ICD-10 has garnered a great deal attention in the last few years with much of the focus being on the good, the bad, and the absurd. Just mentioning ICD-10 can raise a level of reaction in people not typically seen for something like diagnosis coding. The American Medical Association (AMA) has been a vocal opponent of ICD-10 because of its burden and cost for practicing physicians to implement. While the AMA has been able to successfully keep this change at bay for more than a decade, the federal government has made it clear the new codes will be required for use starting October 1, 2014. Therefore, it is important that physicians begin preparing now for this change.
Within “ICD-10”, the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is the diagnosis code set and the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) is the procedure code set for inpatient procedures. The Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) code sets are used today for reporting ambulatory procedures and will continue to be used as they are today with the implementation of ICD-10-PCS. This article will refer only to the ICD-10 diagnosis code set.
ICD-10 & AMA’s Advocacy Against It
Work on bringing forward ICD-10 began in the early 2000s. Since 2002, the AMA has fought against the move to ICD-10 on many fronts including testifying at a key federal advisory body known as the National Committee on Vital and Health Statistics (NCVHS), sending letters to the Department of Health and Human Services (HHS), sending letters to Congress, and testifying at the ICD-9 Coordination and Maintenance Committee. In addition, the AMA has had several meetings with key Administration officials.
On January 16, 2009, HHS published the regulation requiring the replacement of the ICD-9 code set with ICD-10 as of October 1, 2013. Initially, the proposed rule called for a compliance date of October 1, 2011. The AMA, along with over 100 physician state and specialty societies, expressed their deep concerns in comments to HHS on the aggressive deadline to complete this complex transition in such a short amount of time, which resulted in the first delay until October 1, 2013.
While the AMA’s policy, adopted by our House of Delegates, against ICD-10 dates back to 2006, the more active policy is from November 2011 and has been amended in 2012 and 2013. This policy calls for the AMA to “vigorously work to stop the implementation of ICD-10” and “evaluate the feasibility of moving from ICD-9 to ICD-11 as an alternative to ICD-10.”
Source: American Academy of Professional Coders
In February 2012, following strong advocacy from the AMA, HHS announced it was considering delaying the compliance date. On September 5, 2012, HHS finalized a second delay of one year to October 1, 2014. At this time, all encounters and discharges on or after October 1, 2014 must use ICD-10 codes. ICD-9 codes, and the transactions using them, e.g., claims, eligibility request, etc., will be rejected after this date.
At the AMA’s Annual Meeting in June 2013, a report was brought forward evaluating the feasibility of waiting for ICD-11 instead of implementing ICD-10. ICD-11 is under development and will be brought to the World Health Organization (WHO), the developer of the international code set, for consideration in May 2015. ICD-11 will build on the changes in ICD-10 and will introduce a multi-axial framework with linkages among the diagnostic concepts. The AMA’s report concluded that skipping ICD-10 and moving straight to ICD-11 was not recommended due to a number of uncertainties and greater complexities around its use, especially the impact on physicians who are paper-based. This report, however, was referred back to the AMA Board for further analysis.
A new policy was also adopted at the 2013 Annual Meeting. The policy calls for the AMA to support a mandate for a two-year “implementation” period during which time payers will not be allowed to deny or recoup payment based on the specificity of the ICD-10 code used.
Currently, the AMA is supporting two pieces of legislation introduced in Congress that would halt the ICD-10 implementation, Senator Coburn’s bill (S972) and Representative Poe’s bill (HR1701). Efforts also continue with engaging the Centers for Medicare & Medicaid Services (CMS), the agency under HHS with oversight of the ICD-10 mandate, on the ongoing concerns about the burden of ICD-10 at a time when physicians are being confronted with a variety of reporting programs that if not successful, will result in significant penalties.
The implementation of ICD-10 is a divisive issue for the industry. While many physicians have concerns about the costs and burden of ICD-10, there are many other stakeholders, including government agencies, researchers, large payers, large health system providers, and public health entities, that support the conversion. Stakeholders have already invested millions towards the adoption of ICD-10.
Despite the hard work by the AMA, the adoption of ICD-10 remains a regulatory mandate. The AMA will continue to support the Congressional bills and advocate to stop the implementation of ICD-10, but physicians also need to be realistic that they need to be prepared for ICD-10 in case it is not stopped or further delayed. Failure to be ready for ICD-10 puts all physician reimbursement at risk.
