What healthcare executives should know about ICD-10

Despite efforts by critics to stave off the transition to the ICD-10 coding system, the mandated October 1, 2015 deadline became a near certainty when the American Medical Association (AMA) signaled a cooperative arrangement with the Centers for Medicare and Medicaid Services (CMS) in early July to assist practitioners in making the switch.  

Related: ICD-10: What now?

Bolstered by a commitment from CMS to relax some of the mandate's more stringent requirements for specificity and detail during the initial year of ICD-10 implementation, AMA President Steven J. Stack, MD, said, "Although physicians now have a yearlong transition period, now is still the time to buckle down and make sure your practice is as prepared as possible ahead of October 1."

WatsonStacie Watson, MBA, business lead for the ICD-10 program at Aetna Inc., says there will likely be hiccups in the switchover. She believes, however, that the benefits of ICD-10 will far outweigh the risks, and emphasizes that the transition can be smoother if practices follow Stack's advice.

A historic transformation

Laurie Johnson, MS, RHIA, FAHIMA, is an American Health Information Management Systems approved ICD-10-CM/PCS trainer and director of health information management consulting services, Panacea Healthcare Solutions, Inc. She says ICD-9 is well past obsolete.

ICD-10 adds characters and versatility to the code, updating it from the format established in 1979. "We've learned a lot since 1979 when it went into implementation, and ICD-9 has run out of room for procedural coding," says Johnson. In addition, she says numerous modern medical procedures and recently discovered diagnoses cannot be captured by ICD-9 code. For example, ICD-9 does not include a code for Ebola.

On a more general level, ICD-9 lacks the capacity for coding laterality, the ability to designate whether a diagnosis or procedure pertains to the right or left extremity of a patient. Not being able to specify laterality in the code has led to erroneous payment denials.

JohnsonJohnson, believes ICD-10 will "help eliminate additional documentation requests" that practitioners such as podiatrists have received from payers after performing the identical procedure on both feet of a patient, only to have the second procedure rejected as a duplicate billing.

In addition, Johnson says ICD-10 will capture, record and track secondary diagnoses and co-morbidities that could potentially impact a patient's length of stay in a hospital and ensure proper reimbursement, a clear improvement over ICD-9.

"The value of ICD-10 is that it is a better more current representation of the way medicine is practiced today through both the diagnostic and procedural codes," Watson says.

NEXT: How leadership should prepare for the transition

Getting ready

During the transition Johnson says leadership should be prepared "to look at the big picture and plan for where there may be disruptions."

"As human beings we don't like change, but sometimes change is inevitable. You have to be able to support staff in accepting that change," which she says includes helping physicians find easier ways to document and providing relevant education to them.

Johnson says it is important to note that reimbursement methodologies will change along with the coverage policies of payers with adoption of ICD-10. According to Johnson, managers should be prepared "to evaluate how much money is potentially at risk," and perform an analysis of revenue trends and the impact it will have on operations.

Related: Defining ICD-10 “readiness”

On a practical level, for the October 1 transition period Johnson advises providers to "put together a transition plan" and consider establishing, a command center to get everyone who can answer all of the questions in one room, as opposed to trying to run around the facility trying to find the answers. "If you can get everyone in one room, they can collaborate, make a decision and move forward quickly, as issues are reported," she says.

The biggest questions she says are, "Will the facility be able to process a claim?" And, "Can the payer or clearinghouse process that claim?"

NEXT: Where most payers stand in the preparation process

Payer progress

According to Watson, payers in general are prepared. While CMS has offered testing, only a fraction of providers have taken advantage of the opportunity. "A lot of the concern in the provider community has to do with testing."  Watson says while it is impossible for every provider to test with every payer, a lot of testing has already been done and Aetna has posted their overwhelmingly successful testing results. 

"Aetna has been ready for quite a while. We've been doing testing with many clearinghouses." She suggests that providers that may not have had the opportunity to participate in formal testing take a close look at testing results of organizations such as Aetna. "The information is there," she says, and providers could use it to extrapolate "how the results would be applicable to their own cases."

Related: ICD-10's impact on reimbursement

While Watson says the expansive code set of 140,000 possible codes may at first blush appear burdensome, providers need not feel intimidated. She says for most specialties, practitioners would likely rely on a certain subset of codes "that they would use over and over again. If you're a urologist, there is a certain subset of codes that you'll use repeatedly, just like when using the ICD-9 codes. The code is different, and there is a learning curve, but no one practitioner is going to have to use all of those codes."

David Richardson is a writer based in Baltimore. He writes frequently on topics related to science, technology and public policy.