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Panel discusses conversion to ICD-10

Issue: March 2014

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The ICD-10 coding conversion will be mandatory for physicians on Oct. 1. I asked members of the American Academy of Orthopaedic Surgeons Coding Coverage & Reimbursement Committee and a national compliance expert what this means to private practice and hospital-employed orthopedic surgeons.

Jack M. Bert, MD
Moderator

Jack M. Bert, MD: Why do we have to convert from ICD-9 to ICD-10?

William R. Beach, MD: The current system of ICD-9 is frankly out of numbers. The five-digit, all-numeric system can no longer accommodate new diagnoses. The system requires the logical and ordered listing of disease states. We have reached the critical mass of diagnoses that require a more detailed system. One could argue that adding a sixth digit to ICD-9 would have sufficed, but it would not have answered all the questions. The desire for more detail — a more granular system — has lead to the creation of ICD-10.

One can consider the following questions a new and better ICD system would answer:

The creators of ICD-10, at least for orthopedics, were perfectly logical in their creation.

1. Chronic or degenerative conditions are found in chapter 6 (M). Acute or traumatic conditions are found in chapter 13 (S). The first character of the ICD-10 code is therefore the letter “M” or “S.”
2. The next four or five digits depend on the particular diagnosis, and thus describe the specific condition. For example, a traumatic rotator cuff tear is S46.01. The sixth digit describes the side. S46.011 is a traumatic right rotator cuff tear and S46.012 is a traumatic left rotator cuff tear.
3. The seventh and final digit then describes the natural history of the disease/condition. For non-fractures, it is:
   A = initial visit/evaluation of a condition;
   D = subsequent (follow-up) visit for the same condition; and
   S = sequelae of that condition.
4. The seventh and final digit for fractures is based on the Gustilo classification:
   A = initial encounter for a closed fracture;
   B = initial encounter for an open grade I or II;
   C = initial encounter for and open grade III (A,B,C);
   D = subsequent encounter for a closed fracture with routine healing;
   E = subsequent encounter for an open grade I or II;
   F = subsequent encounter for an open grade III (A,B,C) with routine healing;
   G = subsequent encounter for a closed fracture with delayed healing;
   H = subsequent encounter for an open grade I or II with delayed healing;
   There is no letter “I.”
   J = subsequent encounter for an open grade III (A,B,C) with delayed healing;
   K = subsequent encounter for a closed fracture non-union;
   There is no letter “L.”
   M = subsequent encounter for an open grade I or II with a non-union;
   N = subsequent encounter for an open grade III (A,B,C) with a non-union;
   There is no letter “O.”
   P = subsequent encounter for a closed fracture with a malunion;
   Q = subsequent encounter for an open grade I or II with a malunion;
   R = subsequent encounter for an open grade III (A,B,C); and
   S = sequelae.

Louis F. McIntyre, MD: The big reason for the conversion is that the government says we have to use ICD-10. ICD-9 is running out of codes and is antiquated. Most of the developed world is using ICD-10 and we are late to the game. ICD-11 is coming out. The specificity of ICD-10 is such that it will lead to better coding and reporting and will enable tracking of disease states and treatments. Some ICD-10 proponents make the case that coverage denials will be less frequent with ICD-10 because of the increased specificity.

Bert: Do private practice or hospital-employed orthopedic surgeons need specific training to make the conversion?

Ranjan Sachdev, MD, MBA, CHC: Physician training is going to be critical to the success of converting to ICD-10 as documentation will have to be more detailed and specific. This is true for fractures that have more codes in ICD-10. For example, in the case of fractured clavicles, the surgeon has to document the location of the fracture, if it is displaced, if it is closed or open and if it is open the surgeon has to use the Gustillo classification to detail the type of open fracture. The surgeon also has to document routine healing, delayed healing and malunion if present. This will require physician training which is specific and different from staff training for ICD-10 as it will have to focus on provider documentation needed to support the chosen code. A good approach is to do a gap analysis based on physicians’ current ICD-9 documentation and documentation needed for ICD-10 then focus the training on the changes that need to be made. It is also a good idea to familiarize physicians with ICD-10 PCS, as their operative notes will have to cover certain specific items to be used by the hospital for coding inpatient procedures.

