Survey finds a smooth road so far
On Oct. 1, 2015, the 10th revision of the International Classification of Diseases (ICD) code set was implemented in the United States. This was the largest and most far-reaching change since the adoption of ICD-9 in 1979, and was anticipated to have a profound impact on medical practices.

Two months after implementation (December 2015), KarenZupko & Associates, Inc. (KZA) conducted a survey to measure that impact. The survey was distributed to practices that sent providers or staff to a 2-day training meeting in either 2014 or 2015; 151 practices from across the country responded, with 146 practices identifying their size. Because the practices had sought education prior to the implementation date, the following data could be biased toward a more positive or "rosier" outlook on the implementation of ICD-10.

Three cohorts are well represented in the data set: small practices with just one or two physicians (n = 62), medium-sized practices with between three and seven physicians (n = 44), and large practices with eight or more orthopaedic surgeons (n = 40).

Few transition problems
Not surprisingly, among this group of proactive practices, relatively few reported substantial problems with the implementation of ICD-10 (Fig. 1). This can be attributed to an early involvement in coding education, a proper and well-contextualized use of software tools (including coding modules in electronic health record (EHR) systems and the AAOS Code-X product), and a serious study of the clinical documentation improvement (CDI) guidelines for practitioners.

Judy Larson, the billing manager of OrthoIllinois (Rockford, Ill.) reported, "Getting involved in the ICD-10 training process early on definitely seemed to pay off for us. Monthly training newsletters were distributed to our 30 physicians, as well as to our physician assistants and nurse practitioners. These newsletters not only focused on how the new codes would appear but also addressed the importance of deep documentation specific to comorbidities and documentation of external causes when applicable.

"We created a timeline with our EHR system and our clearinghouse," she continued, "and we sent out payer questionnaires to our top insurance carriers to allow us to review where they were with their internal processes." As a result, OrthoIllinois did not see any change in the volume of denials between ICD-9 and ICD-10. The practice intends to monitor the situation on a monthly basis for the foreseeable future.

KZA consultant Margi Maley, BSN, MS, is pleased with the positive transition experienced by such practices. "This has enabled us to develop a curriculum for 2016 that reaches beyond the basics of orthopaedic ICD-10-CM and focuses on the reporting of comorbid conditions to support the medical necessity of services. With bundled payments for joint replacement on the very near horizon, this education will provide the edge that practices need to track the impact of these conditions on their outcomes and complications."

The training challenge
The most frequently noted challenge in the transition to ICD-10 was the need to train physicians and staff on the new ICD-10 code set and the clinical documentation required to support diagnostic coding, according to survey respondents (Fig. 2). Many practices reported that training occupied the most time and required the greatest investment of resources. As a result, sustained education for both physicians and staff may be necessary to support accurate reimbursement and guarantee compliance.

David Kanzler, CEO of the 30-physician Hinsdale Orthopaedics (Hinsdale, Ill.) reported many successes, but also shared some of the pitfalls experienced. "Adjusting to the new wording and descriptions in ICD-10 has been challenging," he reported, "as has converting all of our content and EHR templates."

Mr. Kanzler emphasized the importance of "training, training, training" and the necessity of making content end-user friendly. Tools, resource guides, filtering operations, and custom-built lists of frequently used codes have been especially helpful. Going forward, Mr. Kanzler and his team will use any denial feedback to improve their choices of payable diagnosis codes.

Claim denials
Most respondents reported that claims are not being delayed or that only a limited number of denials have been logged since ICD-10 went into effect. Less than 5 percent of practices have experienced significant disruptions in the claims process as a result of the transition (Fig. 3).

Based on these results, it appears that practices currently experiencing limited denials will need to tighten clinical documentation, provide more education, and complete the time-consuming, but necessary, EHR template tune-ups. Practices may also wish to reach out to any "problem payers" for an explanation of why claims are being denied so that they can take corrective action. Many practices reported that only one or two payers were problematic and that the rest were not delaying or denying claims at higher levels than before.

More than 80 percent of responding orthopaedic practices have not found an uptick in denials due to lack of specificity; however, such confidence should be tempered. Currently, Medicare is not denying claims based on specificity as long as a valid ICD-10 code from the right category is used. Starting on October 1, 2016, this temporary relaxation of the rules will end, and all ICD-10 codes must fully comply with specificity requirements to be accepted and paid. Practices should be prepared for this "second shift" and not become complacent as a result of this limited-time concession meant to ease the transition.

 "Even though the Centers for Medicare & Medicaid Services (CMS) is allowing leniency in selection of a nonspecific code, the ICD-10 code must be valid, and laterality must be coded and documented. If the encounter is for a dislocation of the shoulder, for example, the documentation and coding must identify which shoulder is affected—right versus left," commented KZA consultant Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP.

"Not all payers are following CMS guidance for leniency," she continued, "so specificity is a critical factor in code selection. Practices should be auditing and monitoring documentation to encourage practitioners to select the specific code and to document to that specificity. This will support medical necessity to ensure proper payment. Payers—including CMS—will eventually audit claims for lack of specificity, which could result in 'clawbacks' on payments for claims that lack proper documentation."

A clear plan to audit the clinical documentation of providers is needed to prepare for the "second-shift" to code specificity on Oct. 1, 2016.

Other concerns
One concern frequently voiced prior to ICD-10 implementation was the impact on billing office productivity. However, according to the results of this survey, most practices reported no or relatively minor reductions in billing office productivity due to ICD-10.

Joseph B. Koscielniak Jr, MD, a solo practitioner in Merrillville, Ind., experienced just as many ups and downs as other respondents, but ended his discussion on a positive note. "Additional training will only help to improve my practice's ability to code properly; optimum coding will streamline the reimbursement process to a greater degree. I realize that ICD-10 is not a static tool and that revisions are bound to happen in the future. Thus, taking a proactive position by additional training will ultimately optimize our ability to code properly and enhance the bottom line."

Kyle M. Lee is national meetings manager for KarenZupko & Associates, Inc.