The reality of ICD-10 and what it means to physicians’ practices will come into focus beginning Oct. 1. But there are things that specifically urologists should know in the days, weeks, and dwindling months before adopting the code set becomes the new normal.
National Report-The reality of ICD-10 and what it means to physicians’ practices will come into focus beginning Oct. 1. But there are things that specifically urologists should know in the days, weeks, and dwindling months before adopting the code set becomes the new normal.
Dr. KaufmanIt’s not the end of the world, says Jeffrey Kaufman, MD, a urologist in Orange County, CA and president of the AUA’s Western section.
“I have been in the AMA House of Delegates, where for the past several years, many have decried the transition as Armageddon. However, as I have taught myself the system, it just doesn’t seem like that big a deal,” Dr. Kaufman said. “For some specialties, including orthopedics and trauma, the explosion in detail will, indeed, be overwhelming. But for urology, the universe of codes is finite and much smaller.”
That sentiment appears to be shared by a majority of urologists. According to an online survey conducted by Urology Times in July, more than half of respondents-52%-said they were “very prepared” for the transition to ICD-10. Thirty-eight percent of urologists indicated being somewhat prepared, and 10% were not at all prepared.
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Stephanie N. Stinchcomb, CPC, CCS-P, ACS-UR, director of Reimbursement and Regulation at the AUA, said that urologists will need to be familiar with all urology-specific ICD-10 diagnosis coding but may need a working knowledge of approximately 50 to 100 of the new codes, depending on their practices and specialties.
Dr. TerryBut, according to W. Jeff Terry, Sr., MD, chair of the Alabama delegation to the AMA and a urologist who worked on behalf of the AMA on ICD-10 implementation, the statement that urologists need only concern themselves with up to 100 codes is misleading.
“In Alabama, our primary insurance company is Blue Cross Blue Shield [BCBS], with 90% of the business in our state. They are making plans… to have physicians code up to 10 diagnostic codes per patient encounter,” Dr. Terry said. “What this means to me is that, if I see a patient with a kidney stone, diabetes, heart disease, high blood pressure, dementia, and high cholesterol, I cannot just code for the kidney stone. I must code for all the other medical problems, as well, and I am simply not qualified to do this with accuracy for diseases that I don’t treat.”
It’s true that urologists and others will be required to use more specificity in their coding, according to Mark Painter, CEO of PRS Urology in Denver. But coding for underlying disease is necessary for the U.S. medical system to evolve from one of straight fee for service to one based on quality, outcomes measurements, and group payments, he said.
“If physicians aren’t actively coding the underlying conditions that patients have, we’re not really differentiating treatment at the level that would make sense to risk adjust,” Painter said. “We have almost identical coding instructions in ICD-9 that we have in 10. And, yes, there are more codes and there is more specificity in 10. But if payers, like BCBS of Alabama, wanted 10 diagnosis codes on every claim, they could do it now. They don’t need ICD-10.”
Under ICD-10, urologists will have to document, for example, details such as whether something is on the right or left; whether it’s an initial encounter, subsequent injury, or a sequela; and more. Urology is spared many of ICD-10’s seven-digit codes, except when there’s a traumatic injury to the genitourinary system. These include instances where there is a foreign body in the genitourinary tract, which is the T19 code. Those codes, according to Stinchcomb, will have to include a seventh digit indicating whether it’s an initial encounter, subsequent encounter, or sequela.
Including all the needed information initially will save back and forth with coders and potential delays in claims submissions, Stinchcomb said.
Available crosswalks, which are ICD-9 codes converted to ICD-10, are available through the Centers for Medicare & Medicaid Services website, CMS.gov, where physicians can download the general equivalency map and reimbursement crosswalks, according to Painter.
Ms. StinchcombFor commonly used and more specific urology codes, the AUA has created a crosswalk of the top 100 urology codes on laminated pages. Some companies, including PRS, offer crosswalks for urology in Internet-based software programs.
“The crosswalk is one of the tools available to urologists, but it isn’t the end-all and be-all,” Stinchcomb said. “I’m a certified professional coder in two national entities, and it’s not always cut and dry.”
Urology coders still need to reference a print or online version of the ICD-10 codebook. Urology practices should also read the guidelines and update the information on their systems, as well as make sure their encounter forms are updated with the new codes, she said.
Urologists should anticipate some frustrating changes in the new code set, Dr. Terry warned.
“If I document ‘urosepsis’ in the hospital, every physician knows exactly what I am talking about,” Dr. Terry said. “Well, the insurance companies and Medicare will not accept ‘urosepsis’ in the new ICD-10 system. You must say in the medical record, ‘urinary tract infection with septicemia.’ ”
There are some areas in which the number of ICD-10 codes does vastly increase. One of those is in hematuria, for which there are four codes in ICD-10, according to Painter.
Mr. Painter“There’s gross hematuria, benign hematuria, other microscopic hematuria, and then there’s unspecified hematuria,” Painter said.
Documentation differences from ICD-9 to ICD-10 shouldn’t be a leap for urologists, who tend to be relatively specific on their documentation, he said.
“I’ve reviewed hundreds if not thousands of charts in audits. Most of the time, in the actual clinical documentation, I see that urologists are specific on their documentation. They will say that it’s gross hematuria in their notes. And they’ll say how many red blood cells. Then, they’ll choose unspecified hematuria. So, there are a lot of folks that really are not going to have to change their documentation at all,” Painter said.
“On the other side of the coin is the electronic medical record, which may have a template built by the practice that’s driven by the diagnosis. Urologists might have a template that says ‘unspecified.’ And underneath the template, the information is there to make it specified. So, what they really need to do is change their template so they map the better code.”
