ICD-10 Medical Coding System Likely to Improve Documentation, Reimbursement

ICD-10 is the system that will replace ICD-9 for all parties covered by the Health Insurance Portability and Accountability Act (HIPAA). ICD-10 contains a code set used for inpatient procedural reporting and a code set used for diagnosis reporting. Physicians billing for professional services will only be affected when reporting diagnoses codes on their claims, but both physician and hospital selection of ICD-10 codes relies heavily on physician documentation. Therefore, documentation must be scrutinized. The most widely noted impact ICD-10 will have on documentation is increased specificity, with enhanced reporting of the patient’s presenting problem(s). Expanding from a pool of 14,000 3/5-digit codes to 69,000 7-digit codes, and accommodating this change, are daunting tasks. These anticipated burdens make it hard for physicians to recognize the positive effects ICD-10 may create, such as:¹

• Better clinical decisions as better data is documented, collected, and evaluated;
• Improved protocol and clinical pathway design for various health conditions;
• Improved public health reporting and tracking of illnesses and severity over time;
• Better definition of patient conditions, providing improved matching of professional resources and care teams and increasing communications between providers;
• Support in practice transition to risk-sharing models with more precise data for patients and populations;
• Provision of clear objective data for credentialing and privileges, and support for professional Maintenance of Certification reporting across specialties;
• Better documentation of patient complexity and level of care, supporting reimbursement and measures for quality and efficiency reporting; and
• Reduction in audit risk exposure by encouraging the use of diagnosis codes with a greater degree of specificity as supported by the clinical documentation.

With the Oct. 1 implementation date rapidly approaching, physicians need to ask themselves, “Am I prepared?”

Getting Started

Everyone has a role and responsibility in transitioning to ICD-10. Active participation by all involved parties guarantees a more successful outcome. Practice administration must ensure that each aspect of implementation is reviewed and appropriately addressed. If not already done, immediate steps should be taken to verify the products and services that affect implementation. These include:

• Payer mix and related contracts: Entities not covered by HIPAA (e.g. workers’ compensation and auto insurance companies) may choose not to implement ICD-10. Since ICD-9 will no longer be maintained post-ICD-10 implementation, it is in the best interest of non-covered entities to use the new coding system.² For payers who are required to transition to ICD-10, it is important to identify whether patient eligibility, claim processing, and/or payment timelines will be affected, as well as fee schedules or capitated rates.
• Vendor readiness: Physician groups may use a variety of vendors to assist with different aspects of the revenue cycle, including an electronic health record (e.g. documenting services and transmitting physician orders/prescriptions); a practice management system (e.g. scheduling and registering patients); a billing service (e.g. processing patient claims and payments); and a clearinghouse (e.g. verifying patient eligibility and obtaining authorizations). Know when software and/or hardware upgrades are available and if there are additional upgrade fees. Identify vendors that provide support services, training, and tools or templates to ease the transition. Most importantly, inquire about a testing period for products and applications to ensure functionality and adequate feedback on use of the system(s).
• Internal coding and billing resources. Identify physicians and staff who use ICD-9 codes and need to know ICD-10 codes in order to fulfill their responsibilities. Both physicians and staff can assist in identifying common clinical scenarios and the most frequently used ICD-9 codes, in order to develop a list of common ICD-10 specialty codes. Payer coverage policies currently include ICD-10 codes for provider review and comparison. Revise current forms/templates that include diagnosis codes to reflect this updated information. Schedule ICD-10 training for clinicians, office managers, billers, coders, and other key staff. Coding professionals recommend that training take place approximately six months prior to the ICD-10 compliance deadline.³ Training sessions are available from consultants, professional societies, payers, and other entities. Cost varies depending upon the type and length of training. CMS provides some free services, but in-depth training or certification for at least one practice member should be considered.