ICD-10 implementation means changes at all levels. One of the first responsibilities for managers will be to analyze the practice environment and personnel to determine specific needs to bring the practice into compliance and readiness for implementation. The entire process will require many managers to assume duties with which they’re unfamiliar or require them to step out of their comfort zone.
Managers will take on the role of overseeing and coordinating the implementation of ICD-10 and that will include contacting vendors, payers, clearinghouses and billing professionals. Contracts will all need to be evaluated, revised, updated and receive final approval before the official implementation date. New policies for employees will need to be revised, distributed and a signed copy returned.
Budgetary concerns will occupy a large part in managers’ responsibilities. Operating funds must be set aside to account for the inevitable reimbursement delays to come. There will be numerous software and hardware updates, purchases and IT considerations. Testing is a crucial part of preparation to ensure that the practice can communicate appropriately with others in the system. It’s a process that will take time and will rely on the readiness of other entities.
The transition to ICD-10 will require training and education for all staff members and sufficient money will need to be appropriated. Implementation will affect staff members in different ways. Managers will be responsible for determining the level of education each individual requires, ensure staff participation and that they’re fluent upon completion. Managers will want to explore various instruction methods, from online options to on-site instruction. Not all staff will need the same level of training.
The workflow in practices and the billing department will experience delays. These should be expected. Staff training and system testing will require a significant amount of time, resulting in a loss of productivity prior to implementation. It may be necessary to hire extra staff in various departments to alleviate back-up and loss of productivity. Additional personnel may be required for up to six months following implementation.
Significant risk accompanies ICD-10 implementation. HIPAA compliance for securely transmitting medical information is critical. Sufficient safeguards must be in place. Part of the implementation process involves how information will be stored and manipulated by those within the practice and entities with which the practice works.
The additional documentation and coding required by ICD-10 places much more patient information at risk and security measures must be addressed.Risk management also extends to potential loss in revenues after the conversion. The best laid plans may encounter snags and delays. A contingency plan to handle any problems will be essential.
The implementation of the new coding system is a major undertaking at all levels of the practice. It will require new methods, practices and policies. Medical practice managers will be extremely busy ensuring that staff receives training, the revenue flow experiences minimal disruptions, and the practice is in compliance for the ICD-10 conversion. During the transition, managers should take care not forget to obtain the ICD-10 training they need.
The implementation of ICD-10 will affect the entire practice, from clinicians and billers to the front desk. With all the emphasis placed on coding changes, it’s easy to forget that anyone who deals with patient information will need some form of training and that includes the front desk staff. They will be responsible for much more than checking IDs and collecting co-pays.
Not everyone in the practice will need the same level of training. Front desk staff will need increased communication skills when dealing with clients. Many patients have heard about changes, but have no idea how it will affect them. Front desk personnel will be responsible for answering basic questions for patients and billing matters.
Front desk staff will also responsible for verification of patient insurance information and creating the rudiments of the client’s file. There are HIPAA compliance and patient privacy issues to consider and digital considerations concerning patient requests for their personal information. There will be new forms to be explained and signed.
The front desk will need to explain to patients how any changes in their insurance plan will affect them at the office. There may be changes in technology used during the pre-registration phase. Many offices will be using tablet technology that enables patents to submit their own identification photos and insurance information. Assistance and instruction in using the technology will be required.
Education and training is never wasted. Many clinicians may want to provide the basics of ICD-10 to staff that will primarily be involved in patient access, compliance and financial services. If the front desk is involved in any coding activities, they’ll require more inclusive information, understanding, and the application of ICD-10.
One aspect of the change for front desk staff that clinicians typically don’t consider is interacting with the irate patient. The Affordable Health Care act has wrought changes in coverage for patients. Others will be using insurance coverage for the first time.
Some of the changes will be reflected in patient co-pays and the ability to see the practitioners with which they’re familiar. In the first months of ICD-10 implementation, patients may be billed in error to due to unjust claim denials and front office personnel must be able to explain what’s happened and why.
Clinicians need to prepare the front desk staff for these potential problems and arm them with the information needed to remain calm, friendly and provide explanations to frustrated and angry clients. Front desk staff must be able to address issues and communicate changes in terms the patient can understand.
The previous role of front desk personnel becomes more difficult with the changes that will come with implementation of ICD-10. The role of front desk staff as liaisons to field patient questions and complaints will take on new importance in regard to patient satisfaction, retention of established clients and attracting new patients.
