Judy Larson, CPC


Published 6/1/2013

Getting Ready for ICD-10

Rockford Orthopedic Associates is moving forward

Although many orthopaedic practices may be crying, “Say it isn’t so!”, the Centers for Medicare and Medicaid Services (CMS) has announced that on Oct. 1, 2014, the codes used to report medical diagnoses and inpatient procedures—currently the International Classification of Diseases, 9th edition (ICD-9)—will be replaced by ICD-10 code sets. Orthopaedic practices, therefore, have approximately 15 months to make the transition.

Rockford Orthopedic Associates, Ltd., (ROA) isn’t waiting. According to orthopaedic surgeon Scott W. Trenhaile, MD, and billing manager Judy Larson, CPC, members of the practice are confident that CMS won’t delay ICD-10 implementation again. As a result, they’re improving documentation and putting processes in place now to avoid as much financial impact as possible next year.

Recently, David L. Cannon, MD, of the AAOS Practice Management Committee, spoke with Dr. Trenhaile and Ms. Larson about the steps ROA is taking.

David L. Cannon, MD

Scott W. Trenhaile, MD


Dr. Cannon: How long ago did the practice begin to focus on ICD-10?

Dr. Trenhaile: Our billing department began working on this in April 2011.

Dr. Cannon: What were your first steps?

Dr. Trenhaile: Our billing manager began having weekly meetings with the billing staff, and we started training them on anatomy and physiology so they could understand and be able to work with the new codes. We worked with an ICD-10 draft form of the codes and were pretty formal about the training, including keeping a log of attendance and doing some testing.

Ms. Larson: We weren’t asking staff to learn the codes because the codes were subject to change. But we wanted staff to be able to locate codes and know how the codes would be indexed.

Dr. Trenhaile: We’ve also created a steering committee and recommend that every practice have one—as well as a physician champion. The steering committee established the framework for how the practice will implement ICD-10.

Dr. Cannon: What’s the role of the orthopaedic surgeon in this ICD-10 transformation?

Dr. Trenhaile: Probably the biggest role is to remain positive and keep everyone interested. From a physician’s perspective, I think the focus needs to be on documentation—the operative reports, histories, and physicals. We need to pay attention to details like laterality, causation, location, and previous history to make our documentation as clean as we can.

Dr. Cannon: Do you have a particular set of ICD-10 resources?

Dr. Trenhaile: We rely on information from CMS, the American Academy of Professional Coders (AAPC), the American Health Information Management Association (AHIMA), and the American Medical Association.

Dr. Cannon: Which has been the most helpful and what information do you think is missing?

Dr. Trenhaile: I think the AAPC has been the most helpful. In terms of what’s missing, we’re just not confident that the draft form we’re using will be the final implemented version.

Ms. Larson: As a coder, I would definitely say that the AAPC and AHIMA have some good online research. Unfortunately, I still haven’t seen a good solid set of information.

Dr. Cannon: How much time are you dedicating to this process?

Dr. Trenhaile: Currently, it’s a quarterly board meeting, our yearly retreat, and executive meetings every 2 weeks. This fall, the steering committee will meet more regularly as we start implementation. For most of the physicians, it’s not a lot, but people like myself and a few others on the steering committee meet every week or two to keep moving the process forward.

Ms. Larson: From a billing and coding standpoint, one of the biggest challenges is going to be working with insurance companies. I think our steering committee will have a couple of people focused on that area because I don’t think that some of the insurance companies will be ready to reimburse the new ICD-10 claims. I think that will be a huge challenge.

Dr. Cannon: Dr. Trenhaile, you are the office champion. Have you assigned ICD-10 duties to other physicians or staff?

Dr. Trenhaile: We have three camps—practice management, clinical, and information technology (IT). From the physician standpoint, we are identifying the steering committee members. We will meet, discuss, set expectations, and talk about changing documentation habits.

We’re also involving the clinical people who work with the physicians so it becomes a team effort. We’ve let them know that this is coming and that we need to be thinking about it. But each camp has its own implementation effort.

Dr. Cannon: How much time is being dedicated to this process by coders and other staff?

Dr. Trenhaile: Our practice management side is very organized. The practice management and billing staff are doing at least an hour a week. A physician who is more involved in practice management will need to spend more time and will need to take that into account.

As for IT, we implemented software to be compliant with the 5010 implementation, which is required to deal with these ICD-10 codes. Some electronic medical records (EMR) providers will allow that, but others are completely unprepared. Our IT committee constantly interfaces with our EMR vendor about our other hardware and software capabilities to ensure that technologically, we will be able to make the shift easily.

Some groups have reported that they love their EMR system and their practice management system, but that their EMR vendor is not prepared for the ICD-10 launch and has no real plans to get up to speed. If that’s the case, the practice should start now to find an EMR with those capabilities.

Judy Larson, CPC

Dr. Cannon: What did your IT people need for the technology assessment? Anything other than making sure that the EMR would be compatible?

Ms. Larson: We have an EMR analyst who worked on that particular aspect of the process with the software company and our clearinghouse to ensure that everything would transmit correctly. We’re continuing to work with them to ensure that they stay up to speed so we can go live when necessary.

Dr. Cannon: What other practice functions were included in your assessment in terms of collecting and entering the information?

