July 31, 2013

Physician Practice Costs for ICD-10: Clinical Documentation

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Physician offices are inching slowly toward ICD-10—very slowly. A recent survey of 1,200 practices conducted by MGMA reveals that loss of physician productivity, staff efficiency, and changes to clinical documentation are still major concerns.i

While MGMA and the physician community at large are reluctant to implement ICD-10 (and have raised many roadblocks to its progress), the organization’s May 16, 2012, letter to CMS provides valuable guidance regarding the six key areas of cost impact to watch.ii

MGMA advises ICD-10 will add significant costs for physician practices and clinical laboratories in these six areas:

  • Staff education and training
  • Business-process analysis
  • Changes to “superbills”
  • IT system changes
  • Increased documentation costs
  • Cash flow disruption

The association suggests costs for physician practices to convert from ICD-9 to ICD-10 range from $83,290 for small practices to $650,000 for large groups (those with more than 100 physicians). Independent practices will foot their own bills, while hospital-owned or affiliated groups may ultimately receive outside support. Regardless of who pays for ICD-10, the biggest chunk of change will be spent on increased documentation, cash flow disruption, and IT costs.

This article is the first in a series to further explore these expenses, propose cost-saving solutions, and put forth best practices regarding physician practice preparations for ICD-10. This month I’ll address the costliest line item on MGMA’s ICD-10 budget—changes to clinical documentation.

Tackling Changes to Clinical Documentation

The need for increased clinical documentation for ICD-10 is a global concern. Every stakeholder and trading partner in healthcare’s revenue cycle understands that clinical documentation must be more granular to meet ICD-10’s coding, billing, and quality reporting requirements. In fact, this added level of documentation granularity drives nearly all the expected benefits of ICD-10 coding.

It’s predicted by MGMA the cost will be anywhere from $44,000 to $178,500 per practice, and 2013 is the year to begin assessing documentation and identifying gaps. Physician practices should begin this effort now by taking the following four steps: assess, implement, monitor, and support.

Assess Documentation

Ongoing clinical documentation assessments should already be underway as part of a physician practice’s compliance and quality improvement process. Documentation assessments done now for ICD-10 also help to improve reimbursement under ICD-9. No need to wait 18 months to see the results; documentation assessments deliver return on investment now.

In her April 2013 AHIMA webinar on Improving Physician Documentation, Deborah Robb, BSHA, CPC, Physician Management Consultant for TrustHCS, lays out the most common “gotchas” of poor documentation in physician practices:

  • Learned or acquired bad habits
  • Coding and billing misconceptions
  • EHR technology gaps

She suggests that assessments are ICD-10’s mandatory first step. “Practices shouldn’t proceed down the path toward ICD-10 implementation without first assessing their current clinical documentation to ensure that every visit meets clinical indicators and medical necessity criteria,” states Robb. And while ICD-10 documentation changes are specialty-specific, three questions should be asked of each and every group:

  • Are complications and chronic conditions documented properly?
  • What are the practice’s top denials and reasons for denials?
  • How do your denial rates compare to those of your peer group?

 


 

Implement Education

With documentation gaps identified, the next step is to conduct ICD-10 education. Physicians and office staff must understand the new ICD-10 requirements for their specialties and unique patient mix.

Comparison data from other practices and/or peer groups is extremely valuable. And physicians react better to real ICD-10 codes derived from their own, current charts—not mapping or modeling. Show physicians and staff very specific cases where dollars will be left on the table under ICD-10 because of incomplete documentation.

Evaluation and Management (E&M) code leveling will occur. Under-documenting is just as fraudulent as over-documenting. The goal is always to produce complete, accurate, and relevant documentation for each and every visit.

Finally, in-person education is optimal with physicians through short diagnosis-specific or procedure-specific workshops backed by multimedia support, such as mobile reminders or prompts, cheat sheets, and other tools. Again, focus must be on documentation needs by specialty. More time—and a broader base of education—is needed for internal medicine, general practice, and family practice groups.

Monitor Progress

Monitoring of clinical documentation changes in advance of ICD-10 is part of the same ongoing assessment process mentioned above. Monitoring should be physician-specific, and corrective action should be taken at the clinician and/or specific ancillary staff level. The focus should be on understanding the documentation and coding problems that physicians face, and then innovating new processes and procedures to support them.

Support Clinicians

Physicians are going to face hefty challenges with coding and documentation in ICD-10. They represent the “human” side of ICD-10 and require additional support and helping hands. During the recent HIMSS ICD-10 Forum, the following physician support tasks were identified and discussed:

  • Update all EHR documentation templates for ICD-10 now, specialty by specialty.
  • Make other staff members and clinical professionals within the practice part of clinical documentation; help physicians with their charting needs.
  • Reduce documentation burdens wherever possible, including the use of technology (upload data from other systems to contribute to documentation).
  • Explore the Snomed-ICD-10 crosswalk requirement of Meaningful Use (may be easier for physicians than ICD-10).

Another support mechanism currently being explored and implemented is the use of medical scribes. Practices can employ medical scribes directly or recruit them from existing medical transcriptionist ranks. Scribes focus on capturing all necessary information by recording details of the patient episode during the visit, thereby allowing the physician to focus purely on face-to-face patient discourse.

Physicians Get Ready

Physician practices are ready for what’s now. But are they ready for what’s next? MGMA’s recent survey and 2012 HPID letter provide key areas for focus and targeted attention over the coming months. Using their resources, I’ll continue to explore top expenses and provide guidance for physician practices.

About the Author

Torrey Barnhouse is the founder and president of TrustHCS, a firm dedicated to serving the coding, auditing, ICD-10 preparation, clinical documentation, and revenue integrity needs of healthcare organizations. Currently, Torrey serves on the AHIMA Foundation Board and the Remington College HIM National Advisory Board. He is a national speaker and author on a number of industry-related topics. He holds a bachelor’s degree in psychology from Abilene Christian University.

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i ““ICD-10 Implementation Study, June 2013”. Legislative and Executive Advocacy Response Network (LEARN), MGMA. Available online at: http://www.mgma.com/WorkArea/DownloadAsset.aspx?id=1374753

ii “HPID Comment Letter to Marily Tavenner, May 16, 2012”. MGMA. Available online at: http://www.mgma.com/workarea/downloadasset.aspx?id=1370843