Why ICD-10 concerns me deeply

If you’re a practicing provider, chances are you still feel some anxiety about several issues related to the ICD-10 transition that are critical for maintaining the health of your practice. These probably include reimbursement, documentation workflows, potential audits, and claims denial.

As a family medicine provider, what I hope to see develop is the opportunity for providers to encourage payers to be more transparent about topics like the level of coding and documentation detail they’ll require so that physicians can reflect on them and ensure they have the appropriate internal systems built.

This will be a painful process and could potentially have a negative effect on clinical decision-making and patient care. That concerns me deeply.

Simply put, providers don’t want to create unnecessary systems of documentation that mean more clicks, burdensome workflows and highly detailed use of the new code set if they don’t absolutely need to. Increased transparency on the part of payers would go a long way toward easing the aforementioned concerns. Because right now, providers are waiting for payers to put their stakes in the ground and say, “These are what our rules are and this is what we’re going to be looking for when we review your clinical documentation.”

The opportunity for all of us is to create an atmosphere where providers and payers can have honest conversations that move ICD-10 transition planning out of the conjecture stage. Providers need to know exactly what to expect from their payers. If you think of it as a partnership, then providers don’t want to get too far ahead without knowing payers’ plans, and payers want to know what’s reasonable for them to expect of physician practices. The common enemy is an unhealthy percentage of denied claims, because in that situation, no one wins.

Looming over all of this is the Oct. 1 deadline that the Centers for Medicare & Medicaid Services (CMS) has established, a hard stance that now looks like a mistake. A phased rollout of ICD-10 might have prevented the current situation where much of the preparation is happening at once and has providers scrambling. Given the assumption that CMS will not push back the deadline, Oct. 1 could very well be a kind of big bang in healthcare.

On Oct. 2, many practices may have to cope with delayed claims reimbursement and a flood of questions about which ICD-10 code is the right one. There may be a mass denial of claims and in the following days, weeks, and months, a lot of confusion as providers seek reimbursement. These issues could extend beyond practices to healthcare organizations such as imaging centers and laboratories that might not be able to fully accept ICD-10, forcing providers to submit ICD-9s and ICD-10s at the same time.

If a provider practice hasn’t completed its testing, staff training and development of new documentation workflows by the October deadline, then they’re going to experience greatly impaired efficiency for a long time afterward. This will be a painful process and could potentially have a negative effect on clinical decision-making and patient care. That concerns me deeply when it comes to ICD-10 because many of these problems can be prevented by increased transparency by payers.

It’s unrealistic to say that all of these problems will become avoidable thanks to meetings and conversations at health IT events throughout 2014. Transparency by payers and honesty by providers can help ease the burdens that ICD-10 will place on the industry over the coming months and after the October 1st deadline. It’s not a stretch to say that both payers and providers can make more progress toward successful ICD-10 transition together than they can alone.

Brian Anderson is a family physician and senior manager, clinical content, athenahealth.  He can be reached on Twitter @bandersmdThis article originally appeared in athenahealth’s Health Care Leadership Forum.

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  • Stewart Segal

    Once again, providers can expect to get screwed! Payors will use the complexities of the new coding system to delay or deny payment for services rendered, maximizing the payor’s provide at our expense!
    Yes, it will be a big bang. Actually, it will be a gang bang! Everyone except the insurers of America and Medicare will pay a huge cost for this abomination.

  • southerndoc1

    I don’t get the concern about what degree of documentation will be required under ICD-10. Documentation will still be done according to CPT guidelines, and they’re not changing. ICD-10 is just about the diagnosis (not that I’m a favor of moving to the new codes – I think coding will actually become less, rather than more, accurate).

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      I think the ICD is used to determine medical necessity for the CPT, so if the ICD is more granular, there is a more granular way to decide that the CPT is not necessary and therefore will not be paid. Referencing Jason’s example of a laceration, perhaps we will be witnessing the insanity of paying for 3 stitches, but not for 5 stitches, or other crazy things like that.

      • southerndoc1

        But for E&M codes (the vast majority of primary care charges) documentation will still be the same, won’t it? It’s just picking the ICD code that will be more tedious and more error-prone.

        • FEDUP MD

          Yes, but this is at the expense of likely having many claims rejected for random reasons. For example, in my peds subspecialty, if you code ADD at any point, you risk getting the claim rejected because it is a “mental health diagnosis” and we are not psychiatrists, even if the ADD code is relevant to the main code we submit. So we have a lot of kids with work around codes…..

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Yes, primary care will most likely the least affected by the new complexity.

          • Deceased MD

            Least affected? How so?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Because primary care uses mostly E&M and there really isn’t an ability to tie office visit CPTs one to one with ICD codes through medical necessity rules, like they can, and will, do with more procedural CPTs.

