PAGE 1

ICD-10 ACtIon GuIDe

for

MeDICAl PrACtICes

Presented to you by The Cooperative of American Physicians, Inc.

ICD-10 ACTION GUIDE FOR MEDICAL PRACTICES

PAGE 2

PAGE 2

Table of Contents

Introduction............................................................................................................................. 3

What.Is.Changing.and.Why?............................................................................................... 4

. What.Are.the.Main.Provisions.of.the.Change?....................................................... 5

. When.Does.It.Go.Into.Effect?........................................................................................ 5

ICD-10.and.Your.Practice...................................................................................................... 6

. What’s.the.Potential.Downside?................................................................................. 6

. What’s.the.Potential.Upside?....................................................................................... 7

Recommendations.for.Compliance................................................................................... 8

. Basic.Recommendations................................................................................................ 8

. Advanced.Recommendations.....................................................................................10

Conclusion..............................................................................................................................13

ICD-10.Transition.Checklist...............................................................................................14

ICD-10 ACTION GUIDE FOR MEDICAL PRACTICES

PAGE 3

Introduction

The.International.Classification.of.Diseases.(ICD).is.a.medical.classification.list.by.the.World.Health.Organization.(WHO).that.is.updated.annually.and.used.by.more.than.25.countries..

The.current.ICD-9.code.set.is.more.than.30.years.old..Many.consider.it.to.be.outdated,.as.it.does.not.reflect.recent.advances.in.medical.technology.and.knowledge,.and.has.an.extremely.limited.ability.to.expand..

On.October.1,.2015,.all.medical.practices.will.be.required.to.adopt.new.ICD-10.coding..In.this.booklet,.we.will.cover.the.new.code’s.structure,.its.requirements,.important.dates,.and.all.other.information.you’ll.need.to.comply.with.the.new.standards.

We.hope.you.find.this.guide.valuable.as.you.transition.to.ICD-10.

ICD-10 Grace Period

The Centers for Medicare and Medicaid Services (CMS) announced on July 6, 2015

a one-year grace period for ICD-10 submissions that lack exact specificity.

•. Medicare.contractors.will.not.deny.claims.based.solely.on.the.specificity.of.the.

ICD-10-CM.code.as.long.as.a.valid.ICD-10.code.from.the.right.family.of.codes.is.

used...Moreover,.physicians.will.not.be.subject.to.audits.as.a.result.of.ICD-10.

coding.mistakes.during.the.first.12.months.following.ICD-10.implementation.

•. Physicians.will.not.be.penalized.under.the.various.CMS.quality.reporting.

programs.(PQRS,.MU).for.errors.related.to.the.additional.specificity.of.the.

ICD-10-CM.code,.as.long.as.a.valid.code.from.the.right.family.of.codes.is.used.

•. If.Medicare.contractors.are.unable.to.process.claims.within.established.time.

limits.because.of.ICD-10.administrative.problems,.such.as.contractor.system.

malfunction.or.implementation.problems,.CMS.may.in.some.cases.authorize.

advance.payments.to.physicians.

In.order.to.be.reimbursed,.you.must.STILL.submit.using.ICD-10..You.cannot.submit.

using.ICD-9.

Therefore, we strongly advise you to be fully prepared for the October 1

implementation.

ICD-10 ACTION GUIDE FOR MEDICAL PRACTICES

PAGE 4

What Is Changing and Why?

ICD-10.consists.of.two.parts:

•. ICD-10-CM.(Clinical.Modifications).diagnosis.coding,.which.is.for.use.in.all.U.S..health.care.settings.

•. ICD-10-PCS.(Procedural.Coding.System).inpatient.procedure.coding,.which.is.ONLY.for.use.in.U.S..hospital.settings..

When.most.people.talk.about.ICD-10,.they.are.referring.to.ICD-10-CM,.which.is.the.primary.focus.of.this.guide.

The.ICD-10.code.set.reflects.recent.advances.in.medicine.and.uses.current.medical.terminology..It.also.provides.greater.detail.and.more.specific.information.about.the.diagnoses,.along.with.the.flexibility.for.future.expansion.that.the.current.ICD-9.lacks.

