July 5, 2016

The transition to the International Classification of Diseases and Related Health Problems 10th revision (ICD-10) appears to have gone well so far, despite widespread anxiety that it would wreak havoc across healthcare as providers struggled to comply with the new coding structure, heightened specificity and documentation requirements.  The Centers for Medicare and Medicaid Services (CMS) reports that total claims denials and other claims metrics remained essentially unchanged from the historical baseline to the fourth quarter of calendar year 2015.

In a blog post, Andy Slavitt, CMS acting administrator, likened the healthcare industry’s anticipatory concerns surrounding ICD-10 to the Y2K information technology disaster that never took place.  “With preparation, planning, a focus on the customer, collaboration, clear accountability, and metrics, the dire Y2K fears didn’t come to pass.  Instead, ICD-10 became like what actually occurred on Y2K, an implementation and transition most people never heard about,” he said.

So far, so good.

Nonetheless, providers still face significant hurdles in two main areas as the ICD-10 transition continues.  According to Sharon Merrick, director of payment and practice management for the American Society of Anesthesiologists (ASA), it is not yet clear how much of the ICD-10 implementation’s success so far stems from the first-year concessions for providers negotiated by the American Medical Association in collaboration with the CMS.  These flexibilities allow providers to be reimbursed for wrongly coded claims as long as the erroneous code submitted is in the same broad family as the correct one.  Providers will no longer be reimbursed for these wrongly coded claims when the “grace period” ends on September 30, 2016.

In addition, following a five-year freeze on the addition of codes, a backlog of 5,500 ICD-10 codes will go into effect on October 1.  This backlog, accumulated by the ICD-10 Coordination and Maintenance Committee, includes approximately 3,650 new ICD-10-PCS codes and approximately 1,900 new ICD-10-CM codes, as well as 500 revised ICD-10-PCS codes and 351 revised ICD-10-CM codes. 

Coding expert Stanley Nachimson of Nachimson Advisors said work will be needed to implement these additional codes, “but not like the full ICD-10 implementation.”

The new codes relate to devices, the addition of bifurcation as a qualifier, additional body parts, congenital cardiac procedures and placement of intravascular neurostimulators.  Approximately 97 percent of the ICD-10-PCS codes are in the cardiovascular system section.  Changes to ICD-10-CM cover a greater list of body systems and sections of the code book. 

What Now? 

If you haven’t already done so, it’s not too soon to assess how your practice has fared to date with ICD-10 implementation, identify areas in need of improvement and start implementing solutions. 

An article in Health IT Outcomes stresses the role of accurate coding in helping providers navigate the shift from volume to value through participation in federal programs, such as the Physician Quality Reporting System (PQRS).

“Using invalid and outdated codes and not properly reporting patient encounters causes increased work hours to deal with problems, and can cause your facility to lose eligibility for participation in these important programs,” according to the article.  “Missing benchmarks due to invalid codes can prevent eligibility for pay-for-performance programs that offer your facility valuable financial incentives based on performance.  Keeping your working terminologies up-to-date will prevent your patients and clinicians from losing out on many important incentives.”

Fortunately, a plethora of resources and tools is available to help you avoid these pitfalls and continue with your transition to ICD-10. 

The Next Steps Tool Kit and a companion Infographic, available from CMS, offer a process for evaluating your ICD-10 efforts based on three steps:

1. Assessing progress using key performance indicators (KPIs) to compare your practice’s performance before and after October 1, 2015 (when ICD-10 went into effect).  Examples of KPIs include:
   • Days to final bill—number of days from time of service until provider generates and submits claim
   • Claims acceptance/rejection rates
   • Claims denial rate
   • Incomplete or missing diagnosis codes
   • Payment amounts—amounts provider receives for specific services, with a focus on high-volume, resource-intensive services
   • According to CMS, it is not necessary to track all 18 suggested KPIs listed in the Tool Kit.  Even small efforts to identify and track the KPIs most relevant to your practice will help improve your productivity and cash flow.  CMS suggests tracking KPIs separately by payer to help pinpoint root causes of problems.
2. Troubleshooting findings by developing a feedback system to document issues and share findings among staff; checking clinical documentation and code selection; identifying issues in your practice management systems, electronic health records or coding tools that could increase days to final bill and claims rejection rates; resolving issues with payers; and conducting hospital chart audits with a focus on high-risk cases.
3. Maintaining progress by keeping your systems and coding resources up to date with regular reviews of the ICD-10-CM and ICD-10-PCS General Coding Guidelines.  (Proposals can be submitted at least two months in advance to the ICD-10 C & M Committee for review at its meetings held in March and September.)

The CMS website Road to 10:  The Small Physician Practice’s Route to ICD-10, includes an overview, webcasts, action plans, checklists, interactive case studies, quick references, resources and contacts.  Marc Leib, M.D., chair of the ASA Committee on Economics, who has delivered webcasts on ICD-10 for pain procedures and surgical and obstetrical anesthesia (see below), recommends Road to 10 because it compiles information from numerous other CMS ICD-10-related websites into a single location.

Anesthesia Business Consultants offers F1RSTCode, an anesthesia-specific ICD-10 documentation application for clients that guides providers through the logic of ICD-10 and provides intuitive support on the correct level of detail needed in a diagnosis.  For more information, contact info@anesthesiallc.com.

A two-part series in ICD-10 Monitor delves into strategies for clinical documentation improvement using KPIs.  ICD-10 Monitor also sponsors Talk Ten Tuesdays, webcasts featuring industry experts and providers who share their experiences with the transition to ICD-10.

ICD-10 Coding Concepts:  A Refresher

Although physicians do not have to know the codes, primary responsibility for the accuracy of ICD-10 coding remains with them, David A. Lubarsky, MD, chief medical and systems integration officer at the University of Miami said in Anesthesiology News.  “Coders simply won’t be able to ‘build’ ICD-10 codes without all of the building blocks of information being in the chart.”  

