“Whether you like it or not,” said John McGraw, MD, “in less than a year, ICD-10 is going to be here.” Dr. McGraw, chair-elect for the AAOS Board of Councilors (BOC), was addressing members of the BOC and the Board of Specialty Society (BOS) during their Fall Meeting. The panel of experts he introduced echoed his call for readiness.
Why make the switch?
“Don’t shoot the messengers; it’s not our fault,” began M. Bradford Henley, MD, MBA, FACS, a member of the AAOS Coding, Coverage, and Reimbursement Committee (CCRC). “But beginning on Oct. 1, 2014, anyone who uses the International Classification of Diseases, Ninth Edition (ICD-9) can expect a denial.”
According to Dr. Henley, the transition to ICD-10 has nothing to do with the passage of the healthcare reform act known as “Obamacare” and will have no impact on Current Procedural Terminology and Healthcare Common Procedure Coding System level II and level III codes, which will continue to be used for physician and ambulatory services, including physician visits to inpatients, and for supplies.
Dr. Henley explained that ICD-9, which has been used for nearly 40 years, is outdated, neither flexible nor exact enough, and no longer has enough codes to describe the services provided by physicians. On the other hand, ICD-10 has improved descriptions of diagnoses and services, updated terminology to reflect modern medicine, improved quality of coding for health service measurement and substantiation of medical necessity, and captures longitudinal disease information.
ICD-10 has approximately 69,000 diagnostic codes and approximately 87,000 procedural codes (used by hospitals); most musculoskeletal codes will have seven characters (both alpha and numeric). Dr. Henley outlined the structure of ICD-10 codes (Fig. 1), including the different characters and chapters most relevant to orthopaedics (for example, chapter 13 diseases of the musculoskeletal system and connective tissue and chapter 19 injury). He noted that injuries are arranged by anatomic site rather than type of injury.
“Pretty much anything you can think of can be captured in ICD-10 coding,” said Dr. Henley. He encouraged extensive documentation to support accurate coding and enable better risk adjustment.
One tool that may prove helpful is the “pick list” feature of Code-X, which contains several databases. Entering code words will progressively reduce the number of codes that could potentially describe the condition. The AAOS is working to refine the list of qualifiers to establish specific lists and enable practitioners to “hone in” on the correct code. “This is going to be our savior,” said Dr. Henley.
R. Dale Blasier, MD, current chair of the CCRC, noted that the committee has spent a considerable amount of time identifying what would be most important for AAOS members to know. He pointed out that musculoskeletal conditions in general require greater documentation for ICD-10 than for ICD-9, that fractures will require more detail, and that encounter codes will change during follow-up.
For example, fracture coding will require documentation of whether the fracture is closed or open (closed is the default), the location of the fracture on the bone (upper end, lower end, or shaft), laterality, pattern, and displacement (displaced is the default); open fractures require documentation of Gustilo type (types I and II are low-grade; types IIIA, IIIB, and IIIC are high-grade).
This means a larger documentation burden for the physician and more opportunities for errors, omissions, and denials. A recent gap analysis study showed that physician documentation is “pretty good” at capturing laterality and specific fracture type, but often missed the number of parts, the Gustilo type, displacement, comorbidities, and type of healing seen in subsequent encounters.
“Surgeons will need to look at specific sections of ICD-10 to see how things are described so the documentation can mirror the descriptions,” advised Dr. Blasier. “ICD-10 is big; it’s an unfunded mandate that will slow you down and will change how you practice. What you need to remember is that it’s not what you do but what you document that counts.”
Thomas J. Grogan, MD, chair of the Practice Management Committee, offered some practical considerations in preparing for ICD-10. He suggested that members consider the impact of the potential loss in productivity, delays in reimbursement, and increase in claims denials that could result from the transition and affect practice revenue.
To make the transition “as painless as possible,” Dr. Grogan recommended that members take advantage of current resources from the AAOS, including participating in webinars and using the Code-X product. He also suggested conducting an impact analysis to assess a practice’s readiness for ICD-10. Because most orthopaedic surgeons are in small group practices of five or fewer physicians, education is important and cost will have a significant impact on the practice.
In conducting the impact analysis, physicians should choose a representative from each area of the practice that will be affected and have this group perform the analysis, identify the areas at risk, and prepare plans to mitigate that risk. “Remember, there will be no grace period,” he said.
Dr. Grogan also recommended that practices contact their software vendor(s), evaluate their current information technology systems, provide additional training, test systems prior to implementation, and plan for a temporary drop in income of up to 30 percent, with a corresponding loss of productivity. Practices, he said, should establish an implementation timeline (Fig. 2) and prominently post it. “We can make this happen,” he said, “but I’m not sure that the carriers or other payers will be ready.”
Because in most practices a limited number of diagnosis codes account for a substantial percentage of billings, Dr. Grogan suggested focusing on those. He also recommended educating everyone in the office, including administrative and front office personnel, coders, other back office staff, and physicians. Everyone, Dr. Grogan stated, needs education.
“Contact your vendors and see which are ready for ICD-10,” said Dr. Grogan, who reported that a recent survey of vendors found that a third had not even started preparing for ICD-10. “That’s scary,” he said, “and we may not know the answers until the very last minute.”
Elizabeth Fassbender is the communications specialist in the office of government relations. She can be reached at firstname.lastname@example.org
- Centers for Medicare and Medicaid Services (CMS) Get started with ICD-10: Basics for Medical Practices and FAQs: ICD-10 Transition Basics.
- American Health Information Management Association (AHIMA)
- ICD-10 is Coming—Are You Ready?
- Switching to ICD-10: The impact on physicians
- HIMSS ICD-10 PlayBook Financial Risk Calculator
- AAOS Practice Management Center