Note:.This.is.not.an.issue.for.traditional.Current.Procedural.Terminology.(CPT).or.Healthcare.Common.Procedure.Coding.System.(HCPCS)-based.reimbursements,.since.these.codes.are.not.part.of.ICD-10.and.are.not.scheduled.for.change.at.this.time.

ICD-10.provides.much.more.granularity.of.detail.than.ICD-9..While.ICD-9.CM.has.14,000-plus.codes,.ICD-10-CM.has.more.than.68,000.codes..The.transition.from.ICD-9.to.ICD-10.is.different.in.that.the.structure.of.the.codes.will.also.be.changing..

While.there.is.no.simple.one-to-one.match.between.ICD-9.codes.and.ICD-10.codes,.there.are.general.equivalence.mappings.(GEMs).available.to.assist.in.translating.data.from.ICD-9.to.ICD-10..Keep.in.mind.that,.like.mastering.a.foreign.language,.true.fluency.in.ICD-10.is.more.complex.than.just.trying.to.cross-map.elements.from.one.system.to.the.next,.because.many.codes.will.not.directly.translate.or.could.have.multiple.translations..Therefore,.it.is.important.that.all.staff.understand.how.to.“natively”.generate.and.utilize.codes.under.ICD-10.

ICD-10 ACTION GUIDE FOR MEDICAL PRACTICES

PAGE 5

The.basic.structure.of.the.ICD-10.code:

Characters.

1-3.(the.category.of.disease);.

4.(etiology.of.disease);.

5.(body.part.affected);.

6.(severity.of.illness);.and.

7.(placeholder.for.extension.of.the.code.to.increase.specificity).

.

x x x x x x x

i i i i i

1 - 3 4 5 6 7

Example:. S 8 6 5 2 1 Z .ICD-10.does.not.directly.impact.provider.use.of.CPT.coding.for.outpatient.procedures.and.physician.services.or.HCPCS.

WHAT ARE THE MAIN PROVISIONS OF THE CHANGE?

ICD-10.is.mandated.for.all.Health.Insurance.Portability.and.Accountability.Act.(HIPAA)-covered.entities..Converting.to.ICD-10.is.a.HIPAA.code.set.requirement..Most.providers,.including.physicians,.are.HIPAA.“covered.entities”.and.must.comply.

WHEN DOES IT GO INTO EFFECT?

Although.the.deadline.has.been.extended.twice.previously,.it.is.currently.set.for.October 1, 2015,.and.is.expected.to.take.effect.at.that.time.

A.one-year.ICD-10.grace.period.was.announced.by.The.Centers.for.Medicare.and.

Medicaid.Services.(CMS).on.July.6,.2015..While.the.grace.period.does.allow.for.

some.flexibility,.you.still.must.submit.claims.using.a.valid.ICD-10.code.from.the.

correct.family.effective.October.1,.2015..Hence,.we.strongly.advise.physicians.to.

be.fully.prepared.for.the.October.1.implementation.

ICD-10 ACTION GUIDE FOR MEDICAL PRACTICES

PAGE 6

ICD-10 and Your Practice

WHAT’S THE POTENTIAL DOWNSIDE?

1. Lack of payment.

After.the.mandated.conversion.date,.any.ICD-9.codes.used.in.transactions.for.services.or.discharges.on.or.after.the.compliance.date.may.be.rejected.as.noncompliant.and.the.transactions.may.not.be.processed..That.could.cause.immediate.cash-flow.consequences.for.your.practice.

2. Significant implementation costs.

Most.practices.are.expected.to.incur.significant.costs.in.terms.of.new.software,.training.of.staff,.and.initial.reduced.productivity.as.they.make.the.switch.to.ICD-10..The.AMA.published.a.study1.dated.February.12,.2014.that.found.that.small.practices.can.expect.to.spend.anywhere.between.$56,639.and.$226,105.to.fully.implement.ICD-10..Medium-size.practices.may.need.to.spend.more..

