Updated on: March 14, 2016

Party with ICD-10: Who Else Do Clinicians Need To Worry About?

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Original story posted on: July 29, 2013

On December 21, 2012, some say, the Mayan Calendar predicted the end of the world. Something similar happened a decade ago because of Y2K. People all over the world decided to throw parties during their last moments on Earth. Perhaps September 30 is a good day for coders and clinicians to get together and have one big last hurrah.

 

There could be a heartfelt goodbye to ICD-9; perhaps, a moment of silence. Then, at the stroke of midnight, everyone could comfort each other when their computers go up in smoke as they try to process ICD-10 codes.

Actually, this article is about a different kind of party. There are many parties outside of the clinic who are invested in the ICD-10 transition. Here are a few things physicians should consider as they deal with these parties while making the transition next year to the new diagnosis code set.

Software

The very structure of ICD-10 means the fields in software programs must change. The codes will be alphanumeric and take up to seven character spaces, and the logic of how they are used will all need to be accounted for. This applies to any software used by clinics or vendors that currently contain ICD-9 codes. With just over a year to go, it is advisable to place a call to software vendors and ask what they are doing to ensure a smooth transition. A few sample questions to ask:

  • Can the system handle alphanumeric structure?
  • Does the code format include a decimal? What is the character length specification?
  • Can the system house both ICD-9 and ICD-10 codes?
  • Will the system be able to map forward from ICD-9 to ICD-10 and backward again if you need to keep historical data?

Some vendors may charge for an upgrade; others may already have it set up. These are budget considerations that can be significant. There are a number of systems in a typical clinic that are worthy of some scrutiny:

  • EHRs
  • Billing systems
  • Clinical systems
  • Code look-up software
  • Medical record abstraction systems
  • Scheduling and registration systems
  • Accounting systems
  • Clinical protocols

Health Plans

One fear is that the office may be ready, but the health plans that play such a large role in the cash flow of a healthcare provider’s clinic will not. This may result in delayed reimbursement and increased denials. The most important question for these parties is, “Which codes will they recognize?” This will shape many of the other changes that need to be made by clinicians and staff. Rumor has it that Medicare will make LCDs for most specialties available by October 2013. These LCDs may list the ICD-10 codes private payers will use to come up with their list codes that meet the definition of medical necessity. It would be wise to stay in contact with each payer who does business with the clinic as the transition draws nearer. Many may offer new contracts, so this may be a good time re-evaluate these agreements. Consider the following steps:

  • Identify contracts in which reimbursement is tied to particular diagnoses
  • Contact payers and discuss potential changes to existing contracts
  • Determine timing of contract negotiations
  • Modify agreements as needed
  • Communicate contract changes to staff

Current medical policy is based upon ICD-9 codes and nomenclature. Since ICD-10 contains greater specificity, it is anticipated that most health plans will require more detail in reporting and claim submission. Unspecified codes will likely result in a denial, or at least a review.

Internally, the biggest concern may be new documentation requirements, but a little diligence and preparation can overcome that hurdle. Externally, there may be dozens of parties who do business with a typical clinic that have their own hurdles to overcome. Unfortunately, providers and coders have little control over the actions of these other groups. The best they can do is to prepare themselves, and then reach out to these outsiders and pester them until it is clear that they are ready to join the party.

ICD-10 certainly won’t be the end of the world, but it is still a good idea to party with those who are prepared.

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.
Evan M. Gwilliam, DC, MBA, BS, CPC, CCPC, CCCPC, NCICS, CPC-I MCS-P, CPMA

Evan M. Gwilliam, DC, MBA, BS, CPC, CCPC, CCCPC, NCICS, CPC-I MCS-P, CPMA, executive vice president of ChiroCode and Find-A-Code LLC, graduated from Palmer College of Chiropractic as valedictorian and is a certified professional coding instructor, medical compliance specialist, and professional medical auditor, among other things. He provides expert witness reports, medical record audits, consulting, and online courses for healthcare providers. He also writes books and articles for trade journals and is a sought-after seminar speaker. He has a bachelor’s degree in accounting and a master’s of business administration, and he is one of the few clinicians who is a certified ICD-10 Instructor and certified MACRA/MIPS healthcare professional.