Preparing for ICD-10
Basics on ICD-10 Diagnosis Codes
ICD-10 addresses several issues that exist today with the ICD-9 diagnosis code set, including:
lack of specificity of the information conveyed in the code, at times;
use of outdated medical concepts and terminology;
lack of laterality to identify side of body; and
inability to further expand codes in diagnosis chapters, which has resulted in new codes being assigned in unrelated chapters.
Table 1 shows the differences between the ICD-9 and ICD-10 diagnosis code sets.
Table 1.
Comparison of Diagnosis Code Sets
| ICD-9 | ICD-10 |
|---|---|
| 3–5 characters in length | 3–7 characters in length |
| Approximately 13,000 codes | Approximately 68,000 codes |
| First digit may be alpha (E or V) or numeric; digits 2–5 are numeric | Digit 1 is alpha; digits 2 and 3 are numeric; digits 4–7 are alpha or numeric |
| Limited space for adding new codes | Flexible for adding new codes |
| Less detailed information in codes | More specific information in codes |
| Lacks laterality | Has laterality (i.e., codes identifying right vs. left) |
The expanded number of characters of the ICD-10 diagnosis codes allows for a greater level of detail in the code to identify disease etiology, anatomic site, and severity, as seen in this example:
| S52 Fracture of forearm |
| S52.5 Fracture of lower end of radius |
| S52.52 Torus fracture of lower end of radius |
| S52.521 Torus fracture of lower end of right radius |
| S52.521A Torus fracture of lower end of right radius, initial encounter for closed fracture |
Overall, the increased specificity of the ICD-10 codes is more flexible, which means that emerging diseases can be quickly incorporated. The higher level of detail in the codes provides the ability to more precisely code the diagnosis. As with ICD-9, ICD-10 codes are to be reported at the highest level of detail possible. ICD-10 reflects advances in medicine and medical technology making the code set more relevant to today’s understanding of diagnoses. ICD-10 also provides an improved ability to measure health care services and conduct public health surveillance.
Implementation Activities
Physician practices should already be working through their project plans for the implementation of ICD-10. The following activities provide an overview of the work that needs to be done to successfully implement ICD-10. Some of the work can be done simultaneously and the amount of time it will take to complete each step will depend on the practice’s resources, scope of work, and business processes.
1. Conduct a Practice Assessment
Completing a practice assessment will identify what areas need to be updated for ICD-10. Consider the following when completing the assessment:
Identify all current work procedures used today with ICD-9, e.g., checking eligibility, public health reporting, quality reporting, etc.
Identify all computer systems used today with ICD-9, e.g., practice management system, electronic health record, disease registry, etc.
Identify all staff who use ICD-9 and what their role is
Identify all forms that are used with ICD-9, e.g., encounter form, “superbills,” etc.
Identify any current coding support tools used for ICD-9
2. Contact System Vendors
Most practices will need to have some type of system update by their vendor in order to support ICD-10. The two biggest systems impacted will be the practice management system and the electronic health record. Other computer systems used in the practice that may be impacted include a disease management registry, e-prescribing module, and code selection software.
The following is information to obtain from the vendor:
If the system will be updated, since some systems may be too old or no longer supported by the vendor.
The timing of the installation of the updates.
Any charges for the updates to the system.
Any testing that will be completed by the vendor to demonstrate the updates are functioning.
Any additional services or products to support ICD-10.
3. Complete a Documentation Assessment
Because of the greater specificity in the ICD-10 codes, clinical documentation may need to be improved to better capture all of the concepts that are needed in order to choose the best diagnosis code. Despite concerns that documentation will become more cumbersome for ICD-10, practices may find that their current documentation is adequate. For example, ICD-10 pregnancy codes are broken down into trimesters, which is already in the documentation.
To do a documentation assessment, practices should look at their high frequency diagnosis codes under ICD-9 and determine what those codes will be in ICD-10. There are resources today that provide mappings of the ICD-9 codes to ICD-10 codes. The practice can then take their current documentation and determine if all of the necessary information is present to allow for choosing the most detailed ICD-10 code.
Better documentation will benefit the practice today with ICD-9 coding, since reporting the most specific code may result in fewer denied or pended claims. In addition, practices will find that better documentation will support them when completing quality reporting and in the event of an audit. It also may reduce the need for additional information requests from payers.
