How Your Medical Practice Can Avoid ICD-10 Pitfalls

Like many who oversee their practice's day-to-day operations, Kafi Miller is strapped for time and has a lot of competing projects.

Still, Piedmont Ear, Nose, Throat's business office manager, who oversees operations for the 51-person, Atlanta-based practice, spends at least five hours per week just researching the new ICD-10 code set.

While the deadline to transition is more than two years away - CMS recently proposed a new Oct. 1, 2014, implementation date - Miller knows the transition will be wrought with challenges for all involved.

So over the next year, one of Miller's top priorities is to make sure her staff, in addition to the technology her practice uses, is ready for the change.

"Right now we're currently trying to learn the ICD-10 codes that will affect our practice," says Miller. "And once we're able to identify those codes, we'll create a 'pick list' for providers in our EHR module templates where they can select the old code but it will pre-populate with the new alphanumeric ICD-10 codes. It's just customizing our templates, learning what we need, and getting ready for the transition."

Like Miller, many other practice managers will face the similar time-consuming task of making sure staff and physicians are up to speed with ICD-10.

But while migrating to the new code set entails hours of learning and embracing change, there are high-tech solutions - and some great low-tech ones, too - that a practice can use to help offset some of the transitional pains.

Big changes ahead

They say you can't teach an old dog new tricks.

But everyone from seasoned coders to freshly minted, post-residency physicians will have to learn many new ones as of October 2014, one year after CMS originally proposed that ICD-10 become reality.

The consequences of not being ICD-10 ready include claims rejections, denials of payment, and challenges in coordinating care with other medical professionals - just to name a few.

But while many practices might be anxious to get ready, CMS' announcement that it will push back ICD-10 to a still-to-be-determined date has slowed momentum.

"The challenge for those who are close to getting their plans in order is that it's actually very hard to implement a project with a moving date when you don't know how to allocate your resources," says Juliet Santos, senior director of business-centered systems for the Healthcare Information and Management Systems Society and a former practice owner. "Sometimes people will think they have more time than they really do to spend on a particular process."

*For more on some of the specific changes related to ICD-10 and the challenges of transitioning, visit http://bit.ly/ICD-10_pitfalls for a Q&A podcast with Santos.

Regardless of its implementation date, the conversion to ICD-10 will represent a huge shift for practices. The new ICD-10 CM (clinical modification) codes and ICD-10 PCS (inpatient procedure) codes will replace the existing ICD-9 numerical codes with more than five times as many alphanumeric codes. And not only does ICD-10 consist of more than 68,000 codes (compared with approximately 13,000 ICD-9 CM codes), but the new codes are longer and more specific.

Still, many practices haven't upgraded their technology so it is compliant with Version 5010 of the Electronic Data Transaction Standard, the specification necessary to input and transmit the new codes.

According to a December 2011 study by the Medical Group Management Association (MGMA), only 32 percent of 147 practice-based respondents reported that their organizations' practice management system had been upgraded to the Version 5010 standards and that internal testing was complete. Nearly 25 percent indicated that either their software had not yet been upgraded or that testing was not even scheduled.

"There are so many things that can go wrong with ICD-10, and 5010, as many of us projected, would be a glimpse into the future, so to speak, as many practices didn't get their software upgraded until the end of the process and weren't able to test with their trading partners," says Robert Tennant, senior policy advisor for the MGMA.

If 5010 conversion and the daunting task of training staff and clinicians for ICD-10 weren't challenging enough, there are a few variables that can derail any well-intentioned practice.

One potential curveball: Workers' compensation claims will still be required to be filed using ICD-9 codes. If these claims are overlooked or miscoded, a practice could be looking at an uptick in rejections.

"Right now if we have a patient that comes in, and you think it's workers' comp, and you bill it and it's not workers' comp, you just resubmit it," says Rhonda Buckholtz, vice president of ICD-10 education and training at the AAPC (formerly the American Academy of Professional Coders). "Now, you've got to find a way in your practice management system to change the code."