Front desk staff will require less education about ICD-10 than nurses, clinicians and billers, but that doesn’t make the training any less important. Practice owners will need to assess the level of involvement the front desk will have in any coding activities and provide commensurate training. Just as important will be education in the impact of HIPAA compliance and patient privacy issues.
Some individuals may have taken the initiative and increased their knowledge and understanding on their own. Others may not be suited for their current positions in the new ICD-10 order. It’s essential that clinicians provide the appropriate training, have an effective means of testing their knowledge, and create a plan for staff members that are unable to make the transition.
Never assume that any practice member is fluent after training. It’s an ongoing-learning process and some instructors are better than others, no matter what medium they’re using to educate. The learning style of the individual must be considered to obtain the training that best suits them, will obtain the maximum results and address information retention.
Without the level of training appropriate to their role within the practice, front desk staff will experience significant stress and loss of productivity that will be felt throughout the office. Clinicians really don’t want clients filling out new forms and patient information in the examination room when they should be focused on the reason for their visit.
Until clinicians are familiar with the new ICD-10 codes and usage, mistakes are inevitable but they can be minimized with proper planning and training. One of the biggest problems for practitioners now is the continued proliferation of myths and misconceptions surrounding the new coding system. Believing that misinformation can lead to compliance issues and be costly for practices.
The following are the top 10 mistakes to avoid about ICD-10 and its implementation.
Take Your Time
This is perhaps the biggest mistake clinicians can make. Many medical professionals are hoping for a delay in implementation or a rollback of the Oct. 1, 2014 deadline. No further extensions will be granted. All entities covered by the Health Insurance Portability and Accountability Act (HIPAA) are required to use the new coding set by the deadline. Reimbursement claims submitted after that date using ICD-9 codes will be denied.
Some Entities Don’t Have To Convert
It’s true that Worker’s Compensation and auto insurance companies can choose to apply for a waiver for exemption from the use of ICD-10. They’re considered non-covered entities and mandatory conversion isn’t required, but it’s in their best interests to do so.
ICD-10 coding provides in-depth details about events that can be of significant use when determining payment, coverage and responsibility. Using ICD-10 coding requires electronic transmission of data that facilitates quick closure of claims. ICD-9 code sets won’t be maintained after the ICD-10 implementation deadline.
State Medicaid Doesn’t Have To Update
This is a fallacy that will cost clinicians dearly if they believe it. Covered entities in the U.S. will be required to make the transition to ICD-10 and that includes state Medicaid programs. The Centers for Medicare & Medicaid Services (CMS) has indicated that it will be working closely with state programs to implement ICD-10 and accomplish it before the official deadline.
ICD-10 Is Impossible To Use
The number of codes in ICD-10 is far greater than the previous version and clinicians will be required to code in greater detail. However, practitioners won’t use the full complement of coding options. A physical therapist and a heart surgeon will utilize a completely different set of coding due to their specialties.
ICD-10 contains an Alphabetic Index and a Tabular Index to help practitioners locate the correct codes. EMRs and billing programs are also available with tools to make coding easier and faster, and can even identify coding errors and potential problems.
Clinicians Had No Input
A significant amount of time, effort and consultation went into the development of ICD-10. Many of the profession’s most respected organizations and societies contributed to the codes. Chief among those entities was the CMS, the American Health Information Management Association (AHIMA), the American Hospital Association (AHA) and the National Center for Health Statistics (NCHS).
No Guides Are Available
Coding manuals are already available for ICD-10-CM and ICD-10-PCS. They’re manageable in size – not thick, unwieldy tomes. While the new coding system can be assisted by modern, computerized technology, they’re use doesn’t rely on software or electronic means.
ICD-10 Is Out Of Date
Even though ICD-10 was created some years ago, it was regularly updated and specifically designed to progress along with technology, techniques and disease discovery. Its reorganization and expanded number of codes reflects that. ICD-10 is the most current source available for coding.
There’s Unnecessary Detail
ICD-10 is based on medical documentation, just like ICD-9. The new system does require more in-depth coding to document patient complaints and provide more specificity. Clinical documentation already contains much of the information required by ICD-10.
The difference is that some information will be documented with a specific code instead of notes and ancillary data. Medical professionals should always endeavor to code to the highest possible level of certainty.
Super Bills Are Obsolete
Clinicians can continue to use super bills, but they may not be adequate for all coding needs. The new coding won’t necessarily make them longer or too complex. Those who use super bills will need to crosswalk ICD-9 codes to the ICD-10 system for accuracy using General Equivalence Mappings (GEMs).
