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ICD-10 brings uncertainty, extra work for ophthalmic practices
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To be direct, not being ready promises to be very expensive, as improperly coded claims will almost certainly be rejected without payment. Resubmission of claims is very time-consuming and expensive and may be associated with long delays in compensation. Unfortunately, being prepared also promises to be very expensive.
Most of our readers are aware that I have not been a major advocate of the benefits inherent in the transition to electronic health records. At significant expense, our practice, Minnesota Eye Consultants, has in the last year made the transition to EHR, and it is no longer an obstacle to patient-centered quality care. To see six to eight patients an hour in the clinic before EHR, I used two rooms and one clinical assistant fed by three COT/COMTs. Because of the extra EHR input requirements, I now require four COT/COMTs to feed me six to eight patients an hour. In addition, I need two clinical assistants, one in each room, to record clinical findings, diagnoses and ICD-9 codes.
So, not including the hardware and software costs, significant training and implementation costs, and a month of reduced patient volume as we made the transition, I now require two more full-time employees to see the same number of patients. These are relatively expensive employees who require significant patient skills and training. The cost is one thing, but it is also extremely difficult to recruit and retain high-quality clinical assistants and COT/COMTs.
Adoption of EHR has, as a side benefit, created a significant number of high-quality jobs, especially when considering all the EHR company employees and trainers and extra personnel required in a practitioner’s office.
Are there any other positives? I must admit, I like not writing in the chart as much as before, although I miss my sketches and even a thousand words are not always as good as one drawing. Fortunately, when needed, I can usually take a picture. Also, I rarely dictate anymore, electronic prescribing is great, and up until now, with ICD-9, our claim denial rate has been low. When I read my records, they are legible and complete and seem more audit-proof than did my written notes. It sometimes takes me longer to get all the information that I need from previous examinations when making care and treatment decisions, but it is there and I can find it.
At Minnesota Eye Consultants, we are in ICD-10 “boot camp.” The battle cry from the drill instructors can be best described as: “Specificity, specificity, specificity!”
It is no longer Open Angle Glaucoma OU. It is Mild Primary Open Angle Glaucoma OD as one diagnosis and Moderate Primary Open Angle OS as a second diagnosis. The presence of associated pseudoexfoliation, pigment dispersion and the like must be specifically noted for each eye separately. The coding of diabetic eye disease is an interesting challenge in itself and again requires the eye, right or left, to be noted, the type of underlying diabetes mellitus, specificity as to the presence and severity (mild, moderate or severe) of background diabetic retinopathy, and the same for diabetic macular edema.
We have always noted these findings in our charts in our description of fundus findings and/or list of problems, but now we need to get the whole thing together in one complete and specific ICD-10 code that many of us might once have considered a run-on sentence.
What is the purpose of all this? Again, I am hard-pressed to find the benefit for the individual patient or already harried and busy clinician/surgeon. Third parties will be able to determine the complexity of a given clinic’s patient mix, and for the subspecialist who is concerned about being judged on a cost-benefit basis, as though his or her patient mix was the same level of difficulty to manage as that seen in a typical comprehensive ophthalmologist or optometrist office, the increased specificity of ICD-10 should delineate the differences. This might keep those who manage the toughest cases, including university medical centers, as being inappropriately branded as inefficient providers, which can carry significant monetary penalty.
So, at Minnesota Eye Consultants, we will be prepared. We are hoping those on the receiving end of our far more specific and detailed claims will be equally prepared. I must admit we have our doubts and are anticipating a significant increase in our insurance reimbursement denials even when we do everything right, as the payers must also adjust to the additional burden. In addition, an increase in denials is a blessing for them.
Significant delays in reimbursement may put some practices that are already on the edge into severe financial distress. The prudent practice might do well to have a little extra capital in reserve.
In addition, we are still uncertain whether we will be paid for the care we provide the newly minted MNsure policy holders, our state’s version on the Affordable Care Act mandate, adding extra stress on the system.
So, as I have stated before, there is no shortage of patients in need of our care. We can all be as busy as we wish. The challenge is getting fairly compensated for the work, or perhaps getting compensated at all.