Ana Croxton, vice president of EDI products and services for NextGen Healthcare, says a practice should make sure its vendors can handle the submission of either ICD-9 codes or ICD-10 codes by payer in an automated fashion. Otherwise, the practice will have to have its billers manually reverse map codes to meet workers' comp requirements.

"You can't ask a clinician to do that," she says.

Pitfall #1: not-so-ready technology

Before life with ICD-10 is simpatico, a practice's technology needs to be. That means practice management systems, EHRs, and other technology should be upgraded to the 5010 standard, and testing with vendors completed.

But for many practices, that can mean upgrading several different products, from EHRs to data clearinghouses, with multiple interfaces. Then, those products must be tweaked to store and recognize the new codes.

Doing this is a lot more time-consuming than many people think.

In addition to the five-plus hours she spends on a weekly basis learning the new codes, Miller oversees testing the codes internally, and communicating with her vendor when the practice runs into problems. "The customization piece is a lot of work with the current EHR vendor we have," says Miller. "Right now it's trying to learn to integrate with our template."

The key to upgrading technology is to establish regular communication and close rapport with your vendor. Once a practice begins the ICD-10 transition, Santos suggests communicating with vendors on a biweekly or monthly basis.

"What they need to do is engage a vendor early," says Santos. "They need to identify a vendor that can assist them in terms of upgrading their software and work with them very closely … and get firm commitments as to what they can do and cannot do."

And as they move forward, practices need to continually check on the timeline for upgrades.

"If [a practice has] any kind of automated interfaces for their services, whether they're X-rays or [picture archiving and communication systems], they have to approach those vendors and see what kind of upgrades are going to need to be done," says Croxton.

Specifically, says Santos, ICD-10 transition leaders should ask something to the effect of "What will you have done by which time?"

Even if systems are 5010-ready, Buckholtz says that practices need to check with their vendors to make sure these companies have enough hardware storage to house the new codes. If adjustments or additional storage are required, practices should ask their vendors on their timeline for getting those things done.

Getting an early start on working with a vendor will also allow a practice to gauge any potential communication pitfalls, or other red flags.

"If the vendor isn't going to get you to where you need to be, that needs to be identified early on, and then that allows you to choose a different vendor or add additional vendors as needed," says Santos. "But if you wait until later, the credible vendors will be very, very busy and may not take on new clients. It would behoove the small physician practices to identify their vendors early, develop a close communication with them, and just be honest. Ask them if there is software that they don't have the capability of upgrading. Will the practice need three or four other vendors to assist them to get through to the finish line?"

Pitfall #2: unprepared staff

In Vitera Healthcare's February survey of 394 practice-based physicians and office managers in the United States, 53 percent of respondents said the practice manager is responsible for the transition to ICD-10, whereas 23 percent cited the billing manager as the project leader.

That means anyone in these roles, or in supporting roles, is part of the last line of defense between the practice and its payers.

And even though ICD-10 is still a ways away, "we've already begun training the billers, because we need our team to understand the differences between ICD-10 and ICD-9, and how the different coding principles will affect us, so they can identify any coding errors our physicians are making," says Miller.

The good news is there are dozens of ICD-10 seminars and workshops offered by everyone from coding associations to CMS to state medical associations.

However, those workshops only prepare attendees with a working knowledge of the thousands of codes available. They don't prepare physicians and coders to navigate their existing technology systems to look up ICD-10 replacements for ICD-9 codes. And while what is learned in a workshop is fresh in the minds of coding staff in the immediate days or weeks following a seminar, much of it may be forgotten if it isn't reviewed.

Fortunately, there are technology tools - such as Web- or software-based programs, and CD-based slideshows - loaded not only with the most updated codes, but with tips on what to consider when selecting a code.{C}

"You want to look at reputable sources," says Buckholtz. "Not just the coding industry, but also your specialty organizations, your state medical societies."

Pitfall #3: physician errors

Physicians will be a practice's greatest liability, as well as its greatest asset, in the ICD-10 world. If they code incorrectly, a practice will see a holdup in payments, or worse.

