One Year Out—What Do Anesthesiologists Need to Know About ICD-10-CM Conversion?

With the ICD-10-CM conversion deadline one year away, many professional organizations and industry experts are warning of a lack of preparation and the serious adverse effects on practice revenues.  The level of alarm and doom is not realistic nor a given outcome for the majority of anesthesiologists.  With reasonable physician diligence in documenting services completely and accurately, successful conversion is likely.  Groups should make sure that their billing companies are preparing them to meet the new documentation requirements—as ABC will do—to avoid claim processing delays or denials beginning on October 1, 2014.

We want to reassure all anesthesiologists, including our clients, that the proverbial sky is not going to fall come October 1, 2014.  Let us start with a review of the facts:

1. What is it?
   • Beginning October 1, 2014, all health care entities must use ICD-10 codes on claim forms. This includes:
     • Diagnosis codes (ICD-10-CM) used by all providers in every health care setting; and
     • Procedure codes (ICD-10-PCS) only used for hospital claims and inpatient hospital procedures.
2. What is different?
   • ICD-10 codes differ in length and structure from ICD-9 codes.  The ICD-10 codes also:
     • Contain more detail about conditions, injuries and illnesses;
     • Include the concept of laterality;
     • Use combination codes to describe conditions and associated symptoms, and
     • Use updated language and terminology.
3. What else do you need to know?
   • CMS has repeatedly stated that the October 1, 2014 compliance date is not flexible.  Claims that are submitted with non-compliant codes will be rejected. Since the conversion affects all HIPAA transactions, managed care plans do not have leeway to accept claims missing an ICD-10 diagnosis code either.
   • The mandate does not affect the use of CPT or HCPCS codes.  Claims for physicians’ professional services in all settings, including inpatient services, will continue to use CPT and HCPCS procedure codes.

Anesthesiologists can increase their chances of a smooth, orderly transition to ICD-10-CM by undertaking the following steps with their practice management software company, and with their coders and billers or their billing company:

• Verifying that the practice management billing system software is updated to accommodate ICD-10-CM;
• Providing opportunities for their coders and billers to get the detailed training they need, or confirming that your billing company is/will be training their staff on the new code sets and technology changes;
• Examining your current practice work flow and making modifications as necessary to superbills and corresponding mapping strategies, and
• Improving your documentation to provide the right level of clinical information to maintain quality and accuracy in the selection of ICD-10-CM codes.

ABC has already implemented the necessary internal software changes and staff training to make the transition from ICD-9-CM to ICD-10-CM.  One year in advance of the deadline, we are beginning to test our ICD-10 coding in order to pinpoint specific documentation issues that may present the need for focused training. Until a payer indicates that it is ready to accept ICD-10-CM and until we have completed our testing, we will continue to report the ICD-9 code, while in parallel determining the appropriate ICD-10 code. Crosswalks programmed into our software will allow for both the ICD-9 and ICD-10 codes, depending on different payer systems and on the documentation submitted by our physicians. 

Anesthesiologists who commit to bringing their clinical documentation up to ICD-10-CM standards prior to October 1, 2014 will be in the best position to avoid cash flow interruptions when their payers convert to ICD-10-CM.  That is not to say that anesthesiologists, or most physicians in general, need to become fluent in ICD-10 coding.  Instead, they need to provide enough detail in their documentation for the coder to select a diagnosis code with sufficient granularity.

Under-documentation will be a costly mistake—and one that can be prevented without too much difficulty.  More than one-third of the changes in ICD-10-CM are intended to distinguish right from left or bilateral (“laterality”).  Taking into account the medical specialty and unique needs of the individual practice, an ICD-10 expert can easily explain the remaining two-thirds.  A good consultant (internal or external) helps target the right level of training at the right time and for the right staff.  This preparation helps identify potential problems ahead of time, which could save significant dollars in the long run.

ABC’s approach is best expressed by Joette Derricks, Vice-President Regulatory Affairs and ICD-10-CM Project Manager, thus: “We do not want to waste our clients’ time in teaching them ICD-10-CM codes.  We see great success with customized training for physicians on documentation requirements.  The easier it is for the physician, the better the results for everyone.”   Over the next few months, our certified ICD-10-CM trainers will be analyzing gaps in client documentation so as to target specific, individualized physician training needs. 

ICD-10 Example for Anesthesiologists: Fractures

As an example of the difference between the two coding systems, let us take a look at the respective codes for a musculoskeletal system diagnosis.  The anesthesia record presented to the coder contains the simple diagnosis “fracture radius shaft.”

To code a fracture in ICD-10 the following will be necessary:

• Anatomic site on bone (proximal, shaft, distal) (not required for anesthesia claims);
• Laterality (right or left);
• Fracture Type (displaced, non-displaced, open or closed; if open there are 3 more subsets to choose from), and
• Episode of care (initial, subsequent, or sequela) (a sequela is a chronic condition that is a complication of an acute condition that begins during that acute condition).

ICD-9 Coding—Without any further detail, we can code this as 813.21 (Fracture of radius and ulna, shaft closed, radius alone).

In ICD-10, we have to code it with the addition of laterality, the fracture type and episode of care.  There are currently 270 ICD-10 code choices for this injury.  For this example, we will choose the right side, closed and non-displaced transverse type fracture, with initial episode of care.  The code would be S52.324A, built as follows:

• S52.3 – Fracture shaft of radius
• S52.32 – Transverse fracture of radius
• S52.324 – Nondisplaced transverse fracture of shaft of RIGHT radius
• S52.324A – Nondisplaced transverse fracture of right radius, initial encounter for closed fracture

As is the case now, coders will not be able to make assumptions.  The documentation will need to be clear, concise and detailed.  The anesthesia record will have to show right or left side, open or closed, initial or sequela in order for staff to code it appropriately.  In ICD-10 there will be very few “not otherwise specified codes,” so coders will simply have to code based on the documentation the anesthesiologist provides or that is available as part of the medical record.  This may mean examining the surgeon’s medical record documentation, e.g. the operative report, to get all the needed information.  Missing particulars could thus significantly slow the billing process.

Beginning to test our ability to select and submit the appropriate ICD-10-CM codes one year out provides us and our clients with a reasonable level of confidence. That is not to say that every practice across the country must be at this stage of preparedness or else expect to suffer adverse financial consequences, but the clock is running.   We hope that sharing some insights into our process and planning will help alleviate fears occasioned by the hype regarding denied claims and cash flow problems when the health industry makes the shift to ICD-10-CM.  We will continue to provide ICD-10 information in future Alerts to ensure a smooth, seamless transition.