GEMs Help In Coding Records
A GEM is a useful tool, but it was never intended for coding medical records. They were created to facilitate the conversion of ICD-9 databases to ICD-10. Anyone can use them and clinicians won’t be required to develop their own GEMs. They’ll be phased out after three years as clinicians and billers become more familiar and efficient with the new coding system.
There are any number of mistakes and errors that can be committed by clinicians who haven’t exhibited due diligence in separating fact from fallacy. Assumptions and misinformation will create havoc for practices, result in denied claims and jeopardize reimbursements.
The rules of coding for ICD-10 have been established in cooperation by the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). It’s a standard to which all clinicians must adhere.
Reviewing The Basics
ICD-10 encompasses 21 chapters and expanded code options that have been reorganized and expanded. Injuries are described by site first and then by type. They include laterality, greater specificity and combination codes.
ICD-10 codes are now identified with an alpha-numerical system that can include up to seven characters and the first will always be a letter. The letters I and O are not used, as they can easily be confused with the numbers 1 and 0. Letters aren’t case sensitive.
The first three identifiers represent the category, the next three describe the anatomical location and severity, and the last is an extension that identifies if it as the first or subsequent encounter, or the result of a previous injury or disease. X is used as a placeholder in some codes.
Injuries are grouped by body part rather than injuries. Clinicians will focus on documenting the current complaint of the client. Never assume that “standard” treatment has been provided or code on a suspected diagnosis. Payers just want the facts of what’s readily observable.
Practitioners will need to document variables that were not required under ICD-10. Clinicians will need to include data on all external causes that led up to the actual injury, the exact location of the injury, and the patient’s actions at the time of the injury.
Documentation will also require information about the environment in which the injury took place, and any measures the patient has taken to alleviate the problem. Additional data must be included on any complications, the results of tests and exams, and very detailed data on the treatment plan.
The conventions for ICD-10 have an alphabetic index of terms and codes that may apply. It’s broken down into four parts: Index of Diseases and Injury, Index of External Causes of Injury, Table of Neoplasms, and Table of Drugs and Chemicals. ICD-10 also has a tabular list that divides codes into different chapters that’s based on condition or body system.
ICD-10 coding conventions dictate that clinicians record the underlying or casual condition first. This should be followed by the condition displayed. Up to 12 diagnosis codes can be included for accurate representation of all conditions related to the patient’s visit.
A new coding convention for ICD-10 provides laterality in reporting. Clinicians now have designations for right, left, bilateral and unspecified. Coding can then be specified for the type of injury, disease or condition, along with an even more finely detailed description of the affected area.
Medication conventions have also been expanded. An example of this is drug under-dosing, a concept that doesn’t exist in ICD-9 but can be coded for under ICD-10. Many of the new codes reflect changes in terminology and technology. Some codes have been updated, while other terms have been eliminated or disassociated from specific conditions.
Even punctuation is addressed in the conventions. Specific guidelines have been established for the use of parentheses to designate supplementary words and terms that should be documented, but won’t change the diagnosis. Clinicians can differentiate between signs, symptoms and unspecified codes.
While ICD-10 codes are extensive and comprehensive, the good news for practitioners is that they generally won’t have to contend with the entire complement of code options, only those that affect their specialties. For instance, physical therapists and dermatologists won’t be coding for the same types of disease or injuries.
Clinicians preparing and training for implementation of the ICD-10 code set have encountered some unusual results. In an effort to be more specific, eliminate waste, reduce fraud and save money, the ICD-10 codes are very specific, sometimes to the point of being humorous.
Practitioners can now provide coding that may leave insurance companies wondering about their clients and the activities in which they’ve been engaging. Every clinician remembers a strange or unique situation for which they’ve billed – and the difficulty they had explaining it to the patient’s insurance company. The following are some examples of the unusual and sometimes humorous coding available with ICD-10.
Members of the animal kingdom can be unpredictable, but ICD-10 coding points out just how unanticipated some situations can really be, from fast moving turtles to equine collisions. In the animal category, practitioners will find some interesting injuries to be noted and places where the event took place.
W59.22XA – Struck by a turtle
W611.2XS – Struck by a macaw, initial encounter
S30.867A – Anal insect bite, non-poisonous
V80.730A – Animal-rider injured in collision with a trolley
Y92.72 – Injury obtained in a chicken coop
All families have problems, but it seems that some clichéd situations are eternal. When families have problems, there’s a code for that.
