ICD-10: What you don’t know may hurt you


Urologists know the International Classification of Diseases-10 (ICD-10) goes into effect Oct. 1, 2015. Whether they understand the transition’s impact and what they need to do to fully prepare are questionable.

National Report-Urologists know the International Classification of Diseases-10 (ICD-10) goes into effect Oct. 1, 2015. Whether they understand the transition’s impact and what they need to do to fully prepare are questionable.

Mark Painter, CEO of Denver-based PRS Urology, says many larger practices are on track for the transition from ICD-9 to ICD-10. However, there are also many urology practices (primarily small- and medium-sized practices) that are nowhere close to where they need to be in less than a year.

“There are many folks who haven’t done system updates or testing and haven’t really begun full-on training,” Painter told Urology Times.

Painter says there’s still time, but the time to start readiness campaigns for ICD-10 is now. Practices need to establish champions or groups in charge of overseeing the transition, start staff and physician training in April 2015, and be ready to test when testing opportunities become available. Only 36% of urology practices have taken the early step of putting someone in charge of overseeing the transition, according to an informal survey conducted on UrologyTimes.com last month.

Barring a third delay, urology and other practices will have no time to ease into the new system. They’ll go from using ICD-9 on Sept. 30, 2015 to starting the next day with ICD-10. And what urologists and their practices don’t know about ICD-10 starting Oct. 1 could hurt them financially.

RELATED: ICD-10 delayed, but don’t put off preparations

Jonathan Rubenstein, MD, a urologist in Baltimore and member of the AUA’s Coding and Reimbursement Committee, is among those who represents the AUA at the government’s ICD-10 Coordination and Maintenance Committee meetings. He says ICD-10 is going to dramatically alter how urologists and other physicians do business.

“It’s going to completely change the way we document our patients and patient encounters. It’s really going to change medicine,” Dr. Rubenstein said. “Not only do doctors need to understand the specificity of ICD-10 and how to code, they need to understand the codes and need to understand what to document-not only if they’re choosing the codes but if someone else is helping choose the codes for them.”

If they don’t, reimbursement is in jeopardy, Dr. Rubenstein says.

Practice readiness is only one piece of this potentially disruptive event. It doesn’t ensure a smooth transition. In fact, part of physicians’ readiness has to include preparing for the system’s failure-at least initially.

Next - ICD-10: A primer

More on ICD-10

ICD-10 preparation: A checklist for urologists

ICD-10: Possible fixes

ICD-10 resources for urologists


ICD-10: A primer

The ICD is owned by the World Health Organization (WHO). In the United States, it was decided several years ago that ICD would be the coding system that the nation’s providers would use for billing purposes.

“The problem is, ICD-9 is really outdated. It was created in 1977. ICD-10 is a much larger system. It’s much more detailed. It really uses much more modern language. But because it’s new, we have to learn a new system. I think it’s really unrelated to ICD-9, just the way that it is set up,” Dr. Rubenstein said.

W. Jeff Terry, Sr., MD, a Mobile, AL urologist and state delegate who works on behalf of the American Medical Association on opposing ICD-10 implementation, says it is the AMA’s policy to "vigorously work to stop the implementation of ICD-10 and to reduce its unnecessary and significant burdens on the practice of medicine."

According to the AMA, implementing ICD-10 alone requires physicians and their office staff to contend with 68,000 codes-a fivefold increase from the current 13,000 codes. Hospitals will have to contend with 87,000 codes. What does this mean to urologists? It depends who you ask. Painter says it might not mean much. Dr. Terry says it could be overwhelming.

“We’ve started pulling different numbers. If you look at the broad spectrum… of where urology codes are, we figure there is about a 20% increase in codes,” Painter said. “But that’s discounting the use of external cause codes. We have external cause codes in ICD-9 and don’t use them, and nobody is expecting that ICD-10 is all of the sudden going to be requiring external cause codes.”

Painter says the majority of urology revenue is driven by, at most, 50 different diagnosis codes in ICD-9. That should grow to about 70 in ICD-10.

“If you really look at the average urologist and what drives reimbursement, it’s even smaller than that. That code set is down to 20. Everybody is trying to tackle the whole thing, when in reality what you need to do is find out where you are with ICD-9, then focus on the translational piece and dealing with those problems,” Painter said.

Dr. Terry says it’s a myth that urologists won’t have a big change in their coding with ICD-10. In Alabama, he says, when a patient has a kidney stone, he has to code for more than just a kidney stone.

"The major insurance carrier in Alabama plans to require physicians to code for all the other problems the patient has, such as high blood pressure, diabetes, coronary artery disease. Diabetes has approximately 250 codes [in ICD-10]. How am I going to get the right one? If I have the wrong diabetes code, that could affect my pay. If I code it differently than the hospital, that could affect my pay. I barely know what diabetes is. I’m a urologist!” Dr. Terry said.

Even in the best-case scenario, the ICD-10 transition is a huge undertaking for practices already burdened by government regulations and unfunded mandates.

“Physicians in our country are looking at huge increases in capital outlays to meet EMR requirements and, at the same time, are looking at penalties for not meeting the meaningful use requirements, for not meeting a threshold for e-prescribing, and for not reporting appropriately in the PQRS program, along with a 2% reduction in payment due to sequestration,” Dr. Terry recently wrote in a personal communication.

And the cost to physician practices to make the change to ICD-10 is dramatically higher than previously estimated, according to a recent study initiated by the AMA and conducted by Nachimson Advisors.