          • southerndoc1

            We’ve already tied our 100 top diagnoses to the broadest, most non-specific ICD-10 codes. Also, as our payment doesn’t depend on population ratings, instead of, as we now do, use six or seven ICD codes per visit, we’ll only use one or two. The quality of data will be much worse.

          • annette ciotti

            can they still nail us for “such and such a lab won’t be covered for such and such a dx” though. Already a problem. True, it’s probably more of a hassle than a reimbursement problem but it’s hassle on top of too many hassles. Time will tell. And Randy, I tried to respond that prayers are genuinely appreciated for Epic users, but Disqus made the message disappear.

      • ninguem

        Margalit.

        Assuming you know any Israeli physicians.

        I’m doing an informal survey. Are the physicians there required to use ICD-10 IN THEIR DAILY PRACTICE

        I don’t mean some statistical analyst or back-office insurance clerk using the ICD-10, I mean the PHYSICIAN being expected to know and apply the correct ICD-10 code to the patient’s disease or injury……..and the physician is punished or penalized if the wrong ICD-10 code is used.

        If an Israeli physician sees a patient and provides some sort of medical service, does that Israeli physician have to enter a ICD-10 code for that patient’s underlying disease?

        So far, what I find invariably, is ONLY the USA physicians are required to use ICD-10.

        It’s been pointed out on this forum before as well, that there are abbreviated versions of ICD-10 used in other countries. We get the full version in the USA.

        As described on this thread, the people making a cottage industry of ICD-10 are trying to get the patient’s entire medical history in a single code………

        …….and then punishing the doctor if the code is not perfect.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          I don’t really know the answer to that. I do know that all other nations use ICD-10, but I don’t know how or even if doctors are the ones coding these things. The last encounters I had with physicians in Israel were many years ago and those were private physicians (cash only) and they coded nothing whatsoever.

          • ninguem

            Margalit

            All other nations use ICD-10……true

            But do all other nations require FRONT-LINE PHYSICIANS to know and use the ICD-10, to use them correctly, and punish them if they do not?

            I’ll answer that question for you. I have yet to meet a foreign national physician practicing outside the USA, using ICD-10 day-to-day in their practice.

            In other countries, ICD-10 is used by back-office personnel for statistical analysis, etc.

            Other countries have abbreviated versions of the ICD-10

            ONLY the USA anticipates using the full ICD-10, AND forces it on front-line physicians.

            Research it yourself, let me know if you find an example contrary to what I just wrote.

  • southerndoc1

    But I already document to that degree in the note, so it’s not the documentation that is changing, just the hassle factor in picking an ICD code.

    • annette ciotti

      I hope you’re right. I do wonder how Epic is going to have us navigate this picking of codes; hope it’s not going to make us snow blind

      • rbthe4th2

        Epic? Oh I pray for anyone I know using Epic, especially now.

  • Deceased MD

    This is utter insanity. How do they think they are going to glean accurate data from this? Likely the physician will put down whatever is necessary to get paid. The piece of this (data mining ) is so unethical I am surprised it has been made legal. (I suppose nothing surprises me anymore though.)

    Is the American public aware of this? They are concerned about privacy of their phone calls but are under the false guise that HIPAA protects them.

  • ninguem

    I just got a flyer for a course on how to code with ICD-10.

    The course costs $450

    Anyone prepared to send me a check?

    I mean, if this is so important, you would think someone would be happy to reimburse me the cost of the course.

    I didn’t think so…………

  • T H

    A question that has not been answered to my satisfaction:

    What is the purpose of ‘data mining?’

    • T H

      Or, to phrase it more precisely, What is the real purpose of data mining?

      • doc99

        Just ask Who Benefits and Follow the Money.

  • Judgeforyourself37

    I can see a day, soon, when documentation, ICD-10, coding, HIPPA, and lord know what else will come down the road, will take so much of a practitioner’s time that there will be scant time to actually care for the patient.

  • doc99

    Medicine ceased to exist as a profession the day the first “Dear Provider” letters went out.

  • Thomas Luedeke

    Another (bad) reason to kiss the private practice goodbye. The AMA may be half-halfheartedly be fighting ICD-10, but the Big Hospital lobby and Big Government folks are cheering, as it will drive those annoying private practice folks out of business…

    In my lifetime, I don’t think I’ve ever seen such a crony-capitalism assault destroying the ability of somebody to pursue their dream as a business owner. ICD-10, insurance company regulatory capture/crony-capitalism, Big Government types believing medical care should be simultaneously unlimited and “free”, etc.

    And in the end, the only ones who will suffer are the patients, and the patient-centered doctors who truly care.