Z63.1 – Problem with in-laws
Z62.891 – Sibling rivalry
W21.31XS – Struck with footwear
Z62.1 – Parental overprotection
Z73.4 – Inadequate social skills, not elsewhere classified
R46.1 – Bizarre personal appearance
G44.82 – Headache associated with sexual activity
R45.2 – Unhappiness
The arts can be dangerous and that’s amply demonstrated by ICD-10 codes that identify the supposedly safe venues in which to enjoy entertainment, but may not be as protected as individuals might think.
Y92.253 – Injured in an opera house
Y9250 – Injured at an art gallery
Y92.26 – Movie house or cinema
Y92.251 – Museum
Work-related accidents and injuries are a common complaint for medical professionals and the new codes reflect such injuries. It would appear that some individuals are at high risk of being injured is some unique ways, and some return for an encore performance.
V97.33XD – sucked into a jet engine, subsequent encounter
X52 – Prolonged stay in weightless environment
V95.41XA – Spacecraft crash injuring occupant
Z89.419 – Acquired absence of unspecified great toe
Leisure time activities account for a large portion of injuries. Sports-related injuries top the list, but there are some lesser known activities that can be just as dangerous. When it comes to leisure time activities, clients are presented with multiple opportunities for injuries.
V91.07XA – Burn due to water skis on fire
Y93.D1 – Stabbed while knitting or crocheting.
Y92.146 – Hurt at prison swimming pool
T63 – Unspecified event, undetermined intent (to be specific)
Some of the ICD-10 codes bring to mind weird and wacky laws that have outlived their usefulness, but have never been removed from the books. It bears remembering that while some codes were developed to address potential problems and injuries of the future as technology advances, many of the codes currently exist because a particular situation actually happened to someone, somewhere, sometime…
Coding with ICD-10 will offer some interesting experiences for clinicians. Practitioners must keep in mind that they need to bill at the highest level whenever possible. That means taking extra time if necessary to track down the correct codes for optimal billing. Getting the codes right will mean the difference between getting reimbursed and delayed payments.
The following is an example of the type of coding required to provide premium treatment for the patient and optimal reimbursement for the clinician.
Mrs. Smith was riding her horse through an orchard road adjoining her property. Her two siblings were riding their horse with her. As she neared an irrigation pond on the property, a Canadian goose flew up and startled one of the other horses. The second horse whirled to put his rump toward the “threat” and lashed out with both back hooves. One hoof struck Mrs. Smith on the tailbone causing immediate pain. The injury happened two weeks prior and she still experiences pain, along with numbness at the tailbone, radiating 3-4 inches in all directions from the site of the injury. Over the counter medications offer no relief. Past medical history is unremarkable. She followed up with her primary care physician who referred her to physical therapy. Patient indicates no x-rays or other diagnostic tests have been done.
Patient is 5 feet tall and weighs 120 lbs. Blood pressure is 120/70, pulse rate 72 and respiratory rate is 16. She has full strength and function in all muscle groups, but now walks slowly and hunched over. Has pain upon walking, sitting and reclining. Range of movement is normal but patient complains of pain upon movement and examination. Special tests: X-ray.
Exam/x-ray shows bruising, swelling and fracture of the coccyx. Treatment is to rest and to address pain. Postural exercises and home exercise for continued mobility.
Y93.52 – Horseback riding, describes the activity at the time of the injury
W55.12XA – Struck by horse, describes what caused the injury
532.2XXA – Fracture of coccyx, initial encounter for closed fracture, describes the anatomical area where the injury is located and indicates this is a first time injury
R26.2 – Describes the symptom of the injury (constant pain and difficulty walking, sitting and reclining)
Clinicians know that ICD-10 codes are much more specific, but part of the learning curve will be wading through massive numbers of potential codes to arrive at the options that best suit the injury or need. The new codes include activities ranging from gardening and pollen reactions to knitting and running into a lamp post, complete with initial and subsequent encounters. It’s unlikely that therapists will require the codes for those potential incidents, but it points out the increased specificity of the new codes.
One of the challenges that practitioners will face is the sheer volume of data contained in the new code sets. GEMs provide a partial solution, but in an effort to stamp out fraud and save money, clinicians are now being inundated with too much information. GEMs, EMRs and other software can sort through data quickly and provide potential solutions, but they can’t make decisions about what to display for a given situation.
The final decision on which codes to utilize will ultimately fall upon the practitioner. GEMs and other computerized solutions can present the possibilities, but it will be the clinician’s practical experience and understanding of ICD-10 to code accurately and profitably.