In his webcast presentations at the Road to 10 website, Dr. Leib presents the key coding concepts of ICD-10 with an emphasis on anesthesia for pain management and surgical and obstetrical procedures.  Following are some of the highlights of the presentations:

• Despite the fact that ICD-10 contains 69,000 codes, most physicians and anesthesiologists included, will use only a small percentage of them.  The number of ICD-10 codes used by anesthesiologists is not much larger than the number of codes used in ICD-9.
• Some of the most important areas of change from ICD-9 to ICD-10 are:

Laterality:  Correct ICD-10 coding designates right or left side.

Initial versus subsequent:  Correct ICD-10 coding requires documentation of whether the encounter is an initial or follow-up visit.  Indicating “patient returns” or “seeing patient for the first time with____” will allow your coding professionals to select the proper seven digit code.

Disease acuity:  Unlike ICD-9, ICD-10 allows the clinician to indicate whether the disease state was mild, moderate or severe.  If clinicians cannot document and communicate how sick patients are to begin with, they will not be able to explain why treatment took longer or why more resources were used.

Complications:  ICD-10 contains single codes that include the underlying disease as well as the common complications or comorbidities.  For example, only one code is needed to describe Type 1 diabetes with kidney disease and dialysis, whereas in ICD-9, two, three or four codes were needed to describe that condition.

Underdosing:  An important new concept in ICD-10, underdosing refers to patients who do not take their medications as directed and who do not get well or do not get well as quickly as if they had taken their medication correctly.  These patients can end up in the ER or the hospital, both of which count as negative occurrences in the quality systems being implemented by CMS and private insurers.  However, if the patient is being readmitted because they did not take the medication or take it correctly, that must be recorded.

• Describe the patient to the best of your knowledge at the time you see them.  If you know the diagnosis, there will be a code.  The unspecified codes should only be used when you don’t have the information necessary to select a specific code.  Gone are the days of defaulting to the “not otherwise specified” (NOS) code.  Payments for claims using the old default code are typically curtailed or denied in ICD-10.
• Know your role:  The role of the clinician is to document as accurately as possible the nature of the patient’s condition and the services performed to maintain or improve that condition.  The role of the coding professional is to ensure that coding is consistent with the documentation.  The role of the practice manager is to ensure that all billing is accurately coded and supported by the documentation.
• Ensure that coding supports the patient story, but coding must be supported by what is in the medical record.
• Avoid “over-coding.”  If it isn’t relevant to the visit, don’t code unless it is a condition that presents additional complexity and risk.
• Use the right codes for pain procedures:  Pain can be caused by a number of different factors, including psychological factors, postoperative pain, neoplasm related pain, medical device pain, chronic pain or chronic pain syndrome.  It is important to note the cause of the pain to select the proper code. 
• If the reason for the encounter is pain management or the placement of a neurostimulator for pain management, G89 is used as the general pain code.  The reason for the encounter is the first code listed, but if the patient is there specifically for pain treatment, G89 is the first code.  If you are treating the underlying condition and pain management is the secondary part of that treatment, list that condition first, then use G89 as the secondary code. 
• If the encounter is for postoperative pain, whether you do a block postoperatively or in the recovery area or even in the preoperative area prior to surgery, but the block’s purpose is strictly for postoperative pain control, not for surgical anesthesia, then use G89 as the secondary code and the surgical procedure that will cause the pain as the primary code.  Each surgical procedure will have a code for postoperative pain.  Your coder should list that first and the G89 will be the secondary code.
• Neoplasm-related pain:  If the cause of the chronic pain is due to some type of neoplastic process and that is the primary reason for the encounter, then use G89 as the first code with the specific neoplasm code as the secondary diagnosis.  If you are seeing the patient because of the neoplasm (not likely to happen), and happen to treat the pain as well, then the malignancy would be listed as the primary diagnosis and G89 is the secondary code.  The primary purpose of the visit will determine which code is listed first. 
• If the pain disorder is exclusively psychosocial, use behavioral health code F45.41.  If the pain disorder exists alongside a psychological disorder, use F45.42 and G89 as the secondary code.
• If the reason for the encounter is pain related to an implanted medical device, then that is a complication of the implant.  List complication of implant as the primary code and the code for acute or chronic pain as a secondary code.
• Spinal regions differ by code.  Each different type of diagnosis may have different divisions of the spinal region.  For example, the spondylopathies each have eight different regions of the spine.  If you are dealing with a spondylopathy you need to specify which of those eight areas are affected. 
• Whenever possible, use the same codes the surgeon uses to support the procedure.  This should reflect the post-operative rather than the pre-operative diagnosis.  If the surgeon does not have the information needed to accurately select the ICD-10 code, use the hospital electronic health record or other records as a guide.  For a patient undergoing laparoscopic cholecystectomy for calculus of the gallbladder, for example, ICD-10 includes 40 codes to describe why the patient is undergoing the procedure.
• Carefully document the medical conditions of the patient that are necessitating the surgery to enable your coders to find and determine the correct codes to use when filing claims.  It is up to the anesthesiologist to document the medical condition of the patient in a way that will allow coders to use their expertise to select the proper codes.

Conclusion

Although jokes about the specificity of ICD-10 coding abound (W61.33: Pecked by a chicken; Z63.1: Problems in relationship with in-laws), the new system is expected to yield significant improvements in quality measurement, public health, organizational monitoring and performance, health information technology and reimbursement.  It behooves providers to evaluate and fine-tune their programs now in preparation for the changes that will go into effect on October 1, 2016.

With best wishes,

Tony Mira
President and CEO