Urology practices must have a plan in place to transition to the International Classification of Diseases, Tenth Revision (ICD-10) by October 1, 2015, and should not expect any further delays in implementation, according to the American Urological Association (AUA).
Urologists who believe that ICD-10 will not begin as scheduled this year are in for a rude awakening.
“I’m here to tell you that October 1 of this year, we’re going to ICD-10,” said Rick Rutherford, CMPE, CHA, Director of Practice Management for the AUA, at the 2015 AUA annual meeting. “The head of Medicare and Medicaid and many members of Congress have told me that ICD-10 is not going to be pushed back anymore. It’s going to happen.”
Claims for Medicare and Medicaid beneficiaries must use ICD-10 codes beginning on October 1, 2015. Virtually all large insurance companies are expected to follow suit. A few small insurers may use dual coding for a short time before fully transitioning to ICD-10, said Mr Rutherford.
Urology practice leaders must ensure that steps have been taken to begin using the new coding system. Using a decades-old cliché, Mr Rutherford said that failing to plan now means planning to fail on October 1.
Advantages of ICD-10
A half dozen key drivers of the implementation of ICD-10 have been cited repeatedly, including better data for clinical decision-making, improved ability to track public health, and enhanced capabilities for conducting research. However, 3 factors stand head and shoulders above the rest.
The ICD-10 coding includes more information for measuring the care that is provided to patients. Discussions about bundled payments, quality-based payments, and value-based payments all require data to evaluate and score providers, said Mr Rutherford. The ICD-9 coding lacks the granularity that is required for those types of assessments.
In addition, ICD-10 will improve the efficiency and reduce the cost of claims processing, he continued.
A third major advantage ICD-10 has over ICD-9 is an enhanced capability to identify fraud and abuse.
“It’s all about driving the accuracy of claims submission,” noted Mr Rutherford.
Practices must implement an effective education and management plan to ensure a smooth transition to ICD-10. Heading the list of requirements is a basic ICD-10 clinical modification education program for all physicians and staff. Beyond that, coders must review previous training, and physicians should identify and correct areas of weakness in the documentation.
Information technology personnel must ensure that all software is appropriately updated to accommodate the new codes, which will vastly outnumber the codes contained in ICD-9. Practice managers and staff who interact with payers must communicate and perform tests to confirm the progress made toward implementation of ICD-10.
Mr Rutherford referred to a common business theme leading up to the year 2000 (known as Y2K) and the concerns about banking and cash flow leading up to the year 2000 computing issues. Many medical practices secured a line of credit from their banks before the year 2000 as a hedge against cash-flow issues. He suggested that they may want to revisit the line of credit with their bankers.
“There is a very good chance that in October, November, December of this year, you might see some severe crimps in your cash flow, and you don’t want to miss a payroll, especially not the doctors’ payroll,” Mr Rutherford suggested.
In a recent direct communication with AUA leaders, the American Medical Association encouraged practices to secure a line of credit to protect against cash-flow problems during the early months of the implementation of ICD-10, Mr Rutherford added.
Education in the implementation of ICD-10 should include an assessment of documentation and the identification of gaps that need to be addressed before ICD-10’s implementation. Physicians and staff should have regular coding exercises on common urology cases and services. Each practice should obtain or design quick reference tools for all practice personnel.
The AUA has developed a simple reference tool for the top 100 urology-associated codes, including ICD-9 and ICD-10 coding. Practices can purchase the reference tool through the AUA website. The AUA has also compiled a 52-page PDF document that contains all the urology-associated codes included in ICD-10 and can be downloaded from the AUA website.
One piece of good news relates to the level of integration between ICD-9 and ICD-10. Although ICD-10 has greatly expanded the number of codes, almost 80% of ICD-9 codes can be mapped directly or approximately to corresponding ICD-10 codes.
The implementation of ICD-10 requires several critical interfaces. The codes must work seamlessly with electronic health record (EHR) software, billing software, and ancillary interfaces, such as laboratory work. Practices that outsource consulting support for coding and billing must make sure that the contractors are fully up to date with respect to ICD-10.
A practice that works with insurers who are not ready for the full implementation of ICD-10 will face additional issues. Practice leaders must determine whether dual coding will be necessary, and whether all the practice’s software can accommodate dual coding. Practices must also identify any computer hardware or software changes and purchases that will be required to make the transition to ICD-10.
The Healthcare Information and Management Systems Society has compiled a vendor database called Vital Vendors that is regularly updated. This database allows practices to obtain information on ICD-10’s progress for the specific vendors used by the practice. The information can be accessed for free at www.himss.org/resourcelibrary/TopicList.aspx ?MetaDataID=1113.
ICD-10 Trial Runs
Medicare has sponsored a series of trial runs that allow providers to conduct end-to-end testing of ICD-10 coding for Medicare claims. The final test run will be conducted July 20-24, 2015. Practices must register with their state’s Medicare administration contractor to participate in the test run.
The results of a Medicare trial run in January showed an 81% success rate for claims submission, which the agency considered “good progress,” but Mr Rutherford suggested otherwise.
“How many of you can afford for 19% of your Medicare claims not to be paid?” he asked. “That’s the other side of the equation, and it’s not good. It should be 95% to 96%.”
The January test run with Medicare showed that 3% of claims were rejected because of an invalid ICD-9 code, 3% because of an invalid ICD-10 code, and 13% were rejected because of mistakes unrelated to coding, such as problems setting up test claims.
Appropriate documentation will be essential to the transition to ICD-10, said Mr Rutherford. Practices that use EHRs should establish physician–coder teams to review templates, with an eye toward identifying problems and developing better documentation. ICD-10–ready EHRs have dual coding that affords opportunities to identify weaknesses in the current documentation.
Practice leaders must move toward the October 1 launch date with a sense of anticipation toward potential problems. Mr Rutherford cited 5 potential problem areas that can be anticipated and addressed before October 1, including:
- Will the documentation and coding slow the pace of work? If so, the problem areas should be identified, and efficiency measures should be implemented to deal with them
- Will the transition to ICD-10 result in cash-flow problems? Consider securing a line of credit or renewing one
- Find out what steps commercial insurers intend to take to minimize problems, particularly any “trimming” measures. Specifically, ask for a letter outlining the company’s mapping process for transition from ICD-9 to ICD-10
- More failures will occur with smaller payers
- How will the transition affect the total claims denials? Clinical and coding staffs should work together to identify and resolve documentation issues associated with denials. Devote as much time as possible to advance planning to reduce denials resulting from unrelated mistakes, such as incorrect beneficiary identification numbers, eligibility issues, and coverage charges for new patients in the Affordable Care Act exchange.
A Multistep Process
Mr Rutherford advised practice leaders to view the ICD-10 transition as a multistep process, beginning with the appropriate placement of legitimate ICD-10 codes on claims forms. Practice leaders must then validate the transition of each link in the claims processing chain, including EHRs, the claims system, the clearinghouse, and the payer processor. The required diagnostic codes for certain procedures and tests should be confirmed, such as those that require preauthorization.
As the transition moves into 2016, the emphasis should shift to increased documentation and granularity, a reduction in the use of nonspecific codes, and a reduction in the number of denials and appeals. Beyond 2016, practice leaders should anticipate the emergence of alternative payment models that cover multiple morbidities and increased complexity.