As the deadline to convert to ICD-10-CM codes approaches, don’t get caught unprepared for the transition. This author delineates important differences between the ICD-10 and ICD-9 codes, and offers pointers on what you need to know to update your coding in order to receive full reimbursement in the future.
As part of the final rules of HIPAA Administrative Simplification to Medical Date Code Set Standards, ICD-10-CM was initially adopted in 2009 with a mandatory compliance date of October 1, 2013. Health and Human Services Secretary Kathleen Sebelius recently announced the postponement of the date of implementation for ICD-10 to October 1, 2014. We can all take a deep breath now.
Still, given the magnitude of the forthcoming changes, it is highly advisable to start working now to get your practice ready to meet the actual deadline in 2014.
Why are ICD-10-CM diagnosis codes so important to practitioners? Having 68,000 codes now available, we will or should be able to tell a more complete and accurate story regarding a patient’s specific encounter. Many of the entities we deal with, such as the Centers for Medicare and Medicaid Services (CMS) and insurance payers, noted that ICD-9-CM codes lack specificity and detail in the claims we submit currently. The ICD-9 codes fail to give a full picture of the specific encounter and we often repeat diagnoses on follow-up examinations. Additionally, we may not be selecting diagnosis codes to the highest specificity and/or fully support medical necessity for the encounter we are billing for. Also, ICD-9 is running out of codes to keep up with newly developed advances in technologies and new procedures as only 13,000 codes are available.
All payers are seeking more precise quality data as we move into the “pay for performance” arena in healthcare. How does this relate to new devices and treatment modalities? While most companies with new devices claim that their products are superior in comparison to their competitor’s products, I have not encountered many, if any, products that have statistical data to provide cost to benefit/outcome evidence. This makes it difficult for payers to determine if they should continue to cover the item or procedure, and compare the benefits of different technologies. Finally, the United States cannot compare its data and outcomes with other countries to determine how it is doing in providing quality healthcare services when we are using a different system from the rest of the world.
The belief is that ICD-10 will reflect each patient encounter more accurately, describing underlying causes of disease and explaining complications of care provided. All of this goes toward providing supporting documentation for medical necessity, coverage for payment, statistical tracking of the practice and the practitioner, the type of treatment or procedures performed, and tracking the incidence of disease. Payers would accordingly be able to match the ICD-10 codes to the procedure(s) and products billed, and thus be able to “audit” services provided for easier bill verification.
This should not scare us. We generally are already doing the things we need to do to document the services we are providing. We now have the opportunity to improve our documentation process. General coding guidelines require providers to use appropriate codes to identify diagnoses, symptoms, conditions, problems, complaints or reasons for the specific encounter. We use signs and symptoms when we have yet to determine or confirm a definitive diagnosis. With the numbers of codes available with the ICD-10 codes, we may not need to use codes for signs and symptoms as often as more specific codes are likely to be available.
So why wait until January 2014 to start getting ready to implement ICD-10? We must start looking at how we are documenting and the processes within our office so that we can refine and develop an implementation plan.
Let us first look at the structure of our current ICD-9 coding in comparison to the new ICD-10-CM structure.
The ICD-9-CM code conveys the category of code as well as the etiology, anatomic site and manifestations. The ICD-10-CM code will cover the category of code as well as the etiology, manifestation and severity along with an extension.
General equivalence mappings can assist in converting a code in ICD-9 to ICD-10. However, there may not be a direct one-to-one translation of codes from ICD-9 to ICD-10.
Let’s look at a few examples (see “Comparing ICD-9 to ICD-10 For Common Diagnoses” at right)
As you can see from the examples provided, we will have a learning curve as we switch to the ICD-10-CM codes. This will require that we train all of the staff involved in billing, coding and contracting, and we will need to review our current business practices as well as we move to the new system. It is not as simple as memorizing new set of diagnosis codes.
I offer a to-do list that I am using to develop my ICD-10 implementation plan. I believe this list has helped me to stay organized and I feel I can complete the transition without last-minute anxieties.
1. Organize a team to lead the process. I will be meeting with my billing supervisor and practice administrator once a month to stay focused and meet set deadlines.
2. Assess the practice’s business and clinical impact. Identify areas of business that will be impacted, whether the patient flow will be impacted and if there will be a loss of productivity.
3. Start discussions with software vendors to implement or update electronic health records (EHR) and practice management systems. Test the systems before the “go live” date. Remember that there will be an overlap period in which you will need parallel systems to handle both ICD-9 and ICD-10. Can your vendors and hardware handle the needs of the dual systems?
4. Are there documentation gaps or other gaps within the practice? These include the time you will need to set aside for training necessary staff on codes and documentation needs.
