ICD-10

Washington Update on ICD-10 - March 2015

February was a busy month in Washington DC for parties interested in ICD-10.  The big question on everyone’s mind is will it get delayed again?  ICD-10 has already been delayed three times, twice by CMS and most recently last March by Congress.

The repeated delays make it difficult for anyone to say with certainty what will happen in the future.  The government is a bit like the boy who cried wolf, but remember at the end of that story the people who suffer are the owners of the sheep!

CMS Administrator Marilyn Tavenner reports successful completion of first end-to-end ICD-10 testing.  Testing was completed with over 600 providers and 14,000 claims.  81% of claims were accepted with 6% of claims rejected for ICD-9 or ICD-10 related errors.  CMS will offer to other periods of end-to-end testing April 27-May 1 and July 20-July 24.

Energy and Commerce Subcommittee on Health held a Congressional Hearing on ICD-10 on February 11th to listen to updates on stakeholder preparation.  Six of the seven panelists were in favor of moving forward with ICD-10 on October 1, 2015 with the lone dissenter concerned about implementation costs for small physician practices.

The Government Accountability Office (GAO) released a report on February 6th detailing CMS response to Stakeholder concerns.  It was these concerns that ultimately delayed ICD-10 in 2014.  Senate Finance Committee Chairman Orin Hatch (Republican, Utah) and Ranking Member Ron Wyden (Democrat, Oregon) said the report “gives them confidence” that CMS is adequately preparing for the switch to ICD-10 in 2015.

All three of these events point towards holding the line on the current ICD-10 conversion date of October 1, 2015.  We share many of Dr. Terry’s concerns for physician practices to successfully transition to ICD-10. 

My recommendation would be to prepare for ICD-10 to happen in 2015.  Join me for a webinar focused on how to prepare for ICD-10 and protect physician productivity.

The Danger of Unspecified ICD-10 Codes

Everyone is familiar with the external cause codes in ICD-10.  We have hear examples of walking into a lamppost, bitten by a turtle, or a water skier injured due to water skis on fire.  These examples provide some levity, but many of these examples exist in ICD-9 and will rarely be used in ICD-10.

Today, I want to look at an area of ICD-10 coding (and ICD-9 coding) that is more dangerous and very common in physician practices; unspecified codes.

unspec

Unspecified codes exist in ICD-9, but many people do not realize these unspecified codes also exist in ICD-10.  Unspecified codes are used by many practices to save space on their paper superbill, where there is not room to list out all of the available (and more specific) code choices.  As a result, some of the most commonly used codes in ICD-9 are unspecified codes.

If you have converted your most frequently used ICD-9 codes to ICD-10 codes, your conversion analysis may be underestimating the difficulty of transitioning to ICD-10 because of these unspecified codes.  Most applied mapping tools take an ICD-9 code and show all of the potential options in ICD-10, but these tools typically do not show ICD-10 choices that would be more appropriately associated with a more specific ICD-9 code.

For example, a practice may have 715.96 – OA Knee on their superbill.  The long description of this code is actually Osteoarthrosis, unspecified whether generalized or localized, lower leg.  A mapping tool may show this as a simple 1 to 1 conversion, with the resulting ICD-10 code being M17.9 – Osteoarthrosis of knee, unspecified.

The potential problem in this example is that ICD-10 has 10 additional osteoarthosis of the knee codes that are more specific.  Most in the industry agree that the entire point of migrating to ICD-10 is to provide more detail to provide better health outcomes and ultimately reduce healthcare expenses.  The question is how will payers respond when a claim is submitted with this unspecified code, rather than a more specific ICD-10 code that identifies whether the osteoarthrosis was primary or secondary?  Or which knee: right, left or both?

Payers have never adjudicated ICD-10 claims and will be learning as they go.  We do not know how payers will handle these unspecified codes, but practices need to be prepared to respond as they get feedback from the payers.  An additional complication is that all payers will not handle these codes the same way at the same time.

To protect cash flow, practices should examine which unspecified codes are frequently used in their practice today and be prepared to use more specific ICD-10 codes if and when they are required by their payers.

A Practical Guide to ICD-10...you will never use many of those crazy codes!

I am sick and tired of hearing about the huge increase in the number of codes in ICD-10.  How many times have we heard about 69,000 codes in ICD-10?  While we are on the subject of things that get under my skin, if I hear about a Subsequent Encounter for Burns due to water skis on fire, I might set myself on fire!

These arguments are red herrings used as scare tactics to obfuscate the real issues.