Dr. Trenhaile: We’ve focused on billing, accounts receivable, and financial reporting. We want every aspect of the practice management side to understand the language enough so that we can communicate with each other. We’ve broken it down as far as we can to ensure that everyone is aware of this coming transition.

Dr. Cannon: You mentioned getting the documentation correct upfront. Do you know of an EMR that helps collect the information for you? Can patients input any data?

Dr. Trenhaile: We’ve spent a considerable amount of time on templating and are adjusting our templates to address those issues. Patients are interviewed when they call in before the appointment, so the physician has the information and confirms the history. We’re changing the EMR templates to ensure that ICD-10 issues are covered. Answering certain questions in certain ways opens other templates so we have the information needed for ICD-10 coding.

Dr. Cannon: Do your patients use a portal or does someone talk to them?

Dr. Trenhaile: Both options are available, depending on patient preference. Patients who call for an appointment can be interviewed right then if they have time. If they don’t, they can call back or they can go through the portal.

Ms. Larson: Our patient portal is more heavily used each day, which is a good thing.

Dr. Cannon: What kind of feedback are insurers and payers giving you? Do they anticipate that they will be ready or are you getting some pushback?

Dr. Trenhaile: I think the biggest challenge that we foresee is the insurance companies and our ability to communicate with them. How ready are they? Will they be up to speed when this launch occurs? What will be the financial impact on us?

Ms. Larson: For example, some carriers had problems with some of the code changes for this year (2013). They denied claims because their systems weren’t prepared. We had to work with them to provide the changes to reflect the 2013 code sets and receive reimbursement. Our steering committee will be contacting companies to assess readiness. We will work with our Medicare carriers as well to ensure that their local coverage determinations are up-to-date with the new code sets.

I’m very concerned about the insurance payers. No matter how ready we are, if they aren’t ready, there still could be a financial impact. I think that every practice needs to review their current staffing to address this process, including the time necessary to communicate with payers. If a practice is concerned that it may not have the appropriate staff to implement ICD-10, I would suggest it seek consulting advice as soon as possible to meet the Oct. 1, 2014, deadline. Again, my biggest nightmare is that insurance companies might not reimburse and might actually deny claims based on lack of knowledge and failure to incorporate the new codes into their current reimbursement software.

Dr. Cannon: Have you considered contract language that would require the companies to be ready to prevent access problems for their covered patients?

Ms. Larson: That’s an interesting question. I think we really have to be proactive and communicate with them to ensure they’re going to be ready. I don’t mean just calling and talking to a claims adjuster. We need to ensure that our contract language is changed upfront to reflect ICD-10 conversion issues. If physicians sustain a financial impact, insurance companies could potentially suffer over the long term as well, due to interest and penalties in the contract. It’s a real concern and we are attempting to do our best with payers. Our experiences this year underscore the legitimacy of that concern.

Dr. Trenhaile: Our steering committee, our executive committee, and our contract negotiations people all have this concern on their radar and people should certainly be aware of it.

Dr. Cannon: What about EMR vendors? Should those contracts include financial penalty language if they’re not ready to launch ICD-10 by a certain date?

Dr. Trenhaile: I think discussions about an EMR that basically becomes ineffectual due to its inability to handle documentation are warranted. Some small practices that don’t have EMR systems may want to explore getting external help to tackle some of these issues and figure out the best solution for them. Every practice will require a different solution.

Dr. Cannon: What about surprises you have encountered? Did one surprise stand out?

Dr. Trenhaile: The number of codes—we’ve gone from 15,000 codes up to 68,000 codes, possibly more.

Dr. Cannon: What are the most common questions or concerns that the physicians or staff have had with this process?

Dr. Trenhaile: First, “Why do we have to do this?” And the answer is that CMS says we have to. Second, “Have other places done this?” The answer is that everyone other than the United States, Israel, and Haiti uses ICD-10.

Third, “What’s the difference between the countries that are already using ICD-10 and the United States?” In most countries, ICD-10 is used primarily for documentation and research, but the United States is also using it for the financial side, which makes it far more complex to launch and use.

Dr. Cannon: What would you recommend as the must-do first steps for orthopaedic surgeons?

Dr. Trenhaile: Work on your documentation. Look at your progress notes, operative reports, histories, and physicals. Take steps to improve how you work during the day. You’ll need to change prior to the ICD-10 launch to make the transition seamless.

Dr. Cannon: What tips can you share to make the process easier?

Dr. Trenhaile: First, identify who will do the training. Second, identify the training needs for each department—such as our practice management, clinical, and IT camps. Develop training schedules. Start training—have meetings, address these issues, talk to your EMR provider. The hardest step is simply to start.

Establish a steering committee, find a physician champion, identify the different camps and establish leaders within each, start the training process, and get a plan together.

Ms. Larson: Conduct internal and external testing with insurance companies prior to the actual implementation to ensure that they can receive the transactions and reimburse appropriately. I also think we have to remain as positive and receptive to this significant change in health care as possible—we have no other option.

For more resources on transitioning to ICD-10, visit the AAOS online Practice Management Center (www.aaos.org/pracman) or the ICD-10 section of the Centers for Medicare & Medicaid Service website (www.cms.gov/Medicare/Coding/ICD10/index.html)