July 2, 2013

The ICD-10-CM Transition Is Like Learning to Drive

By

In the near future, inexperienced practice managers who don’t have much formal coding training may be exposed to ICD-10-CM for the first time. They tend to ask the questions: “Why is this such a big deal? Isn’t this just a new diagnosis code set?” But one might as well ask: “What’s the big deal? Isn’t this just like moving to Europe and always driving on the other side of the road?”

 

Sure, it looks familiar in that numbers are numbers and cars are cars, but the new code set will affect every bit of a healthcare operation. Practices cannot afford to be careless with ICD-10-CM, just as drivers should learn the rules before turning into traffic or negotiating a roundabout in a busy street in Paris.

The migration from ICD-9-CM to ICD-10-CM is one of the most significant healthcare developments in recent history. As with any dramatic transformation, work needs to get done while providers still strive to avoid the loss of things that businesses depend on (such as revenue stream). When the time comes to actually start using ICD-10-CM, a clear plan should include asking the right questions. Practice managers need to think through the transformation rationally, plan specific steps, and execute the steps according to a schedule. The purpose is to look ahead and estimate points of greatest exposure, then plan to mitigate associated risks.

Often, simple steps taken at the appropriate time can prevent a world of hurt. Some points and questions to consider:

  • Switching from ICD-9-CM to ICD-10-CM opens up a world of tens of thousands of new diagnosis codes. But does that equate to documenting exciting new detail that can allow for the providing of services that previously were out of reach because documentation was unclear? Or is it more like dozens of new potholes that can knock a medical practice out of alignment?
  • ICD-10-CM offers a highly organized new structure of diagnosis codes. Does this mean that it will be easier to find the correct code, or harder?
  • ICD-10-CM offers new coding rules. This has the potential to simplify issues such as bundling and edits. Yet on the other hand, will it make it even easier to miscode?
  • ICD-10-CM offers an updated medical vocabulary and lots of new terms. Is this an opportunity to re-sync with the rest of the industry, or does it represent a training burden?

No area in any practice will emerge completely untouched by the transition to ICD-10-CM. Procedures that previously were unrecognized now may be reimbursed based on reportable diagnosis codes. On the other hand, if procedures previously were justified using a standard argument based upon some research or clinical study regarding an ICD-9-CM diagnosis, that strategy may be invalid. The documentation may no longer map to an approved code.

The ICD-10-CM transition period is likely to be a challenging time for healthcare providers because many third-party payers will need to update the rules used to adjudicate claims. Medical necessity is established by the selection of diagnosis codes, and some payors will use this opportunity to formulate plans to reduce reimbursement payments. Being prepared may help practices have responses ready so they are not caught off-guard.

How can practices mitigate the risks brought about by this impending change?

  1. Communicate regularly with anyone who may be in a position to affect your practice in a negative way. This includes insurance companies, politicians, creditors — a little advance warning will make it harder for anyone to pull the wool over your eyes, as long as communication happens on a regular basis. Remember the old adage, “Keep your friends close and your enemies closer.”
  2. Watch for payers who try to change terms. The turbulence of the transition represents an opportune time for unscrupulous operators to “update” contracts. Don’t skip the fine print, which may include further payment restrictions or rules that may adversely affect practices.
  3. Keep a cash reserve to tide over your practice when something goes wrong and payments get interrupted. If maintaining savings is not a viable option, consider a line of credit or a credit card dedicated for the purpose. Don’t retire the card or credit line until the possibility of crisis is well past.

Driving in Europe is not impossible, but it is much easier with a little preparation. Learning the laws and regulations may take some time and rigorous study. Yet drivers will gain more skill with experience. Likewise, practice managers already may know how to “drive” ICD-9-CM. That will go a long way towards learning the ways of ICD-10-CM, and if the right questions are asked and a plan is put into place, the ride may even be fairly smooth.

 

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.