ICD-10 Straight Talk: Overview

The following article is written by Angela "Annie" Boynton, BS, RHIT, CPC, CCS, CPC-H, CCS-P, CPC-H, CPC-P, CPC-I, director 5010/ICD-10 communication, adoption and training for UnitedHealth Group and developing member of the AAPC's ICD-10 Training team.

As a result of a final rule published on Jan. 15, 2009, by HHS under the administration simplification provisions of HIPAA, all covered entities (including healthcare providers, health plans and healthcare clearinghouses) are required to comply with new code set regulations regarding the International Classification of Diseases, 10^th Edition (ICD-10) for all covered electronic transactions for dates of service on and after Oct. 1, 2013.

The new code set regulations address usage for the following:

Clinical Modifications (ICD-10-CM) Diagnosis Code Set
Procedure Coding System (ICD-10-PCS) Procedure Coding System.

ICD codes are used to classify diagnoses and inpatient procedures and are one of the fundamental elements of healthcare reimbursement. The conversion to the ICD-10 code sets represents a significant change to the coding structure and will have impacts in a majority of business processes and systems as well as require significant training and updates to numerous medical policies and contracts. These changes will be felt across all types of healthcare providers, facilities and payors.

Diagnostic codes are used across inpatient and outpatient service settings to establish medical necessity, to trigger benefit/coverage determinations and to aide in many quality reporting initiatives. It is a gross misconception for outpatient providers and facilities to think that they will not have to deal with ICD-10 codes in the future.

Over the past few years I have had the pleasure and privilege of discussing the importance of ICD-10 with various providers, provider groups and industry organizations. The common question that is often presented to me: "2013 is almost three years away — why should I care now about implementation?" It is a valid question, albeit one mired in industry misconception, avoidance and fear.

Preparing for the single largest healthcare change the United States has ever seen is not small task. Many organizations are avoiding or ignoring ICD-10 implementation in favor of competing priorities like ARRA, HITECH meaningful use, 5010, health reform, etc. Yet the majority of these organizations do not realize that ICD-10 implementation is bigger than any of these; it has the potential to financially devastate larger, fiscally sound organizations if implementation planning is not addressed early on. Imagine what it could do to smaller, less financially stable organizations.

The longer ICD-10 implementation planning is put off, the harder it will be to comply by the mandate. It has been said over and over again by industry experts, but it is a message that bears repeating: Those who wait until the last minute to prepare for ICD-10 are risking revenue losses in 2013 and beyond. The risks are tangible, in the form of payment delays and rejected claims. The only way to mitigate these risks is to be fully compliant with ICD-10 by the Oct. 1, 2013, mandate. It is an industry accepted fact that revenue will be impacted to some extent. It will take significant resources, time, and planning in order to adequately achieve compliance, and mitigate any revenue impacts.

There is much work to do in order to prepare for ICD-10: communications, budgeting, training, staffing, IT systems, vendor discussions, business associate issues, trading partner testing and 5010 implementation are just a few of the areas of concern. Let's discuss a few things practices can do to get the ball rolling toward ICD-10 compliance.

Plan for the ICD-10 transition

Organize those responsible for ICD-10 implementation in your practice or facility and form an implementation leadership team. Clearly establish who is going to lead the overall implementation effort. Having a clear "chain of command" will help the implementation process.

There is great benefit in conducting an impact assessment. For a smaller organization it may be as simple as asking, "How are ICD-9 codes used today?" Once these areas are identified, it will be easier to see where remediation efforts need to be focused. Having a plan and timeline on paper for the ICD-10 implementation team will help make the process move more smoothly.

Recognize the documentation impacts

In many practices the biggest hurdle in the ICD-10 implementation process will be how to handle the vast new documentation requirements needed for accurate ICD-10 code selection and reimbursement. It is strongly recommended that documentation efforts begin as early as possible. This can be done by performing simple documentation audits comparing ICD-9 coding and documentation with its ICD-10 counterpart and taking note of the gaps.

In its entirety, the ICD-10 code set has just over 155,000 codes. That is significantly more than the 18,000-plus codes we use in ICD-9. Much of the reason for this great expansion is due to the fact that ICD-10 codes are incredibly specific and much more granular than anything we use today.

For example, compare the codes representing "complications of foreign body accidentally left in body following a procedure."

ICD-9 has one code:

998.4, Foreign body accidentally left during procedure, not elsewhere classified.

ICD-10-CM has 50 codes. Here are a few examples:

T81.530, Perforation due to foreign body accidentally left in body following surgical operation

T81.524, Obstruction due to foreign body accidentally left in body following endoscopic examination

T81.516, Adhesions due to foreign body accidentally left in body following aspiration, puncture or other catheterization

Note the specificity in the code descriptions as identified by the underlined terms. When comparing the codes in this manner, it is important to consider what the documentation will need to reflect in order for a coder to accurately select a code.

ICD-10 training

Training can easily be the largest part of any ICD-10 implementation budget. It is important that as early as possible a training plan is developed. A critical point of concern is accepting the fact that there is a significant difference between implementation training and code set training, and when to provide each type of training.

Implementation training is more commonly seen in larger group practices and organizations that have teams of people responsible for the ICD-10 transition and it is given early-on. Implementation training is offered by several industry organizations, such as AAPC, though implementation training is a good introduction to anyone interested in learning about the complexities involved with ICD-10 implementation.

Code set training provides detailed knowledge of the code sets. This is the training that coders will need in order to stay current with the ICD-10 transition. Since ICD-10 is formally divided into two separate and distinct code sets, identification of which code set (ICD-10-CM, ICD-10-PCS or both) and the timing of the training will be critical in any implementation plan.

However, training coders too soon could be a costly risk. In order for coders to be proficient, they must use a code set regularly in order to keep their skills. It is unwise to train coders too far out, less they forget and ultimately require retraining. CMS recommends training coders 6-9 months ahead of the ICD-10 implementation date, and ensuring that coders have continual practice throughout 2013. This timeline will obviously vary given the specialty, setting, size of the organization and the number of coders that require training. Planning and budgeting for a strategic training plan will help to mitigate productivity losses as a result of training. Furthermore, ICD-10 training is intensive. Do not underestimate the amount of time coders will likely need to become fully proficient in ICD-10. Plan for 20 hours for outpatient coders learning the diagnostic set (ICD-10-CM) and 50 hours for inpatient coders learning both the diagnostic and procedure sets (ICD-10-CM/PCS).

Avoiding ICD-10 will not make it go away. It will make the process more costly, more difficult, more resource intensive, and more stressful. The only sure way to lessen the costs associated with ICD-10 implementation is to understand the impact that implementation will have on your organization. Even as I write this, I know there will be organizations that will go out of business because they waited too long to implement ICD-10. There will be revenue impacts across all settings, provider, facility, vendor and payor alike. Physicians, practices and facilities that do not adequately prepare for ICD-10 risk not getting paid for the services they render. The best advice is to start implementation planning now, the longer it is put off the harder and more costly it will be.

Ms. Boynton is a multi-credentialed coder and the director 5010/ICD-10 communication, adoption and training for UnitedHealth Group. She is an adjunct faculty member at Massachusetts Bay Community College and is a developing member of the AAPC's ICD-10 Training team (www.aapc.com). Ms. Boynton frequently speaks and writes about coding matters, including ICD-10 and 5010 implementation.

The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.

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AAPC Instructor Advises Coders to 'Bone Up' on Anatomy and Physiology for ICD-10