The Perfect Storm of ICD-10

By Melody W. Mulaik, MSHS, RCC, CPC, CPC-H, PCS

January 2012—In today’s chaotic healthcare environment there are many items that generate discussion and confusion. Arguably one of the top items that falls into this category is the implementation of ICD-10-CM. For many hospital employees the implementation of ICD-10 will have little to no effect on their job, so why is this a big issue for the entire healthcare community?

Currently, both physicians and hospitals utilize ICD-9-CM codes to report diagnosis information to third party payors. For radiology services these codes indicate the radiologist’s definitive findings or symptoms, conditions, problems, complaints, or other reason for the radiological service. Many insurance payors utilize this information to establish medical necessity by indicating the nature and severity of the condition which ultimately results in the payment, or nonpayment, of the imaging service.

There are many problems with the current ICD-9 codes. They do not consistently describe 21^st century care since many of the disease categories are full and there is no additional room to add more descriptive codes. The current codes do not provide sufficient details on a patient’s medical condition. Additionally, the current codes contain outdated and obsolete terminology. These problems produce inaccurate and limited data. The current ICD-9 system is over 30 years old and was never designed for use in healthcare reimbursement.

Effective October 1, 2013 all healthcare providers must begin using ICD-10 on submitted claims. For this to occur there are significant changes that must occur for both the providers and the payors. Any system that contains diagnosis codes must be modified to accommodate more fields since the maximum code size will increase from five to seven digits. Additionally, the number of codes will increase from 16,000 to 68,000 to allow for greater specificity and details about the patient’s condition.

One of the sources of conflict and concern relates to how much the implementation of ICD-10 will really impact the physicians. The current range of opinions varies from no impact at all to complete and catastrophic destruction. As with most things, I think the answer lies somewhere in the middle.

Individuals that claim there will be no impact primarily base their argument on the fact that systems, such as Electronic Health Records (EHRs) will be able to prompt the physician to enter the correct data, and thus all the information will be available for correct code assignment and the physician will not need to change their documentation practices. When utilized appropriately, EHRs do indeed provide a great benefit to the physicians, but they are not the magic bullet that will help all physicians. Radiologists are a good example of this since they typically do not use EHRs in the same manner as other physicians. Radiologists dictate the results of their exams frequently with some macros to guide the process, but each patient is separate and distinct and therefore usually the exams are as well.

The other extreme believes that the majority of payors will not be able to process claims appropriately resulting in a severe cash flow disruption for most providers. Additionally, the costs to update the majority of systems will be detrimental for most providers thus causing practice closures.

The reality is that we do not know exactly what is going to occur as a result of the implementation of ICD-10. One thing we do know for sure is that the United States is the only country not utilizing ICD-10, so we are behind the rest of the world in terms of tracking patient morbidity and mortality. That in itself is not the main driver of why we need to implement this new code set, but it is an important component. In order to adequately prepare for this monumental change, we need to prepare for a Category 5 storm in the hopes that it is just a tropical storm. To do anything less would be folly.

The implementation process has already been underway for over two years, and we now have less than two years remaining. The Centers for Medicare and Medicaid Services (CMS), software vendors, and other affected organizations are well down the path of preparing for implementation and are on target for the implementation date of October 1, 2013. When the American Medical Association (AMA) recently made a public announcement that they believed the implementation of ICD-10 should be delayed, they did not receive an overwhelming positive response from the healthcare community because most people believe that it is a little late in the process. While it is understood that there are many unknowns related to the implementation, there is still time to address specific concerns related to costs, readiness, and cash flow disruptions.

I am frequently asked if the implementation of ICD-10 will be delayed. Given how CMS has handled other recent issues, I sincerely believe that it will not be delayed. There may be a grace period, or a period of non-enforcement for lack of compliance, but CMS has repeatedly stated that October 1, 2013 is a hard date that will not be changed.

So the bottom line is that even though there are pockets of conflict, confusion, and concern, the implementation of ICD-10 is moving forward and all providers and organizations must be moving quickly towards the goal of being ready for whatever may come on October 1, 2013!

Melody W. Mulaik, MSHS, RCC, CPC, CPC-H, PCS is president and co-founder of Coding Strategies, Inc. She can be contacted at melody.mulaik@codingstrategies.com.