Jonathan Rubenstein, MD
The deadline for converting to ICD-10 coding (October 1, 2014) is fast approaching. The Centers for Medicare & Medicaid Services (CMS) has declared March 3 – 7, 2014 as the initial testing week for the electronic data interchange of ICD-10 codes. Medicare Part A, Part B and DME contractors must be prepared to process test files submitted by providers and suppliers. The AUA offers a virtual training course available at AUA Coding Seminars 2014 and ICD-10 coding workshops at all the regional live seminars held in 2014. As the healthcare community gears up to convert to ICD-10 coding, many groups – including the AUA and the American Medical Association – are working on behalf of members to delay implementation. We recently sat down with Maryland urologist Dr. Jonathan Rubenstein, a member of the AUA Coding and Reimbursement Committee and chief faculty for the virtual training course to discuss what the urology community needs to know about ICD-10.
Q: Is ICD-10 really going to happen? What are the odds that our efforts to postpone implementation will be successful?
Despite efforts from the AMA, AUA and other organizations, there have been no signs that ICD-10 will be further postponed. Everyone should be preparing for the transition to ICD-10 to take place on October 1, 2014. The fact that Medicare did their ICD-10 testing in March 2014 further strengthens the notion that the government plans on moving forward and strengthens the belief that this will not be pushed back. I think there is too much riding on this transition to turn back now.
Q: A recent report from the medical claims clearinghouse Navicure indicated that 74 percent of practices haven't started their implementation plans, but still believe they'll be prepared in time for the October 1 deadline. What do you see as the reasons for the late start in implementation plans among urologists?
I think there are a number of reasons for the late start in implementation plans among urologists: a hope that the implementation date will be pushed back, denial that this is really happening, a (false) belief that having a robust EMR system or professional coders/billers or an online ICD-10 search tool will allow them to quickly and accurately find the correct code to use. In addition, providers and medical practices also feel overburdened with PQRS, Meaningful use of EMR, denial management, increased oversight, effects of the ACA, changing insurance landscape, and a whole host of other non-medical issues which are also at the forefront and affecting their practices. It is possible that once they get the PQRS and Meaningful Use plans in place, that they will turn their attention to ICD-10.
I need to stress that this is really happening, and that no EMR system, professional coder/biller or online ICD-10 search tool can prepare anyone for the massive change. The fact that 74 percent haven't started their implementation plans is terrifying. A successful transition takes a tremendous amount of work: EMR, practice management, clearinghouses, payors, provider education, coder/biller education, changing superbills, changing documentation patterns, understanding nuances of ICD-10, etc. The earlier to start the training and transition, the better. This is not something that can be started a month or two in advance.
Q: What do you foresee as the effect on physician productivity during the transition to ICD-10?
I believe one should plan on a 3-4 percent increased time (average) per patient encounter merely for documentation of the correct ICD-10 code choice. While there will be no foreseeable change for many patients, for others there could be a significant amount of time documenting and choosing codes. Those who best understand ICD-10 and who are most prepared will see the lesser end of this increase, while those unprepared will have a tremendous stress placed upon them and their practices. Practices should consider reducing their schedule, albeit slightly, during the transition period; this could turn into a permanent reduction, but also due to the time for Meaningful Use of EMR and other programs that increase provider work.
The main reason for the reduced productivity lies in the fact that ICD-10 has so much more specificity (that needs to be documented) and number of new rules compared to ICD-9. There is an increased need to document specificity such as etiology (of certain conditions), laterality (of certain conditions), location of the process (certain conditions), visit number (initial, subsequent, for sequelae of the condition; mainly for trauma and external injury), among other items. There are also exclusions and sequencing rules that need to be understood. The providers need to understand the ICD-10 coding process for successful code choice; those who do not understand will fail to document correctly, and therefore it will not be possible to code correctly.
I have additional concerns for providers who perform work in hospitals who are away from their own EMR system. If one does not understand ICD-10, they will not dictate or document correctly, such as for consultations or for surgery. Without proper documentation, the provider's own coders and/or hospital coders will be calling them, asking them for further information or to put an addendum on their dictation or notes, to allow the proper code to be chosen. This process will add a significant amount of time to payment, and work to providers.
Q: What benefits, if any, do you anticipate that ICD-10 might have for practices?
ICD-10 is a much more elegant coding system than ICD-9; a lot of thought was put into the structure. It makes much more sense than ICD-9, has room to expand, and can clearly place patients into specific categories. This will be a huge benefit to research and public health concerns. Practices should (eventually) see reduced denials and requests for medical records, improving time to payment, for those who are using ICD-10 correctly.
Q: What should practices be most worried about?
I am most concerned with the potential cash flow nightmare that providers and practices will face starting October 1, 2014. While the reduction in cash flow will be most pronounced in those who are least prepared, it will still affect those who are well prepared, albeit less. Those who believe that ICD-10 is merely an expansion of ICD-9, or those who believe that they can just search for a code on their EMR or with a search tool will be the ones who will be most affected. Those who believe that they will just use the "unspecified" codes for each condition will be the ones with the most delays in payment, request for records, and denials. By looking at the ICD-10 code set, I see very rare cases where "unspecified" codes can be correctly used in ICD-10, as the coding system is so comprehensive. I could see a situation where "unspecified" codes are denied outright and records are requested by payors to see if the patient truly warranted an "unspecified" code, or if the provider merely didn't take the time to learn the specificity needed to code correctly and chose the "unspecified" code out of convenience or lack of education.
Due to the potential for a severe loss in productivity and reduction in cash flow, I recommend that all practices strongly consider whether they should increase their lines of credit or take out loans during the ICD-10 transition.