As ICD-10 Enters Year Two, Practices Reflect on Transition

Oct. 1, 2015 - the implementation date for ICD-10 - came and went with none of the drama that had been foretold. Many experts compared it to Y2K, an event we'd been warned might bring all of civilization to its knees. As with Y2K, predictions of a crisis were greatly overblown. The flood of denied claims and lost revenue that could put smaller practices out of business didn't happen.

"It went surprisingly well," says Barbie Hays, coding and compliance strategist for the American Academy Family Physicians. "We had a few phone calls; there were some questions about whether preventive services are [billable] with a problem visit and everybody was trying to figure out what to do with the hilarious accident codes, like 'struck by orca, initial encounter,'" Hays says, laughing. "But generally it was not nearly as bad as people expected."

Prep Paid Off

While the smooth transition was unexpected by many, it probably shouldn't have been that much of a surprise. To most experts, this was definitely a situation in which preparation paid off, and most practices were at least reasonably well prepared. The repeated postponements of the implementation date had caused some experts to fear a "boy who cried wolf" effect, giving practices the impression that ICD-10 was never actually coming and causing them to give up preparing for it. In the end though, most practices made good use of the extra time. "It was almost a non-event for us," says Carl Olden, a family physician in Yakima, Wash. "We were ready even before the last delay." The only challenge for Olden's group was keeping everyone interested and up to speed during the delay, but they managed it. "We pushed the message that better documentation equals better care," he says. Olden's six physician practice focused on the advantages that ICD-10 offers in terms of telling the full patient story - identifying comorbidities and stratifying risk. The strategy was successful. "We wanted our physicians to be educated," he says.

Olden's practice made use of resources available from CMS. "They actually worked," he says. Yet, even with such attention to preparation, the group was still concerned about productivity losses. "We thought it would kill us - taking the extra time to document everything so carefully," Olden says. "But we've had no productivity loss and no billing loss. With the [EHR] platform we're using, we get a screen with all the subchoices," he says, "Once you've learn it, it's just a few more clicks and not much more burden at all." The education is ongoing. "We're teaching people to not be too dependent on crosswalk codes," Olden says.

Not Just No Loss

Mott Blair, a family physician in Wallace, N.C., was not only pleasantly surprised that his practice didn't lose any money after ICD-10 took effect, but that they've actually profited from the added specificity of the new codes. "There has been a real and unexpected financial benefit," Mott says. "Being able to code with more specificity has made it possible to code for the complexity of the patient. For example, with a patient with type 2 diabetes, ICD-10 codes can capture neuropathy or that the patient is hypoglycemic. We've started up an ACO and have had shared savings because we could document how sick the patients were. Without ICD-10 we probably couldn't have done that," he says.

This doesn't mean there aren't still some bugs to work out. Getting problem lists up to date has been an ongoing task for many practices. "We're still occasionally bringing in an ICD-9 code but we're gradually getting rid of them," says Olden. Mott's practice is dealing with that as well. "We're still working on [ICD-10 codes]," he says. "Patients don't come in with just one problem, and that makes it tricky." However, these are minor problems compared to the disaster many were predicting. "It's just busy work," says Olden.

The relative ease of the transition was especially welcome because so much is changing in healthcare. "Change is never easy, but when a whole lot comes at once, as it has in healthcare recently, it's nice when something goes smoothly," says Mott.

Another October, Another Deadline

While everyone is enjoying the relief - and in some cases the profits - over the smoother than expected transition, it's still not time to relax quite yet. Practices, like Olden's and Mott's, that made sure to really learn the codes and make use of the specificity of the new system have nothing to worry about. On the other hand, practices that have been reliant on unspecified codes may be in for a rude awakening now that CMS's one-year grace period for unspecified codes has passed. "As we move on to more specificity for coding, we may see that everyone has a false sense of security with their coding," says Tammie Olson of Management Resource Group, an Ocean Springs, Miss., firm which offers financial management and support services to practices. Not all private payers agreed to a grace period, but many of them have gone easy on unspecified codes and that is likely to end soon.

Many practices aren't ready. "I often code OP (operative) reports [used to bill for surgical procedures] and perform E&M audits (evaluation and management) and the documentation is still lacking for laterality, chronic versus acute, old injuries versus new injuries, and there is often no link for manifestation codes," Olson says. "I really feel that once we hit the one-year mark providers will see that they use nonspecific codes more than they think they do."

How much of an effect it will have on payment is harder to guess. It will depend on when coders address the problem. However, both Hays and Olson expect at least some increase in denials in the coming months. Though Hays isn't terribly concerned. "Medicare doesn't see it being that much of an issue," she says. Nonetheless she is trying to prepare AAFP members and have them ready for the post-grace period world. "I tell our members to be aware of the codes they are submitting. You need to be aware of what they cover in the first place, of course." She advises running a list of the top 25 or top 50 codes you use, then looking for unspecified codes to see if you can get more specificity. In addition to really understanding the codes you're submitting, you also need to be aware of what your software is doing. "You also have to understand your electronic health records program," says Hays. "[EHRs] are not always putting in as specific codes as they say."

Olson also sees a few other potential problems on the horizon. "I have seen that some providers are coding specific, but not documenting it specific. As we move into the one-year mark for ICD-10, there will be more audits by Medicare, and the documentation and the coding has to match or providers will be paying back. We are not out of the woods yet," she says and adds, "And don't forget that we have 1,943 new codes, 422 revised codes, and 305 deleted codes for 2017. This is going to have an impact on all providers if they are not prepared. The denials have not been huge so far this year but that could change drastically now that the grace period has run out."

The Long Game

In any case, the worst is certainly over, and the benefits are already beginning to come to light. A smooth transition that didn't bankrupt the average small practice, and in at least some cases is already providing savings. This is something that not many would have likely expected to see a year ago. Now practices can begin to focus on how to make ICD-10 work to improve patient care.

"After a year's worth of ICD-10, we're starting to get an idea of the health of the population we serve," says Olden. This is especially important in the community where he works - a poor area where many patients have multiple illnesses.

ICD-10 will also help make things smoother for doctors (as well as patients) in the everyday routine of practicing medicine. "Because it is more specific, ICD-10 will make it easier to establish medical necessity, making payments and adjudication of claims quicker," says Olson. "It will also enable providers to obtain pre-certifications without an initial denial for procedures, hospitalizations, and so forth. In other words, payers are going to understand up front what's going on with the patient and what's being done to the patient. When providers get paid, patients don't get bills. When a patient needs a procedure ASAP, ICD-10 should help facilitate that."

As we move into a pay-for-performance based model and the payment rules derived from the [Medicare Access & CHIP Reauthorization Act of 2015] take effect, "ICD-10 is paving the way for the future of payment," says Hays. She puts it like this, "Tell your patient's story, tell it well, and reap the benefits."

Avery Hurtis a freelance writer based in Birmingham, Ala. She may be reached at editor@physicianspractice.com.