4. Contact Clearinghouse and/or Billing Service
Practices that use a clearinghouse and/or billing ser vice need to contact them about their implementation of ICD-10 and any impact it may have on the practice’s usual claims submission process. The practice will need to know if the clearinghouse and/or billing ser vice will be doing any testing with them and if so, when it will be done.
5. Contact Payers
During the implementation of ICD-10, payers will be reviewing their medical policies and may make changes to their benefit coverage and reimbursement that is triggered by the diagnosis code. Practices should talk to their priority payers about any changes they will be making to their benefit coverage or reimbursement and when their updated policies will be available for review.
6. Undergo Installation of System Upgrades
The vendor will complete the system upgrades and any testing that they will perform.
7. Update Internal Work Procedures
Any updates to internal procedures used to support coding needs will need to be completed, such as “superbills”, quality data collection forms, public health data collection forms, etc.
8. Complete Testing of Systems
Testing of the systems has two parts. The first is internal testing within the practice to ensure that the systems are working properly and can generate the necessary administrative transactions and reports for ICD-10, which the vendor might do. The second phase of testing is external with the clearinghouse, billing ser vice, and payers. External testing involves sending test transactions, e.g., claim, eligibility request, etc., to confirm that the other organization can receive the transaction and process it correctly. Full “end-to-end” testing will include the other organization sending the response transaction back so the practice can confirm it can receive it.
9. Complete Staff Training
Most staff within the practice will need to be trained on ICD-10. The level of training will depend on the role of the person and what their interaction is with diagnosis codes. Clinical staff will need to understand how their documentation will impact the ability to identify the correct diagnosis code. Coding staff will need the most intensive training. Practices will need to determine the best method of training for their staff.
10. Monitor Data Post-Implementation
Before the switch to ICD-10, practices should consider monitoring specific data related to the processing of claims. Collecting baseline data before the switch to ICD-10 will allow the practice to compare the performance of transactions and reimbursement under ICD-10. The following are specific data that the practice can track:
Number of pended claims for additional information related to diagnosis
Number of denied claims related to diagnosis coding
Average reimbursement for specific priority (high volume or high dollar) services performed
Overall account receivables
Number of other transactions (eligibility, prior authorization) that include diagnosis codes pended or denied
ICD-10 Resources.
Detailed information on ICD-10 is available through the following resources. State and specialty medical societies may also provide additional resources.
| Organization | Website |
|---|---|
| AMA Web site |
www.ama-assn.org/go/icd-10 These resources are free and include fact sheets, articles, and implementation tools. |
| AMA Bookstore |
https://commerce.amaassn.org/store/search/searchResults.jsp?search=ICD-10 There is a charge for these resources, which include ICD-10 coding workshops, webinars, books, and specialty specific coding cards. |
| National Center for Health Statistics (NCHS) |
www.cdc.gov/nchs/icd/icd10cm.htm NCHS develops and maintains the ICD-10 diagnosis code set. ICD-10 diagnosis code set files are available for free on their Web site, along with the General Equivalency Mappings (GEMs) that map the ICD-9 codes to the ICD-10 codes. |
| Centers for Medicare & Medicaid Services (CMS) |
www.cms.gov/Medicare/Coding/ICD10/index.html CMS has many free resources available on its Web site, including implementation guides, checklists, timelines, frequently asked questions, and recorded webinars. |
The transition to ICD-10 will take time and resources. Practices need to, if they have not already, assess the impact ICD-10 will have and the amount of work needed to prepare for it. Good planning will ease the implementation disruptions as much as possible.
Summary
The AMA continues to harbor serious concerns and reservations with the significant burden of the ICD-10 mandate and continues to convey these points to policymakers in Washington. The AMA is well aware of the concerns of physicians related to the growing number of burdens being placed on their practices, of which ICD-10 is a large one, and continues to advocate for overall regulatory relief. While the AMA has been working for many years to hold back the implementation of ICD-10, at this time, it does remain a regulatory mandate. Because of this, it is important that physicians prepare for its implementation in order to avoid the rejection of claims and cash flow interruptions.
Biography
David O. Barbe, MD, MHA, MSMA member since 1985, is Chair of the AMA Board of Trustees and a family physician from Mountain Grove, Mo. Mari Savickis is the AMA Assistant Director of Federal Affairs. Nancy Spector is the AMA Director of Electronic Medical Systems.
Contact: David.Barbe@Mercy.Net
