As orthopaedic surgeons, we are facing ever-increasing challenges to practicing medicine and managing our practices. We must learn to deal with many new problems, ranging from the establishment of new delivery systems to the introduction of new payment models. These changes can have a significant impact on how we practice orthopaedics as well as on our practice revenues.

Two of the most significant challenges we face are meeting the meaningful use requirements for electronic health records (EHRs) and implementing the International Classification of Disease, 10th edition (ICD-10).

EHRs and meaningful use
The Centers for Medicare and Medicaid Services (CMS) has set standards for the “meaningful use” of EHRs. Initially, eligible physicians and practices that meet these standards will receive incentive payments; in 2015, however, medical practices that do not meet these criteria could be subject to financial penalties.

The goal of the meaningful use program is to encourage implementation of EHRs to improve health care in the United States. Meaningful use of EHRs has several perceived benefits, including the following:

• providing patients and physicians with more complete, accurate health information
• enabling better access to the information by a range of healthcare providers
• allowing patients to take a more active role in their and their family’s health care

Under the Health Information Technology for Economic and Clinical Health Act, which was signed into law in February 2009, the Department of Health and Human Services has released four regulations related to EHR implementation. Two define the “meaningful use” objectives that providers must meet to qualify for incentive payments and two define what is necessary for an EHR to be certified.

Rollout of the three stages of “meaningful use” began in 2011 and will continue through 2016. Data capture and sharing were the primary aims of Stage 1 (2011–2012). Stage 2 will begin in 2014 with the goal of advancing clinical processes. Stage 3 will be implemented in 2016 with the goal of improving patient care outcomes. Specific objectives have been established for each stage of implementation (Table 1).

Achieving “meaningful use” can be daunting without good technical support and a good understanding of what is required. Each stage requires providers to meet a series of essential “core objectives” and a selection of other objectives chosen from a set menu. These objectives are designed to ensure use of certified EHR technology for things like e-prescribing, clinical decision support, problem lists, and allergy and medication lists. All are reported through either CMS or the state Medicaid agency.

Providers will be required to report three core clinical quality measures as well as a selection of additional measures from a list. In stage 1, providers must meet 15 core objectives and 5 of 10 menu objectives, for a total of 20 measures. In stage 2, 17 core objectives and 3 of 6 menu objectives must be met. It is crucial that orthopaedic surgeons and their practice managers understand these requirements and work with their EHR vendors to be certain they are able to meet them.

ICD-10
Currently, the United States uses the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for reporting diagnoses and inpatient procedures. But in 1990, the World Health Organization endorsed the use of ICD-10 and most industrialized countries have since adopted and implemented ICD-10.

ICD codes are used to classify patient morbidity and mortality for statistical purposes. The United States has been using ICD-9 since 1978; in 2003, ICD-9 was adopted as the standard code under the Health Information Portability and Accountability Act (HIPAA). ICD-9-CM consists of three volumes; volumes 1 and 2 contain codes for diagnoses and symptoms, while volume 3 contains codes for inpatient surgical and nonsurgical procedures.

Originally, the United States was scheduled to implement ICD-10 on Oct. 1, 2011. However, implementation has been delayed several times, first to Oct. 1, 2013, and most recently, to Oct. 1, 2014. It is extremely unlikely that implementation will be delayed any further.

The conversion to ICD-10 will be difficult. In the United States, the National Center for Health Statistics, under the Centers for Disease Control and Prevention, is responsible for development and maintenance of ICD-10. ICD-10 has two parts: ICD-10-CM, which updates volumes 1 and 2 of ICD-9-CM, and ICD-10-PCS, which updates volume 3.

The two systems have significant structural differences. Coding under ICD-9-CM consists of three to five numeric digits with only two alpha characters (V and E). ICD-9 has approximately 13,800 diagnosis codes and another 4,000 procedure codes. ICD-10-CM will use three to seven alphanumeric codes and will include approximately 69,000 codes. In addition, ICD-10-PCS will include 87,000 inpatient procedure codes.

The Medical Group Management Association estimates that implementation of ICD-10 will significantly increase a practice’s direct and indirect costs, as well as result in significant practice disruption for 3 to 6 months. In addition, the time required for documentation will increase by at least 15 percent.

The cost of implementing ICD-10 has been estimated at between $475 million and $1.5 billion over 10 years. The cost for implementing ICD-10 in a small to midsized practice has been estimated at $300,000; for a large practice, implementation costs could be as high as $3 million. This includes the cost of staff education and training, business process analysis, changes to superbills, information technology costs, increased documentation, and cash flow disruption during implementation.

In addition to the costs for implementing ICD-10, practices must also incur costs for updating electronic claims submission procedures under HIPAA from American National Standard Institute (ANSI) 4010 to ANSI 5010, a process that should already be underway.

The conversion to ICD-10 has created a great deal of angst among providers, who constantly ask why the United States is making the move. In fact, there are several reasons. For example, the current ICD-9 codes are outdated and do not reflect advances in medical technology and knowledge. In addition, some complex body systems have run out of room for new codes. As a result, new codes are often assigned to chapters in other body systems, making them difficult to find.

The use of ICD-10 has many perceived benefits. The increased specificity will enable better identification of diagnosis trends, public health needs, epidemic outbreaks, and bioterrorism events. For providers, ICD-10 could mean fewer denied claims, improved benchmarking data, improved quality and patient care management, and improved public health reporting. Proper implementation has an estimated cost savings to the healthcare system of between $700 million and $7.7 billion.

It is important that providers and their practice managers begin planning for implementation of ICD-10 now. The change in the coding system will not only affect the practice but also how the practice interacts with payers, the billing office, clearinghouses, and partners that require coding information.

A number of products—including apps for handheld devices, computer software, and add-ons to electronic health records—are available to help with implementation and improve efficiency. AAOS members can obtain additional information from the following sources:

• The American Association of Professional Coders ICD-10 Provider Office Changes: www.aapc.com
• The Health Information Management Systems Society ICD-10 Playbook: www.himss.org
• The NCHS website: www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm
• The CMS website: www.cms.hhs.gov/ICD10/01_Overview.asp#TopOfPage
• The AAOS Practice Management webpages on EHR resources and ICD-10 resources (www.aaos.org/pracman) and webinars (www.aaos.org/courses)
• The AAOS 8th Annual Practice Management Meeting: Understanding and Preparing for the Future, Sept. 26–28, 2013, Chicago. (www.aaos.org/courses)

Frederick N. Meyer, MD, is codirector of the AAOS 8th Annual Practice Management Meeting. He can be reached at freddoc937@mac.com