June 11, 2013

The Physician Delay in Embracing ICD-10: Another Perspective

By Holly Louie, RN, CHBME, PCS

The widespread lament about physicians’ lack of enthusiasm and failure to embrace and actively participate in the preparation for ICD-10 is well-documented. In addition, it is well-known that a significant percentage of current physician documentation cannot be coded to the most specific ICD-9 codes. That lack of specificity will be even more problematic with ICD-10. So why aren’t most physicians leading the preparatory charge? Why are they turning a deaf ear to the pleas for involvement? Why don’t they feel the same urgency that much of the rest of the healthcare industry is experiencing? I believe the reasons are surprisingly simple. I also believe that physicians will engage when we understand their views and speak their language: the language of patient care and reimbursement within their practice.

He said, she said

In every profession and walk of life, mixed and/or conflicting messages can be very problematic. Which message is most accurate? Which one(s) requires action? To date, on national education calls about ICD-10 physicians have heard that they do not need to make substantive changes, and that an updated superbill with their most common codes will work. Physicians also have been advised that their electronic health record (EHR) will solve all problems associated with the transition, or that a mapping program will provide a universal coding solution. Is a single one of these completely (or even partially) accurate and the final solution to ICD-10? Of course not! In direct contrast to the above promises, physicians have been told that they will need to make major changes in how they document and how they code. So, which representation(s) are they more apt to accept? The most dangerous set of conflicting messages is that you either need to prepare immediately to meet the deadline or you don’t need to do anything, because ICD-10 will not happen in 2014. The industry message to physicians needs to be clear, concise, consistent, accurate, and realistic. Anything less and there is no compelling reason for them to invest attention, time or money.

The message can be perceived as offensive

The industry has not done a good job of separating the goals of data collection via reporting for myriad purposes from delivery of quality care. Physicians focus on providing care to their patients. To them, the care they provide is virtually always medically necessary and of high quality. Payment for quality is perceived as simply payment for what they already are doing.

A message implying that you aren’t providing quality care unless you state specific elements in a medical record to allow for more specific code capture is a road to confrontation, not collaboration. If we take the time to look at the issue from the physician’s perspective, the assessment is the same, the care is the same, the diagnosis is the same, and the outcome is the same either way. Why should a few words matter, and how does that have anything to do with care for my patients? To quote one physician, “so if I actually say all these details, are you telling me my care will be better than it is now?” Perhaps even more insightful was the physician who asked if good documentation of bad care was more important than delivering true quality – and how did more specificity distinguish between the two? As an industry, we must present the need for better documentation in a way that makes sense to physicians from a perspective of care delivery. How can it help them? How can it help their patients? Simply arguing whether more is better or whether it proves quality care is a losing proposition.

Will I still get paid if I don’t make any changes?

This question has been posed by every physician with whom I have spoken about ICD-10. It is a very fair question, and a critical one. Physicians have heard that “unspecified” codes are valid in ICD-10, just as they are in ICD-9. We also know that non-specific diagnoses represent a catch-all category for many physicians. However, the key question for physicians is one of payment, not code specificity. Unfortunately, with rare exceptions, the Centers for Medicare & Medicaid Services (CMS) and commercial payers have not published a definitive answer to that question through local coverage determinations or policies. If the oft-used unspecified diagnosis codes that are reimbursed under current payer policies simply will be revised to reflect unspecified ICD-10 codes and also reimbursed once the transition to ICD-10 is made, there is seemingly little need for significant changes in physician documentation. It is merely a distinction without being a difference. Until the industry knows the answer to that question, it will be difficult (if not impossible) to engage physicians in making changes.

It’s not up to me

Physicians who employed by hospitals often have a completely different mindset than those in independent practices. Because they aren’t responsible for implementation, tools, training and education, or collecting from accounts receivable, they may have even less interest and/or concern about ICD-10. They tend to assume that the hospital will handle everything. While it is certainly true some hospitals and health systems have made major strides toward educating and assisting physicians as part of their integration and implementation plans, others have not. To again quote one physician, “I became employed because I don’t have to do anything but see patients. All the hassles are not my problem anymore.”

Summary

There is still time to help physicians understand and engage in successful ICD-10 implementation. Although it may soon be too little, too late, the industry needs to learn and speak their language – the language of patient care, practice affordability, and payment preservation. The message needs to be honest. There is no magic bullet, product or tool that will solve every ICD-10 issue. If payment models are going to change, physicians need to know the specifics now so there is time to understand, address and implement necessary modifications. And, perhaps most importantly, there must be one consistent message, not numerous conflicting ones.

About the Author

Holly is a member of the Healthcare Billing and Management Association (HBMA) and chairs the ICD-10 Committee.  The committee developed definitions for readiness and end-to-end testing for successful ICD-10 implementation.

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