Yes, there are 69,000 diagnosis codes in ICD-10CM.  Yes, V91.07XD is the ICD-10 code that describes the aforementioned water ski burn.  However, ICD-9 has 16,000 diagnosis codes today, many of which are just as ridiculous.  These codes are rarely used in ICD-9 and will rarely be used in ICD-10. 

spaceman spiff

(ICD-10) V95.40XA – Unspecified Spacecraft accident injuring occupant, Initial Encounter

(ICD-9) E845.0 – Accident involving spacecraft injuring occupant of spacecraft

water skis

(ICD-10) V91.07XD – Burn dues to water-skis on fire, subsequent encounter

(ICD-9) E837.4 – Explosion, fire or burning in watercraft injuring skier

unspec

(ICD-10) T14.8 – Other injury of unspecified body region

(ICD-9) 959.9 – Unspecified site injury

Many of these comical examples are external cause codes.  These codes are rarely used in ICD-9 and CMS has clarified that they are not required for ICD-10.  If your practice is not using these codes today, you will not have to use them in ICD-10.

Rather than focusing on the thousands of unused (but entertaining) ICD-10 codes, most practices should be worried about how many codes their practice will actually need to use in ICD-10.  The best way to do this is begin with the ICD-9 codes your practices uses today.

Here are some steps to get started:

  1. Run a frequency report out of your billing system.  For most practices somewhere between 200-300 ICD-9 codes cover 95% of their encounters.
  2. Convert these codes into ICD-10 using a mapping tool.
  3. Compare the results to see which ICD-9 codes are easily converted to ICD-10 and which are more complicated.

Bonus Tip: Be careful of unspecified ICD-9 codes translating to an unspecified ICD-10 code, these can cause unintended negative consequence for your revenue cycle.

FREE ICD-10 Conversion Analysis

 White Plume provides FREE ICD-10 conversion analysis.

Many practices struggle with how to begin working on their ICD-10 project.  They know the risks to physician productivity and cash flow caused by ICD-10, but it is difficult to communicate the impact to staff and physicians.

One of the BEST ways to get started is to show them the impact to YOUR practice based on the diagnosis codes you use most frequently today. 

All you have to do is email an Excel file with your most commonly used ICD-9 codes.  We will send you back summary data that reports back high level analysis data in addition to the line by line detail.

 

Sample Conversion Analysis:

Capture

 

Electronic ICD-10 Superbill for Medisys Clients

The paper superbill is one of the most productive and widely adopted tools in medical practices in the past 30 years…and it will become extinct on October 1, 2015. 

Despite widespread EHR adoption, the paper superbill is being used by more than 54% of physician practices today.  It is an incredibly flexible and powerful tool that provides two key functions. 

First, it allows the clinician to quickly capture procedure and diagnosis information.  The paper superbill can be designed to match the individual needs of the practice, sometimes even at the provider specific level.  After years of use, many providers can complete the superbill in less than 10 seconds.  The reason this tool is so fast for the provider is that they have developed “muscle memory” to know where the most commonly used codes are on the superbill.  In the fee-for-service model the providers’ time is extremely valuable and cannot be compromised. 

Simultaneously, claims must be submitted to insurance carriers (public and private) for reimbursement.  The paper superbill also provides all of the necessary information to the billing department to submit claims in a timely manner.

The balance of provider productivity and revenue cycle efficiency is the critical blend that makes the paper superbill such a valuable tool for physician practices today.

Unfortunately, the paper superbill will no longer work efficiently after October 1, 2015.  To make matters worse, many practices who use these paper superbills today do not realize this process is doomed for extinction. 

ICD-10 will introduce complexities that make the paper superbill impossible to use for the provider and billing department.

ICD-10 is a mandatory change for all practices and payers.  This is different than any change healthcare has undergone in a generation.  ICD-10 is not an incentive program (like e-prescribing, PQRS or Meaningful Use) and applies not only to government payers but all insurance plans.  If a practice does not successfully transition to ICD-10 all of their non-patient pay revenue will stop October 1.

Most paper superbills communicate both procedure and diagnosis information to the billing team.  Procedures will not change in ICD-10 for the physician practice, but diagnosis codes will.  The average paper superbill has 200-300 ICD-9 codes listed which covers 95% of patient encounters.  The ICD-10 code set is more detailed than ICD-9.  Converting these 200-300 ICD-9 codes into ICD-10 codes, most practices will use 1,200 – 8,000 ICD-10 codes depending on the specialty.  This increase in the number of codes used to cover the majority of patient encounters will be impossible to fit on single page superbill.

ICD-10 is not an optional program, it is a mandate for practices.  The increase in the number of codes demands a change in the status quo of how providers communicate billing information to the billing team.  The paper superbill will no longer work.

Failure to change away from the paper superbill will cause significant productivity declines for providers and will decrease practice cash flow.

More detailed information is required for ICD-10 claims.  Practice leaders must come up with a new method to capture the encounter information from providers and send that information to the billing team in order to maintain current cash flow levels.  The most difficult part of this process will be to provide the additional detail without slowing down providers or hiring additional staff.