5. Develop timelines with “due dates.” Identify targets or markers of success and forward progress. Hold specific staff responsible for specified tasks.
6. Have a training plan and train everyone involved or impacted in phases. This is particularly import for physicians as we are often the ones to show more resistance. Realize that training will have a financial component in either purchasing training and/or time that the office is not producing income when staff is training.
7. Work out a budget to get the transition complete on time. You may need to upgrade or purchase software as well as hardware. Training will incur a cost as will any new forms and documentation processes that will need to change.
8. Discuss and review contracts with payers and vendors. Make sure they will be ready to meet their obligations and that you will not be penalized should the contract language not provide protection for you or is only one-sided. One of the biggest questions that I came up with during this review process is whether my contracted insurance company will be ready to receive claims using the ICD-10 codes and how it will deal with claims submitted the day before the implementation date should these claims require appeals or resubmissions. Also, do the practice management and EHR vendors have a plan for the conversion and how much of the cost will they pass off to you? You will need a parallel system for at least one year from implementation to deal with older claims. Keep this in mind.
9. Review practice workflow and business processes. Take a look at charge tickets (superbills), fee schedules and other business forms that may require updating.
Although this may seem like a daunting task, it appears we now have an additional 24 months to get this done. The old saying of how do you eat an entire elephant — one bite at a time — seems most appropriate for the task at hand. If we have a plan and we work the plan in small bites each week, month and year, we should be ready to hit the starting line — or in this case, the finish line — running rather than trying to leap a massive distance in a single bound.
Let us take a look at a few case scenarios to see what our coding might look like. I would like to direct your attention at how the wording of the documentation will help or hinder how we now need to choose the ICD-10 codes.
Case one. A 40-year-old male presents for an initial visit with an injury to his right great toe, which occurred as an object crushed the toe. The past medical history is without significant findings.
Appropriate ICD-10-CM code: S97.111A
S97.111 = right hallux, crush injury
This base code S97 requires a seventh character so:
A = initial encounter
D = subsequent encounter
S = sequelae
Case two. A patient presents to the office with a history of type 2 diabetes. He has been taking insulin for many years. There is a midfoot ulcer of the right foot. The examination reveals that the ulcer is superficial in which only the skin is injured.
Appropriate ICD-10-CM codes: E11.621, L97.411, Z79.4
E11.621 = type 2 diabetes with foot ulcer
L97411 = ulcer on the right midfoot. This code is needed in addition to the diabetes code to identify the site of the ulcer and that it is superficial.
Z79.4 = long-term use of insulin
You might ask why it matters that the patient is using insulin. This history can explain the complexity of the patient’s medical status and the risk level of complications as they relate to the foot ulcer.
Case three. A 72-year-old male presents to the wound care center with a stage 4 pressure ulcer on the left heel. His past medical history is significant for severe peripheral artery disease and cerebrovascular accident without residual complications.
Appropriate ICD-10-CM codes: L89.624, Z86.79, Z86.73,
L89.624 = pressure ulcer to the left heel
Z86.73 = history of stroke without residual complications
Z86.79 = history of peripheral arterial disease
Case four. A 65-year-old male presented to your partner with ulcers to the lower legs of six years’ duration. The patient weighs 450 lbs. His past medical history includes hypertension, deep vein thrombosis, venous insufficiency, coronary artery disease and chronic anemia. Your partner has performed split thickness skin grafts on these venous insufficiency ulcers. You are seeing this patient while your partner is on vacation. This is the eighth visit for this patient, who now presents with a healed graft.
Appropriate ICD-10-CM code: Z48.817
This encounter is for surgical aftercare of the skin and subcutaneous tissue.
It does appear the Z code section is somewhat equivalent to the V code section in ICD-9, which covers factors influencing the health status of the patient during an encounter with the health system.
I am suggesting to all practitioners to start looking at or auditing current patient notes/documentation so they can identify areas where improvements are required as part of the implementation plan to convert to the ICD-10-CM coding system.
Dr. Aung is in private practice in Tucson, Ariz. She is a Certified Professional Medical Auditor, a Certified Surgical Foot and Ankle Coder and member of the American Association of Professional Coders. She is also a panel doctor at Carondelet St. Mary’s Advanced Wound and Hyperbaric Center. Dr. Aung serves on the Examination Committees for both the American Board of Wound Management and the American Board of Podiatric Medicine.
For further reading, see “Pertinent Insights On Coding For Wound Care” in the July 2012 issue of Podiatry Today or “How To Get Optimal Reimbursement For Wound Debridement And Skin Substitutes” in the September 2012 issue. To access the archives, visit www.podiatrytoday.com .