While.these.numbers.may.seem.high,.what’s.important.is.that.you.assess.what.YOU.might.have.to.spend.in.each.of.the.below.categories.to.make.a.successful.transition:

•. Training.•. Assessment. .•. Vendor/Software.Upgrades.•. Process.Remediation•. Testing•. Productivity.Loss•. Payment.Disruption

3. Potential cash flow problems.

While.the.CMS.one-year.grace.period.allows.for.some.flexibility.in.ICD-10.coding,.you.still.must.submit.claims.using.ICD-10.codes.in.the.correct.family.effective.October.1,.2015..If.you.are.not.prepared.to.do.that,.it.is.still.possible.that.you.could.face.a.short-term.spike.in.delayed.or.denied.claims.

.

1.AMA;.http://www.ama-assn.org/ama/pub/news/news/2014/2014-02-12-icd10-cost-estimates-increased-for-most-physicians.page

ICD-10 ACTION GUIDE FOR MEDICAL PRACTICES

PAGE 7

WHAT’S THE POTENTIAL UPSIDE?

1. Better data. A higher level of detailed information.

The.additional.specificity.of.data.being.recorded.should,.over.time,.allow.health.professionals.to.better.track.best.practices.across.the.United.States..The.deluge.of.detailed.information.that.will.be.generated.by.ICD-10.is.expected.to.create.a.gold.mine.of.actionable.data.by.researchers.and.epidemiologists..

Individual.practices.should.also.experience.long-term.benefits.thanks.to.improved.metrics.that:

•. Measure.their.clinical.performance.relative.to.averages.across.their.specialty

•. Spot.patient.trends•. Find.areas.of.potential.business.and.workflow.improvements

2. More appropriate and streamlined reimbursement.

The.new,.more.granular.coding.system.will.allow.physicians.to.report.more.accurately.the.complexity.of.care.they.provide..Eventually,.this.will.likely.result.both.in.lower.reimbursements.for.more.routine.care.and.higher.reimbursements.for.more.complex.treatments..The.upside......potential.in.this.regard.is.most.significant.for.new.procedures,.since.the.current.ICD-9.system.cannot.expand.with.new.codes.that.reflect.the.cost.of.cutting-edge.procedures..

The.greater.degree.of.granularity.in.reporting.is.also.expected.to.eventually.streamline.reimbursement,.as.the.code’s.high.level.of.detail.should.allow.for.greater.automation.and.less.payer-physician.inquiries.

3. Less fraud.

Having.more.granular.and.accurate.data.should.allow.payers.to.create.more.complex.algorithms.to.detect.and.combat.fraud.

ICD-10 ACTION GUIDE FOR MEDICAL PRACTICES

PAGE 8

Recommendations for Compliance

BASIC RECOMMENDATIONS

These.are.the.steps.you.absolutely.must.take.in.order.to.ensure.your.practice.complies.with.ICD-10.requirements.

1. Identify a team.

Clearly.designate.an.ICD-10.team.leader.who.will.be.responsible.for.driving.ICD-10.adoption.in.your.practice..Remember,.the.ICD-10.leader.does.not.have.to.be.a.physician..Assign.someone.(like.a.coder).who.has.both.the.interest.and.time.to.tackle.this.issue..Be.sure.to.identify.supporting.team.members.and.their.responsibilities.as.early.as.possible..Ultimately,.the.conversion.effort.will.likely.involve.every.member.of.your.practice.

2. Scope out impact.

Identify.every.place.your.office.currently.uses.ICD-9-CM.diagnosis.or.procedure.codes.and.determine.the.impact.of.conversion.(e.g.,.EHR,.billing,.practice.management,.referrals,.hospital.interactions,.public.health.reporting,.applications,.forms,.records,.contracts,.etc.)..Note.that.the.impact.often.covers.a.larger.breadth.of.the.practice.than.initially.assumed..Take.the.time.to.talk.through.the.change.with.every.applicable.member.of.your.team.and.every.part.of.your.workflow—from.clinical.to.back.office..Don’t.forget.to.consider.the.effect.of.ICD-10.on.other.planned.or.ongoing.projects.(e.g.,.HIPAA,.EHR.adoption,.etc.).

3. Talk to your software vendors.

Contact.your.practice.management,.EHR,.and.other.software.vendors.to.find.out.when.they.will.have.ICD-10.updates.available..Investigate.training.and.installation.options..Inquire.if.they.offer.training.at.no.cost.to.the.practice.

