How to prepare yourself for the ICD-10 era

A stark reality of the past year has been the ever-looming ICD-10 transition, which ultimately got punted on by the federal government to October 2015.

With the deadline to make the transition to ICD-10 now more than a year away instead of six months (and who knows if that will even be the case next summer), I’d still wager that many health systems are working to keep their transitions on track — given the financial investments in time and training already sunk into the endeavor.

Health systems and hospitals can use a number of key indicators for their ICD-10 assessment to gauge their progress towards a solid transition once the deadline arrives.

Here are three specific considerations to make:

Have you talked to payers about what degree of granularity they’ll expect when providers submit diagnosis codes?

If your practice has a sense of what the answer will be based on conversations with payers, then you already have a leg up. But many payers have not provided more information about their requirements and they really need to be more transparent about the degree of granularity they’ll require.

This is a problem because physician practices would really benefit from having a stronger sense of what payers will decide on how ICD-10 will affect day-to-day billing concerns. However, payers either don’t know when they’ll want increased levels of granularity, or they haven’t relayed enough of the proper information to providers.

The specific question each practice needs to ask itself is: “What will our payers be doing with these increased levels of granularity granted by ICD-10?” If diabetes used to have two or three different ICD-9 codes, and now it will have upwards of 15, will that make any difference for payers in what they’ll reimburse for?

Not knowing the implications of when more granular documentation will be need can be pretty significant. After all, Medicare pays more for the ICD-9 choice of “diabetes with end-stage renal disease” as one code, rather than as separate codes for diabetes and diabetic nephropathy.

And that leads to another key concern for most practices.

How will the new rules from payers affect the clinical documentation process?

Thinking as a physician, when I select ICD-9 codes, I don’t get very granular if a payer doesn’t require me to. This makes me a more efficient care provider. I spend less time narrowing down the code, which might not make any difference to the payer, and more time with the patient.

If a payer’s policy on level of code granularity won’t affect medical necessity checks, risk-based contract fulfillments or risk scoring with Medicare Advantage, then providers really don’t need to worry about drastically changing their documentation process.

If life in the ICD-10 world means that providers do need to be aware of the new levels of code granularity — and many in the industry think that will be the case — then such a policy could be the difference between documenting “diabetes with end-stage renal disease with retinal diabetic complications of the right eye” and just simply “diabetes.” That’s huge for clinical documentation workflow when it comes to the different number of clicks and time spent in the system.

Providers will be caught off guard if they haven’t developed new workflows to make the new coding process less disruptive. Setting up the appropriate documentation workflow in an ICD-10 world can be complicated, but the burden of having to create and practice these workflows can be eased by including them in your practice’s training program.

How far along are your providers with their ICD-10 training?

The many unanswered questions about ICD-10 and the large technical and process changes hinder user training efforts. Physicians and other care providers should be practicing their code selection and analyzing whether their documentation processes align with clinical scenarios. Unspecified codes will still be able to be used by clinicians, if the case is indeed unspecified.

This includes education on what are still murky issues, but it pays to start with the basics. If clinicians involved with documentation don’t realize there are a range of ICD-10 codes for conditions and complications that previously had far fewer, they won’t know that they’re missing anything in the first place. As noted, that can negatively affect reimbursement. Providers should be as familiar with the code set as possible and should practice using it whenever they can.

The American Medical Association (AMA) recently estimated that it could cost upwards of $250,000 for a small medical practice to fund the training for providers to familiarize themselves with ICD-10. The finding illustrates how important proper training is.

Fortifying your organization for the transition

Anticipation is the imperative that underpins all of these efforts, and it’s only going to become more critical when CMS releases its reimbursement schedules and risk scoring. Most third-party payers will follow the CMS direction. There won’t be 100% correlation, but as payment models evolve to be more sensitive to diagnosis, the transition to ICD-10 sets up a perfect storm for unprepared providers.

It’s worth repeating that providers could be at risk for denial, audit, and other penalties if they aren’t prepared. The AMA also recently recommended that small medical practices start keeping a large reserve of money on hand to guard against the possibility that payers won’t be able to reimburse efficiently for weeks or months once the transition occurs.

Anticipate decreased work efficiency unless offering proper training. Physicians are at risk for losing time while wading through coding decisions, and billers might encounter new obstacles in claims processing procedures. Practices should be prepared for these very real possibilities and assess how such losses of productivity could affect patient care and revenue.

While organizations can’t truly know what will happen from the transition, they can do their best to forecast what their services will look like in the ICD-10 era and not put the transition off just because the government did.

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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