A Call to Action

NPs must bridge the gap in ICD-10 implementation

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*Editor's note: Since this article was published, the implementation of ICD-10 has been pushed back to October 2015.
Simply put, ICD-10 is the largest and most complex federal regulatory mandate to hit healthcare in the last 34 years. The International Classification of Diseases 10th Revision (ICD-10) was endorsed officially by the World Health Organization (WHO) in 1990, and the full version was released in 1994. Canada, France, Germany, Iceland, Norway, Sweden, Australia and Belgium are among the many countries that have adopted this coding system. Even the United Kingdom utilizes various iterations of ICD-10 for its reimbursement and case mix purposes. These countries and others - including Taiwan and the United Arab Emirates - are carefully watching how the United States will implement ICD-10. We remain behind schedule in our preparation to launch it on Oct. 1.

ICD-10 became even more complex with the required implementation of the Healthcare Insurance Portability and Accountability Act (HIPAA) Version 5010, the standards platform on which ICD-10 transactions must be submitted. This implementation was finally enforced in July 2013. With just a few months left before the Oct. 1 compliance date, the majority of provider groups continue to be ill-prepared to implement ICD-10 due to lack of resources - mostly financial restrictions (cash flow issues or return on investment [ROI] concerns) and lack of people resources. In terms of ROI, many practices don't see the value of implementing ICD-10 due to factors such as lack of direct patient benefit, little relevance to reimbursement (ICD-9 is considered sufficient to meet operational needs), and because ICD-10 allows the continued use of nonspecified codes.

ICD-10 was first announced in January 2009, so at this point, the healthcare industry should be in the testing phase of implementation. The reality is that many practices have not started preparing. This predisposes these organizations to catastrophic financial risk and failure. Because the healthcare community is so tightly intertwined, the failure of even the smallest physician groups will have huge repercussions on the hospitals where they currently hold privileges.

Facing Reality

Regardless of anyone's opinion on ICD-10, the reality is that providers will lose money if they can't bill for services because there is no current code to support it in ICD-9. When providers implement ICD-10, they will "invest money" (not "lose" money - a matter of perspective) in a national and global healthcare transformation that will eventually positively impact patients, future patients and provider payments.

It is true that through this progress, someone, sometime, somehow will eventually lose money. It's just a matter of when, who and how that will occur. If we do not convert to ICD-10, we will eventually convert to ICD-11 or another revision. That will require an investment of resources as well, equal to or even higher than what is faced now.

A question that should have been addressed early on is: "Where will the money come from to pay for the ICD-10 conversion?" rather than "Why do we need to convert?" We simply cannot continue to operate a Mac (21st century medicine) on a DOS operating system (ICD-9 as we know it).

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For reasons beyond the scope of this article, there is a gargantuan gap - maybe an abyss - between practice implementation, the current state of readiness and the ICD-10 federal mandate to be compliant by Oct. 1. NPs are capable of filling some of these gaps in support of their own practices as well as those of physician colleagues.

As a refresher, the healthcare industry is making the transition from ICD-9 to ICD-10 for several reasons:

• ICD-9 is 34 years old. It contains outdated and obsolete terms, and it is inconsistent with the current practice of medicine.

• ICD-9 codes provide limited data about patients' medical conditions and inpatient procedures. Having accurate data allows the Centers for Disease Control and Prevention and other population health agencies to have better clinical intelligence, and eventually better business intelligence, to create new care and treatment algorithms for better healthcare delivery.

• The structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full. The current sequencing is also an issue. ICD-9 can only accommodate simple order sequencing; it does not allow for new diagnosis codes to be inserted where it might be otherwise be logical to do so in a grouper.

• ICD-10 codes allow for greater specificity, laterality, exactness in describing a patient's diagnosis, and in classifying patient procedures.

• ICD-10 will accommodate newly developed diagnoses, procedures, innovations in technology and treatment, performance-based payment systems, and more accurate billing.

• ICD-10 coding will make the billing process more streamlined and efficient, which will allow for more precise methods of preventing and detecting fraud.

• ICD-10-CM will allow the U.S. to track disease severity and share disease and mortality data. A critical feature of ICD-10 is the ability to track bioterrorism occurrences and other public health outbreaks on a more specific and accurate scale.

• Some high-level technical considerations should also be reviewed in any discussion about the reasons for ICD-10. The current ICD-9-CM diagnosis codes have three to five digits that are mostly numeric. The ICD-10-CM diagnosis codes have three to seven digits: an alpha first digit, numeric second digit, and alpha or numeric third through seventh digits. This information is highly relevant to coders, technology and the information systems on which ICD-10 must be processed.

• All policies, processes, operations, healthcare information systems and technology must be assessed and upgraded or remediated to support ICD-10. This applies to all HIPAA-covered entities and all providers.

NP Call to Action

The Centers for Medicare and Medicaid Services and ICD-10 thought leaders such as Leidos Health recommend the following critical steps for providers who have not yet started to transition to ICD-10. Some of these activities may or may not be applicable to all small practices. Although many of these steps require the business decision-maker to approve and provide financial resources, nurse practitioners can supply relevant information and valuable leadership required for the implementation.