The most pertinent questions are who is going to provide the more detailed information and when.  Most providers would prefer to operate at the top of their license by taking care of patients rather than spending time with administrative tasks like coding.  However, if the provider gives no additional data billing employees will be unable to assign a more specific ICD-10 code.

Without any workflow changes, providers are projected to spend between 45-90 minutes per day answering follow up questions asking for additional coding detail.  This is unacceptable for busy physician practices, because providers cannot spend this time away from patients or away from their families.  Both of these are bad outcomes.

An alternative would be to use unspecified ICD-10 codes, however these unspecified codes will cause negative unintended consequences.  Payers have advocated for the transition to ICD-10 because they want the more granular data available in ICD-10.  Claims are likely to be denied or underpaid if they contain unspecified ICD-10 codes.  This option simply shifts the back and forth later in the process and delays reimbursement to the practice.

Paper based options for using a multi-page superbill, a super-sized superbill or a microscopic font are impractical for both the provider and the billing team.  Expecting the billing team to code from physician documentation or from written diagnosis descriptions will cause countless hours of lost productivity for the physician and the billing team asking and answering questions regarding more specific coding information.

There is a solution that protects both provider productivity and the revenue cycle process. 

AccelaCAPTURE is an electronic superbill designed to look exactly like the paper superbill.  This reduces the amount of change and shortens the learning curve for the provider.  AccelaCAPTURE allows the user to click or tap to select procedure and diagnosis codes on a computer or table rather than circling the codes on a piece of paper.

During ICD-9 this process is nearly identical to the paper based process.  On October 1st, selecting procedure codes is identical to the day before.  Selecting diagnosis codes in ICD-10 is very easy.  The superbill still looks exactly the same, but when clicking on a diagnosis code the provider is presented with the new code choices in ICD-10.  The new ICD-10 choices are organized to maximize the providers productivity and ensure that an accurate, detailed ICD-10 code is selected.

AccelaCAPTURE makes ICD-10 easy for providers. 

If providers are going to have to provide additional detail to make sure claims are paid after October 1st, we want to do that as efficiently as possible for the provider and at the right time from a workflow perspective. 

AccelaCAPTURE minimizes the impact of ICD-10 for the provider.  The provider can still use a superbill that is familiar to them and that is easy to complete.  The provider can still complete the electronic superbill at the right time in their workflow.  AccelaCAPTURE only requires 1 additional click to select the appropriate ICD-10 code.

This process makes it easy for providers to provide the right code to the billing team the first time.  Once the billing team has all of the necessary information, they can make sure that claims go out correctly and on time.  This prevents costly back and forth communication for the providers, and ensures that the practice can continue to collect reimbursement in a timely manner. 

What do I do next? 

To sign up to see your own customized electronic superbill and prepare your practice for ICD-10 there are three easy steps.

  1. Register your practice and upload a copy of your paper superbill by emailing  
  2. White Plume will create a site just for you where you can review your electronic superbill
  3. Once you are satisfied with your electronic superbill, enter your payment information and you will be ready to go.

Electronic ICD-10 Superbill for eThomas Clients

The paper superbill is one of the most productive and widely adopted tools in medical practices in the past 30 years…and it will become extinct on October 1, 2015. 

Despite widespread EHR adoption, the paper superbill is being used by more than 54% of physician practices today.  It is an incredibly flexible and powerful tool that provides two key functions. 

First, it allows the clinician to quickly capture procedure and diagnosis information.  The paper superbill can be designed to match the individual needs of the practice, sometimes even at the provider specific level.  After years of use, many providers can complete the superbill in less than 10 seconds.  The reason this tool is so fast for the provider is that they have developed “muscle memory” to know where the most commonly used codes are on the superbill.  In the fee-for-service model the providers’ time is extremely valuable and cannot be compromised. 

Simultaneously, claims must be submitted to insurance carriers (public and private) for reimbursement.  The paper superbill also provides all of the necessary information to the billing department to submit claims in a timely manner.

The balance of provider productivity and revenue cycle efficiency is the critical blend that makes the paper superbill such a valuable tool for physician practices today.

Unfortunately, the paper superbill will no longer work efficiently after October 1, 2015.  To make matters worse, many practices who use these paper superbills today do not realize this process is doomed for extinction. 

ICD-10 will introduce complexities that make the paper superbill impossible to use for the provider and billing department.

ICD-10 is a mandatory change for all practices and payers.  This is different than any change healthcare has undergone in a generation.  ICD-10 is not an incentive program (like e-prescribing, PQRS or Meaningful Use) and applies not only to government payers but all insurance plans.  If a practice does not successfully transition to ICD-10 all of their non-patient pay revenue will stop October 1.

