Most small-to-medium medical practices are struggling just to keep up with the changes taking place in healthcare today.

As I work with larger hospital systems and small-to-large physician practices, I can see that the challenges associated with moving toward ICD-10 implementation are most daunting for the small physician practice. Large hospitals and physician practices typically have the resources necessary to get ready for ICD-10, but what about the smaller practices? Many do not have the staff or resources. 

 

Small physician practices are struggling with transition to electronic health records (EHRs), Meaningful Use, reductions in revenue, and increased scrutiny by insurance carriers, including Medicare and Medicaid. Physicians have consistently struggled with managing patient care while also addressing all of these administrative burdens. Isn’t the focus of good medical care supposed to be the patient?

Physicians are frustrated that the patient is no longer the sole center of attention. A physician goes to medical school to help patients and manage their care, and now that seems to have taken a backseat to all of these other issues. No wonder they are hanging back and not spending the necessary time to get ready for ICD-10 – it is not their top priority.   

So, what are some key issues small physician practices need to focus on to get ready despite limited resources and staffing? There are several areas they can concentrate on during the next several months.

As with large physician groups, take a step-by-step approach so the task is not so daunting.

  1. IT Systems: A variety of systems, including practice management, electronic health records, and billing, must be upgraded and modified to support ICD-10. Contact each of your system vendors to make certain you systems have been upgraded and tested for ICD-10. If this has not been completed yet, get a firm deadline. 

Many vendors have been working tirelessly to get systems upgraded, but many managers of EHRs have not built logic trees to drill down to the appropriate specificity when selecting an ICD-10 code. Discuss this with vendors to make certain they are going to provide you with this needed enhancement.

  1. End-to End Testing: Contact your top 10 insurance carriers to get on their schedules to test end to end. End-to-end testing ensures that your claims will be accepted with the new ICD-10 format. This is the most important task necessary to ensure that you will receive payment when ICD-10 is fully implemented. Many insurance carriers are now accepting practices to test with.

 Unfortunately, one of the problems associated with end-to-end testing is that all payers will test with every medical practice they deal with – so the sooner you request, the better chance you have to be included in this important process.

  1. Practice Assessment and Gap Analysis: Understand where your practice stands on required tasks in order to achieve compliance. List the top 25 ICD-9-CM codes you utilize most by running a utilization report with your practice management system. From there, pull 10 records per practitioner and perform an ICD-10 readiness audit. This audit will focus only on conditions treated in the medical practice. In a small practice, if you cannot afford to hire a consultant to do this analysis, you can perform a peer analysis. Each physician can review 10-15 medical records and map the ICD-9 codes to ICD-10 in order to determine if the documentation will support a more specific code.

In my experience auditing medical records, you will find the need for smarter documentation to support ICD-10. This should be the focus of your efforts in getting ready. From this point you can determine where documentation needs improvement.

  1. Documentation: Clinical documentation improvement helps prevent high ICD-10-related denial rates and supports improved compliance. It might be beneficial to look at your EHR templates and make some modifications to improve ease of use as well as documentation. One of the issues I find is that the EHR pulls the data from the problem list, which is not always accurate. The assessment and plan of care is where the diagnosis should be derived from, based on the reason for care. Many built-in templates don’t really meet the needs of physicians. Another suggestion is to look at what additional information is necessary to report a diagnosis to a higher level of specificity. In many instances one or two words can make a difference. 

There are many educators providing documentation training by specialty to prepare physicians for producing the documentation necessary for ICD-10. Many provide this service at a very reasonable cost. It is worth the investment to ensure proper payment and compliance.

  1. Education and Training: Significant time and effort will be required to bring coders and physicians up to speed on the new ICD-10 requirements, which will include new code sets, required documentation, technology, and more. It is important for the small medical practice to investigate training options in your area of speciality. Make certain the trainer is qualified and experienced in ICD-10 coding. Budget to send all the physicians and coders/billers in the practice to at least a day or two of training, based on specialty.

Plan for training at least 4-5 months prior to the advent of ICD-10. There will be a shortage of available training if you wait too long.

  1. Contracts and Coverage Determination Analysis: Health plans will likely modify coverage determination policies and reimbursement schedules, and contracts may be alteredIt is important to review the coverage policies as soon as possible. Many of these policies are available on each insurance carrier’s website.

 Have one member of your staff begin reviewing medical policies relative to the service you provide to see what diagnosis codes support medical necessity with ICD-10. Create a simple Excel spreadsheet with any changes to which you need to pay attention. Communicate the changes with all the practitioners in the practice. It might be a good idea to hold a staff meeting once a month until after the transition in order to discuss coverage with your top insurance carriers and any coverage changes that might affect the practice.

  1. Transition Planning: Plan for a disruption in cash flow for a specific period of time. It might be beneficial to obtain a line of credit to help during the transition. Continue to review documentation to ensure that specificity can be realized to support the specificity requirements of ICD-10. Keep in mind that productivity can be reduced significantly during the learning process, which can create a potential backlog in cash flow. Assess whether coding assistance might be needed during the transitions.

A few closing words of advice: assign one person in the practice to lead the ICD-10 project to ensure cohesiveness. Choose someone who is focused and can execute well and communicate effectively. Taking things one step at a time will keep the challenges less daunting and will help you move in the right direction toward a successful transition to ICD-10. Rely on industry experts to assist with your transition to ICD-10. Yes, this will be a difficult challenge, but organization and focus is the key to success.

Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner

Deborah Grider has 34 years of industry experience and is a recognized national speaker, consultant, and American Medical Association (AMA) author who has been working with ICD-10 since 1990. She is the author of “Preparing for ICD-10, Making the Transition Manageable,” “Principles of ICD-10,” and the ICD-10 Workbook, among many other publications written for the AMA. She has assisted hospital systems and physician practices in transitioning and understanding ICD-10 for many years. She is a senior healthcare consultant with Karen Zupko & Associates and a clinical documentation improvement practitioner helping physicians improve clinical documentation among all specialties.

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