals and health systems will have an additional year to prepare and test technologies and organizational infrastructure and provide additional education for coders, clinical documentation specialists, and other staff. Additional time will also be available for physician education. In fact, most hospitals are moving ahead with their ICD-10 planning, though there is more flexibility for implementation timelines. That’s the good news.

Interestingly, the biggest challenge for successful implementation of ICD-10 for hospitals may not actually be within their walls. Particularly for those with significant percentages of the medical staff who are not employed, the greatest challenge will likely be getting those physicians to prepare before it is too late.

Can we expect any physicians to expend the resources to prepare for ICD-10 in an environment where “final” actually means “maybe, likely, sort of, definitively, for sure, unless” and the reliability of any specified final date depends on the whims of a Congress which makes healthcare decisions based on political whims? If you are interested, descriptions of the way the above act was introduced and voted on with no discussion make for fascinating reading. You should also know that there is still proposed legislation floating in the Capitol that would ensure that healthcare providers would not be required to transition from ICD-9 to ICD-10. This legislation introduced by Senator Tom Coburn of Oklahoma, S. 972, on May 16, 2013, was referred to the Senate Committee on Health, Education, Labor, and Pensions.

So how are hospitals and health systems dealing with these issues? First, it appears that most are proceeding with their implementation plans. The reasons are logical. For example, coders and other staff already trained in ICD-10 must “use it or lose it.” While timetables have been altered, most hospitals want to continually refresh coder knowledge. I won’t delve into the myriad of processes that must be addressed, but suffice it to say, transition plans are generally going forward. But what about physicians?

Interestingly, physician education for ICD-10 is one area where academic medical centers are better situated than the typical community hospital. There are a couple of reasons. One was recently articulated to me from an internist on the faculty of a teaching center. After discussing specific ICD-10 examples for multiple specialties, he stated, “I finally get it. ICD-10 specificity is exactly what I would expect from a resident in morning report.” And yes, he does get it. For example, in my specialty (orthopedics), I would expect a resident describing a pediatric epiphyseal fracture to not only describe laterality and location, but also the Salter-Harris classification. Similarly, for open fractures, the resident is expected to describe once again laterality and location, but also the Gustillo classification of open fractures. Is this specificity highly relevant to dermatologists? Not so much.

Additionally, members of the academic faculty also are more aware of the benefits of ICD-10 for epidemiology and clinical research. In terms of office practice, the majority of academic teaching physicians is more closely aligned with the health system, often as employees, and benefit from ICD-10-compliant IT infrastructure.

But what about community hospitals? Here the challenges are more substantial. The typical physician attitude is an unpleasant blend of anxiety and apathy. Can we really advocate that a small primary care practice spend more than $100,000 (which would not be unusual for ICD-10 readiness), when Congress considers critical clinical infrastructure to be a political poker chip? To say that physicians don’t believe that the new deadline will necessarily be reinforced is an understatement.

So what can we expect as an outcome? First, many physicians will not prepare their offices in a timely manner for ICD-10. It is reasonable to postulate that more physicians will be unprepared for the 2015 go-live date than would have been ready for the 2014 date, since Congressional integrity is more dubious.

How can hospitals proceed? After lengthy discussions with numerous hospital leaders, several trends are emerging. In collaboration with the new timelines for ICD-10 rollout across the hospital, physician leaders are advocating educating the medical staff on ICD-10 from a clinical perspective. That is: Isn’t it clinically better to describe laterality, anatomic specificity, etiology and/or manifestation, using terminology now accepted in our literature? Approaching the medical staff from this perspective makes common sense. There is a much higher level of confidence in this strategy in those facilities with “physician engaged” CDI programs where there is already strong physician leadership and a clinical rather than a billing focus.

As far as the private practice situation, there aren’t a lot of good solutions and each medical community is going to have to individually assess risks, opportunities, challenges, and economic models. Does the hospital have the capacity, regarding private practitioners, to provide ICD-10 physician education, IT infrastructure, staff education, etc., or even anticipate a tremendous influx of employed physicians?

These considerations are complex and require input from legal counsel, but should be part of any organization’s ICD-10 transition planning.

Dr. Paul L. Weygandt is the vice president physician services for Nuance. A nationally recognized speaker and author, he has developed approaches to physician documentation, assisting physician leaders in communicating the importance of accurate, legally compliant clinical documentation.  Dr. Weygandt is also a lawyer, a certified coder and an AHIMA-approved ICD-10-CM/PCS Trainer.

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. Paul is vice president of physician services for J.A. Thomas & Associates (a Nuance company). He is also an AHIMA-approved ICD-10-CM/PCS trainer.

Contact the Author

To comment on this article please go to

Paul Weygandt, MD, JD, MPH, MBA, CPE