What the ICD-10 code changes mean for doctors

June 22, 2011

The 2013 coding update may lead to significant revenue loss if physicians themselves are not adequately prepared.

CMS (Centers for Medicare & Medicaid Services) is firm that the go-live date for ICD-10 implementation is October 1, 2013. There will be no further delays, nor will there be a grace period. Every person touching a medical claim form will be affected, including physicians.

There has been a wealth of information available on the ICD-10 initiative. However, many physicians still believe that this is strictly a “coding” issue. Therefore, it will not affect them in their daily routine, nor will they personally have to undergo any preparation in advance of the go-live date. Most seem to understand that this transition can result in a loss of revenue if they do not ensure that their coders are properly trained in the new code sets, but physicians who do not fully understand the far-reaching effects of ICD-10 implementation will face a significant revenue loss if they themselves are not adequately prepared.

While ICD-10 moves us from our current state of 17,000 diagnosis codes to a future state of 140,000 diagnosis codes, the ability of the coder to appropriately assign those new codes and use the new coding methodology relies heavily on the physician's clinical documentation to complete the process.

It may be true that physicians do not have to actually learn to code. However, under ICD-10 physicians will now have to document at a level of specificity not required in ICD-9, noting such elements as laterality, episodes of care, stages of healing, weeks in pregnancy, etc. Unlike ICD-9, which did not require such elements and left the coder open to select “unspecified,” “not elsewhere classified” or “other” as coding choices, ICD-10 requires such specificity. Absent thorough documentation of diseases, disease processes, accident details and external causes, coders will have no choice but to return records to the physician for clarification and addendums. Large volumes of medical records returned to physicians on October 1, 2013 will no doubt result in a loss of productivity for both the physician and the coder as well an ultimate loss of revenue for the practice, particularly if physician training is delayed.

To further complicate matters for the physician, ancillary order forms on October 1, 2013 must include the correct ICD-10 diagnosis code or a patient will not be able to have diagnostic studies done at hospitals and clinics. Again, the diagnosis now must be specific to the patient disease or injury and will require appropriate documentation in the medical record. Hospitals and health clinics will have no choice but to turn the patient away until such time that he/she can return with an appropriate order form. In the case of electronic orders, a patient may present for studies only to find that their physician ordered them with an outdated ICD-9 code or an incorrect ICD-10 code, again being turned away, perhaps after a night of fasting depending upon the study.

So how can physicians prepare for this change of monumental proportions? Physicians are actually in a better position to learn ICD-10 coding requirements early than the coders themselves. Coders stand to lose knowledge by 2013 if they are not using the new code sets daily, but enhanced clinical documentation has no downside while ICD-9 is still in effect. Coders would no longer have to revert to “unspecified” and “not elsewhere classified” codes. More thorough documentation also results in better patient care and ultimately better outcomes.

To determine how an individual physician's documentation measures up to future ICD-10 standards, a small sample of his/her charts should be reviewed and a gap analysis performed comparing the current state to the required future state under ICD-10. That way, physicians needing more training can be identified and training structured to individual needs. After the initial training, further monitoring of a few charts per week should be performed to determine if the training was effective and where continued gaps exist to determine ongoing training needs. The coding staff also can provide their input as to what elements continue to be missing from clinical documentation to further reinforce documentation requirements.

While the majority of physicians have never seen requirements in clinical documentation change this dramatically in their careers, the change is manageable with proper planning, training and timing. Breaking the initiative down into smaller components such as understanding HHS' final rule, learning the required specificity, understanding the application of codes and developing an auditing and monitoring program is more effective than trying to eat the elephant in one bite. Additionally, after all of the road bumps are worked out, better documentation will lead to more efficient coding and more specificity on insurance claims, which will result in less denials and manual reviews, which equals faster payments at a lower cost.

About the author
Janice Jacobs, CPA, CPC, CCS, ROCC, CPCO, is director, regulatory compliance, IMA Consulting.
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