Most paper superbills communicate both procedure and diagnosis information to the billing team.  Procedures will not change in ICD-10 for the physician practice, but diagnosis codes will.  The average paper superbill has 200-300 ICD-9 codes listed which covers 95% of patient encounters.  The ICD-10 code set is more detailed than ICD-9.  Converting these 200-300 ICD-9 codes into ICD-10 codes, most practices will use 1,200 – 8,000 ICD-10 codes depending on the specialty.  This increase in the number of codes used to cover the majority of patient encounters will be impossible to fit on single page superbill.

ICD-10 is not an optional program, it is a mandate for practices.  The increase in the number of codes demands a change in the status quo of how providers communicate billing information to the billing team.  The paper superbill will no longer work.

Failure to change away from the paper superbill will cause significant productivity declines for providers and will decrease practice cash flow.

More detailed information is required for ICD-10 claims.  Practice leaders must come up with a new method to capture the encounter information from providers and send that information to the billing team in order to maintain current cash flow levels.  The most difficult part of this process will be to provide the additional detail without slowing down providers or hiring additional staff.

The most pertinent questions are who is going to provide the more detailed information and when.  Most providers would prefer to operate at the top of their license by taking care of patients rather than spending time with administrative tasks like coding.  However, if the provider gives no additional data billing employees will be unable to assign a more specific ICD-10 code.

Without any workflow changes, providers are projected to spend between 45-90 minutes per day answering follow up questions asking for additional coding detail.  This is unacceptable for busy physician practices, because providers cannot spend this time away from patients or away from their families.  Both of these are bad outcomes.

An alternative would be to use unspecified ICD-10 codes, however these unspecified codes will cause negative unintended consequences.  Payers have advocated for the transition to ICD-10 because they want the more granular data available in ICD-10.  Claims are likely to be denied or underpaid if they contain unspecified ICD-10 codes.  This option simply shifts the back and forth later in the process and delays reimbursement to the practice.

Paper based options for using a multi-page superbill, a super-sized superbill or a microscopic font are impractical for both the provider and the billing team.  Expecting the billing team to code from physician documentation or from written diagnosis descriptions will cause countless hours of lost productivity for the physician and the billing team asking and answering questions regarding more specific coding information.

There is a solution that protects both provider productivity and the revenue cycle process. 

AccelaCAPTURE is an electronic superbill designed to look exactly like the paper superbill.  This reduces the amount of change and shortens the learning curve for the provider.  AccelaCAPTURE allows the user to click or tap to select procedure and diagnosis codes on a computer or table rather than circling the codes on a piece of paper.

During ICD-9 this process is nearly identical to the paper based process.  On October 1st, selecting procedure codes is identical to the day before.  Selecting diagnosis codes in ICD-10 is very easy.  The superbill still looks exactly the same, but when clicking on a diagnosis code the provider is presented with the new code choices in ICD-10.  The new ICD-10 choices are organized to maximize the providers productivity and ensure that an accurate, detailed ICD-10 code is selected.

AccelaCAPTURE makes ICD-10 easy for providers. 

If providers are going to have to provide additional detail to make sure claims are paid after October 1st, we want to do that as efficiently as possible for the provider and at the right time from a workflow perspective. 

AccelaCAPTURE minimizes the impact of ICD-10 for the provider.  The provider can still use a superbill that is familiar to them and that is easy to complete.  The provider can still complete the electronic superbill at the right time in their workflow.  AccelaCAPTURE only requires 1 additional click to select the appropriate ICD-10 code.

This process makes it easy for providers to provide the right code to the billing team the first time.  Once the billing team has all of the necessary information, they can make sure that claims go out correctly and on time.  This prevents costly back and forth communication for the providers, and ensures that the practice can continue to collect reimbursement in a timely manner. 

What do I do next? 

To sign up to see your own customized electronic superbill and prepare your practice for ICD-10 there are three easy steps.

  1. Register your practice and upload a copy of your paper superbill by emailing  
  2. White Plume will create a site just for you where you can review your electronic superbill
  3. Once you are satisfied with your electronic superbill, enter your payment information and you will be ready to go.

ICD-10 Costs for Physician Practices

In 2008, Nachimson Advisors published a landmark paper projecting the cost of implementing ICD-10 in physician practices.  On February 12, 2014 an updated study was published with additional details and revised projections.  The study projects total ICD-10 costs to range from $21,000 - $82,000 per provider.

ICD-10 is Coming, White Plume can Help

Given the letters CMS sent to AHIMA and AMA last month, it seems clear there is no intention to delay the ICD-10 conversion again.  With less than 7 months before October 1, 2014, the time to prepare is now.  Preparation involves more than just system upgrades.  Practices need to consider how physicians will be impacted, specifically in the areas of charge capture and documentation.  Then take the next step to determine how changes in those two areas will impact the revenue cycle.

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ICD-10 Threatens

Physician Productivity

and Cash Flow

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