Overwhelming changes to ICD codes pending, implementation deadline delayed

Implementation of ICD-10 will be a significant and daunting change for ophthalmology, according to several experts in the field.

“It’s a big transition,” Michael X. Repka, MD, MBA, told Ocular Surgery News. “It’s going to take effort on front-end and back-end operations, and of course, it requires all EHR vendors to be completely comfortable and have it all implemented by [the deadline].”

Physicians and practice managers, who have been taking steps to prepare for the transition to the International Classification of Diseases, 10th Edition (ICD-10) codes, have been given a reprieve. The implementation deadline for ICD-10 was delayed until Oct. 1, 2015, in a Senate vote March 31.

The new codes will replace the ICD-9 code set. ICD codes are published by the World Health Organization and are designed for the collection and processing of disease data. They are used to complete forms submitted to private insurance companies, Medicare and Medicaid for reimbursement.

Physicians, administrators and staff need to familiarize themselves with the new codes and ensure that their electronic health record systems are ready to process claims using the codes.

“My expectation is that it will be a huge expense for all. It is a big deal,” Repka said.

The Centers for Medicare and Medicaid Services previously delayed the implementation date by a year, amid concerns from physicians and the American Medical Association about meeting the deadline.

Repka said there is an upside: Coding is typically easier in an EHR setting.

“You’ve got so many more options. The electronic platform is much more facile at handling them,” he said.

No practice is exempt from the implementation deadline, and every ophthalmologist will be affected, according to Cynthia Mattox, MD, a member of the AAO’s Health Policy Committee. Claims will be rejected if not coded properly.

“None of the old codes that we are used to will be valid,” Mattox said. “Everyone has to get up to speed to understand how the codes are used and to begin using them properly.”

Practices should prepare an extensive list of items that need to be addressed before implementing ICD-10, Riva Lee Asbell, OSN Practice Management Board Member, said.

“Practices have to start preparing everything that they’re going to need with the ICD-10 codes,” Asbell said. “All those people down the food chain who are going to be participating, they have to be ready, as well as you. Making sure that everybody is onboard is a big job.”

ICD-10 Clinical Modification (ICD-10-CM) codes are based on the International Statistical Classification of Diseases and Related Health Problems published by the WHO. The WHO and the Centers for Disease Control and Prevention collaborate on drafting and publishing ICD codes in the United States.

“ICD-10-CM far exceeds its predecessors in the number of concepts and codes provided,” according to CDC documentation. “The disease classification has been expanded to include health-related conditions and to provide greater specificity at the sixth and seventh character level. The sixth and seventh characters are not optional and are intended for use in recording the information documented in the clinical record.”

Ophthalmic codes

ICD-10 codes require more specific and detailed documentation than ICD-9, according to Donna McCune, CCS-P, COE, CPMA, vice president of Corcoran Consulting Group.

“[Ophthalmologists] should start sooner than later by beginning to look at documentation and existing medical records to make sure they’re complete and as specific as possible because ICD-10 codes are extremely specific,” McCune said.

ICD-10 differs from ICD-9 in terms of detail required in coding and submitting reimbursement claims, McCune said.

“A lot of the ophthalmic diagnoses will now have what they call laterality, meaning there will be a different diagnosis code for the right eye and the left eye,” she said. “For example, nuclear sclerotic cataract, which today is one code, becomes four different codes: one for the right, one for the left, one for both and one for the unspecified eye. Payers will not like unspecified codes, or we don’t think they will because they don’t like them today.”

Some common retina codes in ICD-10 (eg, macular degeneration) are not specific to the right or left eye, McCune said.

The most dramatic change will be in diabetic eye disease. In ICD-9, for a patient with diabetic eye disease and an ocular manifestation, there are two separate diagnosis codes, one for the type of diabetes and the other for the ocular manifestation, McCune said.

“In ICD-10, it becomes one code that describes not only the type of diabetes the patient has but also the gravity as well as the specific ocular manifestation,” she said. “So, a code such as type 2 diabetic with mild nonproliferative diabetic retinopathy without macular edema, that’s one diagnosis code. Today, that would be two diagnosis codes in ICD-9.”

All codes for diabetic retinopathy are in the diabetes section of the ICD-10 directory. In ICD-9, diabetic retinopathy codes were in the retina section, Mattox said.