Urologists should also be sure to be more specific on things such as what type of diabetes a patient has, even though diabetes is not their primary focus, Painter said. Getting the information from patients or other physicians provides more accuracy to the clinical record. This specificity will assist in the shift to new payment systems but will likely not affect current fee-for-service payments, he said.
Physicians realized a victory in ICD-10 implementation when, in early July, the American Medical Association and CMS announced a 1-year grace period, with several changes that would help ease physicians’ transition from one code set to the other.
Among the changes: “For the first year ICD-10 is in place, Medicare claims will not be denied solely based on the specificity of the diagnosis codes as long as they are from the appropriate family of ICD-10 codes,” AMA President Steven J. Stack, MD, wrote in a July 6, 2015 AMA Viewpoints article. “This means that Medicare will not deny payment for these unintentional errors as practices become accustomed to ICD-10 coding. In addition, Medicare claims will not be audited based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes.”
CMS also will not subject physicians to penalties for the Physician Quality Reporting System, the value-based payment modifier, or meaningful use based on the specificity of diagnosis codes as long as they use a code from the correct ICD-10 family of codes. Penalties will not be applied if CMS experiences difficulties calculating quality scores for these programs as a result of ICD-10 implementation.
“If Medicare contractors are unable to process claims as a result of problems with ICD-10, CMS will authorize advance payments to physicians,” Dr. Stack wrote.
Urologists should remember that claims submitted during the 12-month grace period, beginning Oct. 1 for claims with dates of service of Oct. 1, 2015 and later, must have ICD-10 codes. Medicare claims processing systems will not accept ICD-9 codes or dual coding for dates of services after Sept. 30, 2015, according to CMS.
That doesn’t mean urology practices should abandon ICD-9 entirely, according to Painter.
“Every office that I know of doesn’t get all their bills in at the end of that day of service. They would still be billing for services in September and maybe even August and July, depending on how far behind they are, in October. Anything with a date of service prior to Oct. 1 still has to be coded in ICD-9,” he said.
There also are a few payers that do not have to comply with HIPAA and are not required to switch to ICD-10, Painter noted. He thinks, however, that even these small non-HIPAA payers, which include auto no-fault, will make the switch because their third-party administrators will have changed to ICD-10.
To prepare for the transition and ensure system consistency, urology practices need to contact specific vendors, making sure they’re updated to ICD-10. Stinchcomb said these vendors include electronic medical record (EMR) vendors, practice management system administrators, and clearinghouses.
The good news is the big payers and venders that supply payers with adjudicated crosswalks, such as McKesson and Optum, are ready for the change, Painter said.
“There are probably smaller groups out there that haven’t updated everything. They just don’t have the money or the wherewithal,” he said.
Government payers are prepared and have taken steps to help ensure urologists and others will not experience payment delays. It’s unreasonable, however, to think there won’t be glitches in the crossover from ICD-9 to ICD-10, according to Painter.
“I don’t expect long delays [in payment], but there are a lot of moving parts. And to walk in believing that there won’t be something missed, somewhere, is probably not accurate,” Painter said.
Stinchcomb suggests each urology practice do a dry run of its practice management system with its top 50 or 100 diagnosis codes, then use the crosswalk for reference and comparison.
Oct. 1, 2015 marks the beginning of long-term change, according to Painter.
“In the long run, if urologists would like to set treatment guidelines and really have data to review on how best to treat patients… ICD-10 actually doesn’t go far enough. There is still going to be more specificity to really do some of the detailed research and treatment guideline development,” Painter said.
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Dr. RubensteinIn fact, the AUA has proposed a number of modifications, clarifications, and requests for new codes for ICD-10-CM. These new codes, if accepted, would not likely be active until Oct. 1, 2016, according to Jonathan Rubenstein, MD, director of coding and compliance at Chesapeake Urology in Baltimore and a member of the AUA Coding and Reimbursement Committee.
“One of the benefits of ICD-10 is its seven-character structure,” Dr. Rubenstein said. “[It] allows for expandability as new conditions arise, and allows for clarifications, as the way we in the United States may use ICD-10 may differ from other countries.”
While ICD-10 is owned by the World Health Organization, the U.S. health system can modify ICD-10 using the clinical modification (-CM) delineation.
Changes can be made to the ICD-10-CM as new diseases are discovered or the needs to clarify the code set or add specificity to conditions arise. “It is, therefore, a fluid document,” Dr. Rubenstein said.
The AUA offers its webpage on ICD-10, complete with options, including an online ICD-10 basic training course for $399 and urology’s top 100 codes crosswalk for $15. Visit http://www.auanet.org/resources/icd-10-basic-training.cfm.
In late July, the Centers for Medicare & Medicaid Services issued a list of questions and answers regarding the CMS/American Medical Association joint announcement concerning ICD-10 flexibilities. Here are some highlights:
Does the guidance mean there is a delay in ICD-10 implementation?
No. The CMS/AMA guidance does not mean there is a delay in the implementation of the ICD- 10 code set requirement for Medicare or any other organization.
What should I do if a claim is rejected? Will I know whether it was rejected because it is not a valid code versus due to a lack of specificity required for an NCD or LCD or other claim edit?
Yes, submitters will know that it was rejected because it was not a valid code versus a denial for lack of specificity required for an NCD or LCD or other claim edit. Submitters should follow existing procedures for correcting and resubmitting rejected claims and issues related to denied claims.
Are technical component only and global claims included in this same CMS/AMA guidance because they are paid under the Part B physician fee schedule?
Yes, all services paid under the Medicare Fee-for-Service Part B physician fee schedule are covered by the guidance.
Do the ICD-10 audit and quality program flexibilities extend to Medicare fee-for-service prior authorization requests?
No. The audit and quality program flexibilities only pertain to post-payment reviews. ICD-10 codes with the correct level of specificity will be required for prepayment reviews and prior authorization requests.
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