Revenue Cycle Management Blog | GroupOne Health Source

4 Major Risks with ICD-10

Written by Kaitlyn Houseman | November 13, 2013

According to CMS, 1 in 5 physician practices will see their Medicare denials double for up to 6 months after October 1, 2014, the deadline for ICD-10. Your practice does not have to be one of them. Get started early with planning for ICD-10.

The quick answer behind why the change from ICD-9 to ICD-10 is to improve clinical communication. The change will allow for better data capture relating to signs, symptoms, risk factors, and comorbidities. The specificity that ICD-9 lacks will be replaced with the ICD-10 code sets so that clinical documentation can better reflect the changes and advances in technology. Denials will no longer be a matter of clarification that can be handled by the billing manager. Denials after ICD-10 will raise questions about medical necessity and/or the clarity of medical documentation.

So, how will ICD-10 affect my practice? 

The change to ICD-10 will affect more than just your coding department and should not be misjudged. There will be a significant change for anyone that captures diagnosis codes, including your clinical and administrative staff. A deeper knowledge of anatomy and physiology will be a huge help when it comes to the specificity of ICD-10 codes.

The risks of not being prepared for ICD-10 should first be identified in order to develop and execute a plan for your practice. Some of the major risks for the changeover include:

  • Insufficient Training
  • Lack of Preparation by EHR Vendors
  • Financial Risks Associated with the High Transition Costs
  • Reduction in Provider and Staff Productivity
So lets explore these risks further in detail so that your practice can avoid difficulties with the ICD-10 transition.
Insufficient Training
Do not underestimate the importance of the training for your entire staff.  You will want to go above and beyond to educate your staff.  Key factors in training will not just be the right content but also taking into consideration the time it will take for someone to absorb all of the information and what their learning style is.  Try to incorporate this into your training agenda.  Be sure to provide additional training in anatomy and physiology for your staff members in preparation for the detail in documentation that will come with ICD-10.
Lack of Preparation by Vendors
By vendor I am referring to your EHR vendor but also your billing company (if you do not do this in house).  You need to have a serious conversation with any vendor that is going to be part of the ICD-10 transition.  Is your EHR vendor guaranteeing ICD-10 compliance on time?  Is your billing company ready for ICD-10? If they answer yes, ask them what their plan and timeline is for their roll out.  Get specific and ask questions.  They should be happy to answer your questions and feel confident. If they do not, then you may need to consider alternative options. Ask if there will be an additional cost for any training or support by your billing or EHR vendor? Will the upgrade for your EHR cost you? These are questions you need to be asking now.  If you wait and end up in a jam trying to find another EHR or billing company you are going to fall behind.
Financial Risks Associated with the High Transition Costs 
Financial resources have been cited to be one of the biggest constraints on a practice's ability to implement ICD-10.  Of course there is the training we mentioned but are you going to be able to afford the risk of an interruption in your cash flow due to ICD-10?  Payer delays due to a lack of readiness can cause your revenue cycle to take a hit.  Talk to the payers and verify their readiness.  If you will need to take out a loan for emergency cash in the event of ICD-10 interruptions, do so ahead of time. Lenders will be more likely to work with you at this point than later on when you are in desperation.
Reduction in Provider and Staff Productivity
Because ICD-10 is going to require more specific documentation, providers will need to deliver.  If documenting in the EHR at the practice is already a barrier for providers then you will need to seek resources to make this easier whether it be a new way of documenting or additional EHR training.  Staff productivity is likely to decrease as well.  A recent study completed for MGMA had shocking results when it came to coding for ICD-10.  Some of the best of the best showed a 55% accuracy rate decline during the first round of testing.  The second time around improved to 63% but that is not satisfactory for any coding department.  As for productivity, it dropped by 50%.     

Where should you begin if you haven't already?

  1. Identify your current work processes that use ICD-9 codes
  2. Talk to your EHR vendor about their plans for ICD-10
  3. Discuss the implementation plans with all key players to ensure a smooth transition:  clearinghouse, billing services, and payers.
  4. Talk with the payers about how ICD-10 implementation might affect your contracts.  Will your payment schedules be altered bases on code specificity?
  5. From your earlier evaluation on what uses ICD-9 codes, what changes to your workflows and processes need to change?
  6. Assess staff for training needs.  Different staff will require different training based on their involvement with the diagnosis coding. 
  7. Test ICD-10 transactions with your clearinghouse and payers. 
  8. Budget for time and costs related to implementation, including expenses for system changes, resource materials, and training.  
  9. Create a timeline for your ICD-10 transition that is realistic. Do not wait until the last minute or even last couple of months to do this.

With proper preparation you should actually be able to improve your reimbursements when ICD-10 begins, but it will take some time and effort on your part.  Be proactive and invest in training for your entire staff. Set goals! And if those are not being met, seek help and resources.