For trauma, there is a new coding rubric, and trauma codes must be specific.

“With any patient who comes in with trauma, the trauma section has been expanded in a really significant way so that you even have to code differently for an initial encounter for something that was traumatic or an emergency situation,” Mattox said. “Different codes are used for follow-up, depending on whether the initial injury is trauma or emergency. So, there are some things that we’re not used to ever having used before.”

Trauma codes must be specific.

“You have to be very specific about what caused the injury,” Mattox said. “If you had a corneal laceration, you would have to put in a code about whether that came from, say, an auto accident or a flying object.”

In addition, glaucoma codes indicate the staging and severity of disease; severity is the seventh character of the ICD-10 code, Mattox said.

“Physicians have to familiarize themselves with the definitions that we have come up with for the staging and the severity,” she said. “That’s a big difference. In ICD-9, we were using the staging codes as add-on codes, and now they are incorporated directly into each code.”

Currently, with ICD-9, physicians have to input a second code describing the severity of glaucoma.

“That would be two separate codes, one for the gravity of the disease and one for the type of glaucoma,” McCune said. “In ICD-10, it will just be one code, and the seventh digit of the code will differentiate or distinguish the gravity of the disease, mild, moderate or severe. So, for glaucoma, physicians who have actually stopped grading the glaucoma in the patient medical record are going to have to go back and start doing that because they will not be able to pick a diagnosis code without it.”

Documentation and detail

Proper chart documentation is the most critical function in ICD-10 coding, Asbell said.

“Chart documentation is probably the most important thing because most people aren’t doing it right. They can’t pick the right diagnosis,” she said. “The key word here is specificity. The physician has to be very specific in their chart documentation. They haven’t been. They’re letting the computer do it all. They’ll just say, ‘cataracts, right eye first.’ You see that a million times in charts. Well, that’s not good enough anymore.”

Asbell recommended that practices obtain external audits of their chart documentation methods.

“I think external audits get a handle on what you have to do to improve your chart documentation so that you can code properly,” she said. “It is probably the most important thing at this point.”

Practices will need to make basic adjustments as they implement ICD-10, McCune said.

“From a business perspective … this is going to be time consuming in the beginning to find all of these new codes, so there will be some additional time spent in order to select a code and get the claim out to the third-party payer,” McCune said.

EHRs will help facilitate the transition to ICD-10, Repka said.

“Workflow will slow down a little bit during the initial implementation,” he said. “The advantage is that some of this will be done in the setting of EHR. In the EHR setting, it’s actually going to be easier. I think that for people who are still doing manual coding, data entry and chart capture, that’s going to be harder.”

ICD-10 requires greater clinical understanding than ICD-9, Asbell said.

“The thing about ICD-10 is that it’s much more specific and requires greater knowledge of clinical ophthalmology than ICD-9 did. So, the encounter form is probably at the top of everyone’s list,” she said.

To prepare encounter forms for ICD-10, practices should make a report of the top diagnosis codes used by each provider, Asbell said.

ICD-10 diagnosis and procedure codes are alphanumeric and contain three to seven characters. ICD-10-CM diagnosis codes number 68,000, whereas ICD-9-CM diagnosis codes total more than 14,000.

“What are the most frequent codes that that person uses? You’re not going to put all 14,000 or 16,000 codes that you may need on an encounter form and you don’t need them,” Asbell said. “The problem with ICD-10 is in the way it is set up. Each code for an eyelid has a different code, where before you just used a modifier. So, you would say RT for right, for example. Now, there’s a code for right upper lid, and there’s a separate code for right lower lid. All of a sudden the codes are multiplied, not because there are more codes, which there are, but because of, simply, the formatting.”

EHRs have not been properly used to compile patient charts, Asbell said.

“I audit, and the electronic medical records have been pretty much disastrous in terms of chart documentation,” she said. “People have not been trained in Medicare regulations for office coding because none of the societies are giving the extensive training in E/M and eye codes. They are in all the other medical specialties.”

John Bell, practice administrator at North Suburban Eye Associates in Wakefield, Mass., said his practice staff has undertaken exhaustive preparations for ICD-10 implementation.