Nurse practitioners should:

• Volunteer to assist the practice in implementing ICD-10. Be an instrument of change.

• Establish a transition team or ICD-10 project manager, depending on the size of the organization, to lead the transition.

• Develop a realistic timeline that identifies high-priority tasks, crucial milestones/relationships, task owners, required resources, and estimated start and end dates. Begin implementation now.

• Determine how ICD-10 will affect your organization. Start by reviewing how and where you currently use ICD-9 codes.

• Develop a contingency plan in case the ICD-10 tasks cannot all be completed on time. Start with your highest risk areas and go from there.

• Account for the use of ICD-10 in authorizations/precertifications, treatment orders, medical records, superbills/encounter forms, practice management, data mining, clinical/business intelligence, billing systems, and coding manuals.

• Review how ICD-10 will affect clinical documentation requirements and electronic health record templates.

• Communicate the plan, timeline and new system changes and processes to organizational stakeholders; ensure that everyone, from the top down, understands the extent of the effort the ICD-10 transition requires.

• Secure a budget that accounts for software upgrades/license costs, hardware procurement, staff training, additional staff requirements (in-house or consultants), revision of forms, workflow changes, and risk mitigation.

• Communicate with payers, billing, information technology staff, the practice management system and all vendors about their preparations and state of readiness.

• Coordinate ICD-10 transition plans among all partners. Evaluate contracts with payers and vendors for policy revisions, testing timelines and costs related to the ICD-10 transition.

• Discuss testing with your clearinghouse, health plans and other external partners. Use their master test plans and test scripts, if possible, to launch a test plan for unit and integration testing.

• Ensure that ICD-10 systems are working properly by testing systems early, remediating high-priority, show-stopper defects quickly, and ensuring that clean claims can be submitted and paid without significant errors.

• Use high volume/high dollar diagnosis-related groups (risk based) first to create ICD-10 test claims.

• Test eligibility verification, quality reporting and other transactions or processes that involve ICD-10 codes from beginning to end.

• Test both within your organization and with your payers and other business partners to ensure that you are able to submit accurate claims and receive payment.

NPs who own healthcare practices will be significantly affected by ICD-10 from implementation, operational and revenue cycle perspectives. NPs employed by hospitals and physician groups will be affected to a lesser degree, mainly in the area of clinical documentation.

A Message for Practice Owners

NP-owned practices face the same challenges and issues as physician-owned practices. I challenge NPs to be proactive in championing and implementing ICD-10 because it has definite direct impact on patient care, population health and operational practices. NPs who are employees should exhibit leadership in transitioning to new documentation guidelines and should become catalysts for good change within their practice settings.

Physician groups desperately need ICD-10 support and champions within their organizations. NPs can fill this role. To add value to the healthcare industry, NPs need to serve as allies of national and global transformation efforts as well as healthcare information technology adoption.

NPs can help bridge the gaps in provider implementation efforts. ICD-10 calls for an all-hands-on-deck approach. For the sake of patient safety, progressive health and wellness, enterprise success, and to ensure sustainability of the U.S. healthcare economy, NPs must play a role in ICD-10 implementation.

Critical Areas of Consideration

• Office-based NPs will continue using CPT codes for billing.

• Train clinical and administrative staff to use the new ICD-10 code set. Cost may vary depending on type of training and resource materials. Carefully negotiate each vendor contract.

• Although many health plans are aiming for payment neutrality, the end result may be payment accuracy with outcomes that vary depending on the case mix. Expect health plan contracts to be renegotiated to include new payment schedules.

• Monitor claims and accounts receivable for several months - paid, denied or pended. Expect workflow changes with increased queries from coders for denied and pended claims.

• Consult with a reputable vendor to assess the overall impact to your practice and to identify the need for systems testing to ensure that EHR/lab/diagnostics/pharmacy interface functionality will continue to work.

• Ensure that all coders are trained and audited for their new knowledge. It is critical that each coder is proficient in ICD-10 well in advance of the go-live date. Coder accuracy is highly correlated to revenue and cash flow.

• Continue to document accurately as a quality assurance measure against medical malpractice, negligence and fraud, and to ensure patient safety. Include specificity and laterality, as always, with the exact type and source of injuries documented.

• Surgery/invasive procedures will require utilizing correct new terminology. To avoid numerous queries from coders, take great care in describing the procedure performed. Accurate documentation results in accurate coding and accurate payment.

• Although ICD-10 consists of about 155,000 total combined codes, the NP only needs to be familiar with the code sets relevant to his or her specific practice. Find out what your diagnostic codes are and familiarize yourself with what you'll be using most often. Know the terminologies associated with your area of expertise.

• Avoid "not specified," "not otherwise specified" or other vague codes. These are acceptable only for the interim diagnosis, not the "final diagnosis." Avoid using these as default codes because it's easy to find, seems to fit the patient or because there is no time to look for the most accurate code. The goal of ICD-10 is to provide the most precise picture of patient status. Switch to a specific code as soon as the workup supports an accurate diagnosis.

Juliet Santos is a nurse practitioner who has extensive experience in the business arena. She is currently the ICD-10 principal for Leidos Health, which provides clinical and technical expertise to the healthcare industry.


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