Preparing Your Surgery Center for ICD-10: Part 4 (Billing and Coding)

Lolita Jones, RHIA, CSS, independent coding and billing consultant, discusses 10 ways ICD-10 will affect billing and coding processes in an ambulatory surgery center. This article is the fourth installation in a four-part series. Editor's note: To read the first three parts of this series, click on the following links:

Preparing Your Surgery Center for ICD-10: Part 1 (Initial Planning)

Preparing Your Surgery Center for ICD-10: Part 2 (Front Office Processes)
Preparing Your Surgery Center for ICD-10: Part 3 (Patient Encounters)


1. Ask outsourced coding vendors for documentation on ICD-10 transition plans. Many ASCs outsource their coding to third-party vendors, meaning surgery center leaders must speak to vendors about their plans for ICD-10 well before the transition. Ms. Jones recommends ASCs ask vendors to document how they will train their coding staff for ICD-10 and provide proof of training completion for any staff who will work on the center's accounts. She says ASCs might also benefit from asking the vendor to assign several specific people to their coding tasks while the ICD-10 transition occurs. "I would want information in writing that this is the person who will handle your coding under ICD-10," she says.

2. Perform a gap analysis on in-house coding staff. If an ASC has not outsourced its coding to a third-party vendor, the ASC leaders will have to perform a "gap analysis" to determine where coder weaknesses lie prior to training. "Usually that will focus on biomedicine skills," Ms. Jones says. "For instance, how strong are they in medical terminology, anatomy and physiology and even pharmacology?" She says ASCs can find free gap assessments on AHIMA's website and other sites. The gap assessment will help the ASC administrator understand where coders need to concentrate their training and how long training will take.

3. Decide how training will take place. Coders can undergo ICD-10 training in a number of different ways. The surgery center can use in-house staff to lead training efforts, hire a consultant to come to the surgery center or pay for staff to go to community college or take online courses. Ms. Jones says ideally, surgery centers will conduct training in-house.

"In a perfect world, it would be great if they could have the training done by staff at the center," she says. "You're talking about a center that is filled with clinical people in a smaller, less political environment than a hospital. If you plan well enough in advance, it's feasible to utilize nursing staff or the administrator to help with training." She says centers can easily purchase training materials for staff to use, but many centers may not be able to dedicate enough time to conduct in-house training.

4. Talk to an attorney about staff training. Ms. Jones recommends surgery centers speak with an attorney about how to train staff members who may leave the surgery center at any point. She says she has seen surgery centers ask staff members to sign agreements saying they will pay the surgery center for the cost of training if they leave the center before a certain date (e.g. Jan. 1, 2014).

If staff members do not feel they can tie themselves to the surgery center for that length of time, she says the employee may be able to sign an agreement that says they will undergo training on their own before a certain date. "You would then give the employee an in-house test to make sure you're comfortable with what they've learned," she says. She says these agreements are important because the demand for ICD-10-knowledgeable coders will increase drastically as implementation nears. "You have to make sure you don't train people who are then scooped up," she says.

5. Ask coders to practice assigning ICD-10 codes before implementation. Ms. Jones says coders need to undergo training in two steps. To begin with, coders should be trained at an "intermediate" level, where they learn the landscape of ICD-10 and the basic changes to the system. After they have completed intermediate training, coders should go through advanced training that lets them practice assigning codes for the specific cases being performed at the center. "

For that internal training, you might have to bring in a consultant or have the administrator head it up," she says. She recommends asking coders to dual code every nth case with both ICD-9 and ICD-10 codes. "This should start in February or March 2013," she says. "It will keep coders' skills sharp and let you keep your eye on the areas where they are weak."

6. Create a spreadsheet of payor preparedness. Ms. Jones advises surgery center billing staff to create a spreadsheet of all its payors and track payor ICD-10 preparedness. "The spreadsheet should include payor name, status of payor's ICD-10 preparedness, name of the payor contact and the date they were last contacted." For instance, the sheet might list: Blue Cross Blue Shield; ready to start testing claims in 10 months; Jane Smith; Jan. 5.

7. Keep an eye on HIPAA-exempt payors. Some payors, including workers' compensation and disability income insurance, are legally exempt from HIPAA transaction standards, meaning they don't have to convert to ICD-10 like other payors. Ms. Jones recommends speaking with these payors to determine their plans for ICD-10. "CMS is saying, 'Well, of course they will transition,' but they might not do it on Oct. 1," she says. Make a separate spreadsheet for HIPAA-exempt payors and keep track of their progress toward ICD-10. She said this is especially important for ASCs that perform a majority of orthopedics cases and therefore rely on workers' comp for reimbursement.

8. Develop a plan for post-implementation payment issues.
Ms. Jones says ASCs should develop a plan for the payment issues that will inevitably arise in the three months after ICD-10 implementation. She says the ASC will likely have to spend more time on billing tasks, meaning the center may need to hire a temporary biller to stay into the evenings. The ASC should also have a contingency plan in case a staff member leaves the center. "There are things you can't plan for, and you need to know that if a person left tomorrow, you would be able to bring someone else in to pick up where they left off," she says.

9. Calculate the potential impact on ASC reimbursement. Prior to ICD-10 implementation, the ASC administrator and billing manager should sit down and calculate how the transition will affect ASC reimbursement, Ms. Jones says. She says managed care contracts should be reviewed to make sure the ASC understands how the transition will impact contract performance, compliance, negotiations and auditing. ASCs should also not discount the impact of ICD-10 on Medicare.

"A lot of people think that because ICD-10-CM does not impact APC payment groups, it won't affect Medicare," she says. "It will still impact medical necessity, and if you're billing a claim with a diagnosis code that isn't justified, that won't go away."

10. Determine whether new codes can be used to renegotiate contracts. Ms. Jones says coders should thoroughly review the ICD-10-CM codebook to see whether new codes can be used to renegotiate contracts. "The ASC may now be in a position to collect information on patient lifestyle that has an impact on surgery and how they're treated," she says.

For example, obesity is coded more thoroughly in ICD-10-CM, with many different codes used to capture the causes and types of obesity. She says this information could be coded and reported on a claim, and ASCs should build that into their contract information.

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