McIntyre All physicians will need to be facile with ICD-10 to ensure proper reimbursement. Private practice physicians risk significant cash flow issues if their coding does not comply with payer ICD-10 requirements. Hospital employees will not be insolted from this as their relative value unit productivity may be affected by denial of claims. Hospital administrators will be adamant about proper ICD-10 reporting.

Bert: What will be the most cost-effective and least painful method of converting electronic medical records (EMR) to ICD-10 in time for Oct. 1?

McIntyre: Your EMR vendor should have a plan for you to migrate to ICD-10. Some vendors will have better tools. The American Academy of Orthopaedics Surgeons has an electronic tool called Code-X that has pick lists that prompt the necessary information to obtain correct ICD-10 codes. In addition, physicians need to become comfortable with the format of ICD-10. To do that correctly, it helps to purchase the ICD-10 book and look up codes that are used frequently. Next, pick your top 25 ICD-9 codes and “cross-walk” them to ICD-10 codes in a spreadsheet. This can be posted near a dictation station for easy selection of codes.

Sachdev: EMR technology properly deployed to match the practice workflow will definitely make the process of implementing ICD-10 easier. Practices have to proceed with some caution. With the deadline fast approaching, it is possible that some EMR vendors may rely heavily on general equivalent mappings (GEMs) to convert ICD-9 codes to ICD-10 codes, but the Canadian experience has shown this to be a mistake. GEMs may be helpful in many cases, but in orthopedics where codes have increased exponentially, it is better to work with a system that uses the ICD-10 database for code selection rather than GEMs.

With the vast increase in number of codes, practices will have to use an electronic version of the superbill (encounter form/checkout form) to accommodate codes. It also will be important for practices to have the ability to customize their superbills by each provider and EMRs not providing this ability to customize easily at provider level may sacrifice efficiency and productivity. In most groups, physician workflow and the types of patients the physician sees can vary. To have one superbill will require many more clicks or typing to get the right code. A good software system will allow physicians to pick most codes with two to three simple clicks/seach words and, with time, have the ability to learn physician preferences and make code selection faster.

Bert: Do physicians have a choice about whether to adopt ICD-10?

David M. Glaser, JD: Unless there is a change in the law, physicians do not have a choice about adopting ICD-10. Shortly after HIPAA was passed, regulations were issued that required physicians to use ICD-9. Those regulations were amended to require physicians to use ICD-10 effective Oct. 1. Unless those regulations are changed, physicians can be subjected to fines of thousands of dollars for each claim that fails to include the proper ICD-10 code after this date. While it is theoretically possible that CMS could opt to extend the deadline, barring a change the regulations are explicit. If I were running a clinic, I would act on the assumption that as of Oct. 1, there will be penalties if we were not able to submit claims with a proper ICD-10 code.

Bert: What should we do if the payers are not ready for the conversion in our area?

Sachdev: Unfortunately, this scenario will require systems to use both ICD-10 and ICD-9 codes and have the ability to switch between them. Since many of the private carriers are secondary providers and participate in Medicare advantage programs, they most likely will be ready for ICD-10 by Oct. 1. The only payers who may not feel the pressure to convert are workman’s compensation carriers, auto and liability carriers, and small regional insurance companies. Practices will still have to use ICD-9 codes when submitting claims to these carriers.

McIntyre: Payers may not be ready and their facility with ICD-10 may not be uniform. It is important to be in touch with your payers to assess their requirements for ICD-10 reporting and to get it in writing. Make quarterly inquiries to find out if and when they will be ready. Have a line of credit available for the possibility of cash flow shortfalls because of claim denials or increased accounts receivable.