For example, though he hasn't seen any major payers' policy changes for ICD-10, Tennant suspects that "unspecified codes," which physicians may increase their use of because they aren't familiar with specific ICD-10 codes, could translate to a lower payment by payers.

In addition to investing in training for physicians, a practice should make sure physicians are well acquainted with using their EHR so the process of coding is slowed down as little as possible.

And whether a provider uses paper or EHRs, Santos says it's a good idea to give them access to a "cheat sheet" of sorts, also known as a "super bill," a document that contains the most commonly used codes, based on the most common diagnoses per specialty, which can be installed on their desktop computer.

"It's really good to have the tool, visually," says Santos. "It helps them to see what the overall choices are."

Additionally, some EHR vendors may have a coding-assistance application or software available. Or, a practice can be like Miller's and create a 'pick list' for providers in the EHR that allows them to input an old code and then see a selection of new alphanumeric ICD-10 codes to swap in.

Pitfall #4: getting details right for claims

Even if your physicians and clinicians have easy access to the most common codes for their specialty and have taken a course or two in ICD-10 coding, a practice might still find its reimbursement is negatively affected.

One of the most common reasons for a claim rejection is documentation that doesn't support that claim.

"Codes can only be selected if documentation supports it," says Tennant. "You might have to follow up with the patient and say, 'I forgot if it was your left wrist or your right wrist.'"

Another reason is that payers may have different policies as to the level of specificity of codes required for a claim.

"Aetna may accept a claim with a certain level of ICD-10 codes, but another payer may reject that," says Croxton.

Additionally, Croxton suggests practices work with IT staff to create rules engines in their practice management systems and EHRs that alert users to combinations of codes that will trigger denials.

"It doesn't tell clinicians how to code, but it tells them, you may not get paid for it," says Croxton. Also, practices need to keep in constant contact with their payers' reimbursement policies.

"We're recommending they keep a tight grasp on their revenue stream," says Croxton. "Ask top payers questions so they know what to expect."{C}

Monitoring reimbursement changes - for example, if the payer requires you to submit different codes for a patient pregnant in her first, second, or third trimester and pays each code differently - will save headaches down the road, she adds.

Pitfall #5: reduced productivity

Even if physicians code correctly, and billing and coding staff submit perfect claims, it is almost certain that ICD-10's most notorious pitfall - reduced productivity - will strike your practice. In order to achieve claim utopia, physicians and staff will probably need to take more time to double check codes as well as supporting documentation. That translates to fewer patient visits and claims that are processed more slowly.

Fortunately, most all technology in use today from the waiting room to the exam room is intended to boost productivity. And if a practice has done everything else to avoid pitfalls, the next step might be to consider investing in technology that boosts overall productivity.

For example, using kiosks or media tablets that run patient eligibility checks might save staff time on the back end, and increase upfront payments (which helps to offset any slowness in paid claims). Media tablets and smartphones that can access a practice's EHR may be helpful for physicians who need to catch up on documentation after they leave the practice.

Another tip for boosting productivity is to try and take the changes in stride, as stress can slow down everyone at a practice.

"For practices, the most important takeaway to providers is 'don't let panic overcome you,'" says Santos. "This is doable and you have to just commit to it and embrace it."

In Summary

While migrating to ICD-10 involves embracing change, there are both high- and low-tech solutions that a practice can use to help ease the transition. Consider the following:

• Check with technology vendors to make sure they have enough hardware storage to house the new code set.

• Train staff using onsite workshops, information offered by industry association websites, software-based programs, and CD-based slideshows.

• Provide physicians with quick access to the ICD-10 version of the most commonly used codes.

• Consider investing in technology that boosts overall productivity, such as patient kiosks and media tablets.

Marisa Torrieri is an associate editor with Physicians Practice. She can be reached at marisa.torrieri@ubm.com.

This article originally appeared in the June 2012 issue of Physicians Practice.