“I think we’re ahead of the curve,” Bell said. “We’ve done a lot more than a lot of people.”

One practice’s experience

Bell said he and his staff met with McCune for a preliminary training session in early fall 2012.

“It was to introduce them to ICD-10 and to tell them it’s coming and tell them about some of the issues,” Bell said. “About that same time, I actually took the top ICD-9 codes that we’d used in 2011 and looked at what the comparable ICD-10 codes would be and put together a spreadsheet so that we could look at it and get more familiar with what was involved.”

In summer 2013, staff again met with McCune for a half-day training session.

“This was much more in depth, talking about the documentation requirements to support ICD-10,” Bell said.

Staff learned about General Equivalence Mappings and the ICD-10 code book.

“I then updated my list of conversions from ICD-9 to ICD-10 to add a few more codes that we’d used a little bit more in 2013 and to fix up the ones where they’ve made some adjustments to ICD-10 in the previous year,” Bell said.

Bell said his billing staff has attended at least two ICD-10 presentations conducted by Corcoran Consulting Group and sponsored by the Massachusetts Society of Eye Physicians and Surgeons.

“They’ve had more experience with [ICD-10] because, obviously, they’re going to have to get more in depth,” Bell said.

This spring, Bell and his staff plan to perform chart audits to pinpoint areas that need improvement.

“The biggest concern we have is breaking the tendencies and the process that the individual technicians use when they’re documenting because they’re so used to doing it, and they do it so much every day, they kind of fall into a pattern,” Bell said. “We’ve got to point out to them that the pattern is going to have to change here and there.”

The practice, which uses the NextGen EHR, also planned to upgrade to meaningful use stage 2 and ICD-10 software versions, Bell said.

Bell said he is concerned about how insurance plans, including Medicare, will edit ICD-10.

“We have no idea what the edits are going to be for ICD-10,” he said. “If we have a problem, how much are they going to refuse? I don’t know how that’s going to work out, how many denials and how hard it will be to appeal them. I suspect there’s going to be some slowdown in receipts, but to what extent, I have no idea.”

More training and information on ICD-10 will be provided at this month’s meeting of the American Society of Cataract and Refractive Surgery and American Society of Ophthalmic Administrators in Boston.

Pearls for preparation

McCune recommended that medical administrators and staff start practicing with ICD-10 codes well before the deadline, even while they are still using the ICD-9 codes.

“It’s definitely more labor intensive, and I think that physicians have become accustomed to having one page of a cheat sheet with all of the codes they ever used,” McCune said. “It would be extremely difficult to capture all of the codes that most physicians use on one or two pieces of paper because of the number of codes that go from one in ICD-9 to two, three, four or five, up to nine different codes for the same disease that they’re currently using just one code for.”

Practices should ensure that their EHR systems are ready to handle ICD-10 coding, McCune said.

“They want to check with their computer vendor and their practice management vendor to find out when the codes will be downloaded into their system,” she said. “And they should sign up to have their computer system tested to make sure that the codes will actually go from their computer to their Medicare contractor.”

Asbell suggested that, for some practices, technicians may be trained in ICD-10 coding to act as a liaison between the physician and the billing department.

“I like that concept,” Asbell said. “Normally, this is something that physicians delegate to somebody else while they see patients. They’re so busy seeing patients they don’t have time to start picking codes during the day. So, it’s a cooperative effort. I think including technicians on your team for this and having them interface with the billing department might be a really important aspect.”

McCune and Mattox said there are various resources physicians and administrators can use as they implement ICD-10.

Mattox pointed to the AAO’s new ICD-10 ophthalmology specific book.

“I have also worked with Dr. Peter Zacharia and Sue Vicchrilli from the AAO to compile a quick reference guide for the glaucoma codes,” she said.

The ICD-10 manual is the primary go-to source for details, McCune said.

“I think [practices] need to gain access to an ICD-10 manual and begin to orient themselves and their staff to finding the codes or researching the book itself,” she said. “Secondly, they need to start looking at the documentation with a critical eye toward very specific details in the impression such as they will be able to select a code without having to return the chart to the physician.”

The AMA, AAO, ASCRS, ASOA, CDC and CMS also offer various resources for practices preparing to implement ICD-10. – by Matt Hasson