The 2014 study found, in some cases, the estimated ICD-10 implementation costs are nearly three times what had been predicted in 2008 by Nachimson Advisors, according to an AMA press release. Why? The newer study includes higher amounts for testing and risk of payment disruption. For example, in 2008 the predicted cost to implement ICD-10 ranged from $83,290 for a small practice, $285,195 for a medium practice, and $2,728,780 for a large practice. The 2014 study suggests a small practice might spend $56,639 to $226,105; a medium practice, from $213,364 to $824,735; and a large practice, from $2,017,151 to $8,018,364, according to the AMA release.

Next: Coding ICD-10 style


Coding ICD-10 style

Dr. Rubenstein says urologists might experience some of the most notable changes in trauma codes because of their specificity.

“There are so many nuances to choosing the correct code,” Dr. Rubenstein said. “In addition, for a lot of the trauma codes, the doctor needs to document in the chart… whether it’s the first time they’re seeing the patient for this condition, a subsequent time they’re seeing the patient for the condition, or if they’re seeing the patient for a sequela of the trauma.”

In ICD-10, unlike ICD-9, urologists will in some cases need to specify laterality. They’ll have to code for either right-side or left-side kidney cancer, according to Dr. Rubenstein.

“You have to document that and understand there’s a unique code for each one of those conditions,” he said.

Laterality isn’t necessary, however, when coding for a kidney stone or epididymitis.

Regardless of how good an EMR system is or how astute professional billers are regarding ICD-10, urologists and other physicians are at the frontlines of coding. They have to learn and understand the codes, Dr. Terry says.

A glitch waiting to happen?

Even the government is planning on problems with ICD-10 implementation. In a February 2014 press release, the AMA referred to an estimate by the Centers for Medicare & Medicaid Services that claims denial rates could increase 100% to 200% in the early stages of coding with ICD-10.

Every step in the process, including practice EMRs, clearinghouses, and payers, is vulnerable to system glitches.

“One of my fears when ICD-10 comes to fruition is the potentially significant delay in payments from insurance companies. The insurance companies, themselves, need to know more than 68,000 codes to make sure they code correctly,” Dr. Rubenstein said. “The problem with practices is they need to get prepared for the potential of very little money coming into the practice starting on Oct. 1, 2015, until everyone is caught up on using ICD-10.”

That’s easier said than done. And if the rollout of Obamacare is any indication, urologists and others could experience problems with reimbursement beginning Oct. 1, according to Dr. Terry.

“[ICD-10] was supposed to be implemented Oct. 1, 2013. That happened to be the same day the Obamacare exchanges went online. If we had really had ICD-10 implemented on that day, I can’t imagine how many doctors would be out of business,” Dr. Terry said.

Even a month without income puts the viability of doctors’ offices in jeopardy, according to Dr. Terry, who practices in a seven-physician practice, which is considered medium sized. Dr. Terry says he has heard that physicians will need 4 to 6 months of money set aside to weather the transition.

“You can’t get a loan or line of credit big enough. It would be an unsecured loan. Most doctors rent their buildings-they don’t have any assets,” Dr. Terry said. “My office needs to come close to $1 million a month to run, so if I need 4 months of income, that’s $4 million. We don’t have that.”

Dr. Terry says at least he is confident that his practice will be prepared for ICD-10. What he says he really worries about is the one- and two-doctor practices in rural America. “They don’t know what’s about to hit them,” he said.

Next: No more delays?


No more delays?

Initially, ICD-10 was scheduled to launch Oct. 1, 2013. The first delay pushed it to Oct. 1, 2014; the second delay, to 2015.

“There’s no good reason to believe that it will be pushed back any further. Many, including hospital systems and insurance companies that had previously invested heavily in preparing for ICD-10 for Oct. 1, 2014, made a lot of grumbling about the delay,” Dr. Rubenstein said.

Dr. Terry, however, says ICD-10 is not ready for prime time and needs to be delayed for another 5 years in order to fix it appropriately.

What physicians might not know is that the argument the U.S. is lagging behind other countries, such as Canada, in transitioning to ICD-10 is misleading.

“We’re the only country that’s going to implement the full 68,000 to 85,000 codes. Canada only implemented approximately 20,000 codes,” Dr. Terry said.

Another notable difference is that the U.S. is the only country that couples the ICD code with physician reimbursement, according to Dr. Terry.

“The whole purpose of ICD, from the very beginning, was for statistical and epidemiological data, not to be coupled with billing codes. But insurance companies use these ICD-10 codes to deny payments to doctors; so does Medicare,” Dr. Terry said. “And we’re the only country that uses these codes in the outpatient setting. That’s where most of the care is-in your office-in the outpatient setting. Other countries just use it for hospital patients.”

Dr. Terry says his plan is to work with others in Congress to achieve another delay, legislatively. His goal is for a 5-year delay to focus on and fix the problem of a flawed implementation plan and too many codes (see, "ICD-10: Possible fixes").

“I agree we need to have an updated coding system, but we must do it the right way so as not to put physicians out of business and disrupt patient care,” he said.

Armageddon or a blip?

Mark Painter says a lot of physicians fear ICD-10 is Armageddon.

“I really feel that this is a digestible change. If you walk through this process and work with the right IT folks and vendors, and you’ve selected well, system-wise, the transition is not going to be that overwhelming. Luckily, urologists are not in the specialties of OB/Gyn or orthopedics,” Painter said. “The payers, while they have the potential of tightening up rules and adding new requirements, don’t appear to be going in that direction. So, I think the overall process probably won’t be as bad as everyone thinks.”

Dr. Terry says ICD-10 is not a urology issue. It’s an across-the-board issue for medicine and the future of the profession.

“Patient care is what I want to stress. It’s a lot more than urology or surgery. The [message] is how flawed this ICD-10 system and implementation process is-how it’s going to adversely affect our profession and the care of our patients,” Dr. Terry said.

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