4. Talk to your clearinghouses, billing service, and payers.

Determine.when.their.ICD-10.upgrades.will.be.completed.and.when.you.can.begin.testing.with.them..Keep.a.log.of.your.conversations.with.all.vendors.and.obtain.everything.in.writing.

ICD-10 ACTION GUIDE FOR MEDICAL PRACTICES

PAGE 9

5. Identify the changes you need to make in your practice.

For.example,.you.may.need.to.update.diagnosis.coding.tools,.“super.bills,”.public.health.reporting.tools,.workflows,.forms,.etc.

6. Identify staff training needs and resources.

Consider.your.options,.ranging.from.traditional.classroom.training.to.distance.education.to.webinars..Your.vendors.and.partners.will.have.many.valuable.resources,.as.will.your.national.or.local.medical.societies,.especially.within.your.specialty..The.Centers.for.Medicare.and.Medicaid.Services.(CMS),.American.Academy.of.Professional.Coders.(AAPC),.American.Health.Information.Management.Association.(AHIMA),.Healthcare.Information.and.Management.Systems.Society.(HIMSS),.and.Workgroup.for.Electronic.Data.Interchange.(WEDI).are.all.also.good.sources.for.both.free.and.paid.training..

Crosswalk.your.current.codes.from.ICD-9.to.ICD-10.to.become.as.proficient.as.possible.before.implementation..Understand.that.the.medical.documentation.will.need.to.be.more.specific.when.using.the.new.codes..Give.yourself.time.to.learn.what.is.required.in.your.chart.documentation.

AHIMA.estimates.that.coding.staff.working.outside.of.a.hospital.inpatient.setting.will.require.16.hours.of.training..Don’t.plan.to.train.your.staff.more.than.six.to.nine.months.before.implementation.without.a.refresher.course.to.ensure.staff.members.retain.the.knowledge.

7. Conduct extensive internal and external testing.

Conduct.internal.testing.to.make.sure.you.can.generate.all.your.transactions.with.the.ICD-10.codes..Conduct.external.testing.with.your.clearinghouses.and.payers.to.make.sure.you.can.send.and.receive.transactions.with.the.ICD-10.codes..Be.sure.to.double-check.the.accuracy.of.the.resulting.data.for.hidden.bugs...

Don’t.skimp.on.this.step.or.wait.until.the.last.minute!.Finding.out.you.have.

a.problem.the.week.before.implementation.will.be.incredibly.stressful.–.and.

it.may.be.difficult.to.find.required.resources,.as.every.other.practice.in.the.

United.States.will.also.be.scrambling.to.prepare.for.the.same.deadline.

ICD-10 ACTION GUIDE FOR MEDICAL PRACTICES

PAGE 10

ADVANCED RECOMMENDATIONS

We.recommend.these.additional.steps.to.ensure.a.successful.transition.to.ICD-10.

1. Establish a budget.

ICD-10.is.not.likely.to.be.a.trivial.expense.item.in.your.annual.budget,.and.you.should.actively.consider.how.much.resources.(in.both.time.and.dollars).you.will.realistically.need/can.allocate..Communicate.this.figure.to.your.ICD-10.team.lead.

2. Develop a timeline.

October.1,.2015.will.be.here.before.you.know.it,.and.this.isn’t.a.transition.you.can.successfully.cram.into.the.last.month..Plan.backward.from.the.adoption.date.and.give.yourself.plenty.of.padding.for.unforeseen.problems.or.delays..Remember,.every.practice.in.the.United.States.will.be.trying.to.make.the.same.deadline,.so.if.you.wait.until.the.last.minute,.resources.might.not.be.available.for.training.or.problem.solving.

3. Implement a tracking system.

You.can.simplify.this.complex.transition.with.the.simple.addition.of.your.own.customized.checklist..This.can.be.as.simple.as.a.spreadsheet.that.addresses.every.key.component,.change,.training,.and.testing.phase..Having.a.tracking.system.will.give.you.peace.of.mind.and.insight.into.whether.questions.are.being.answered.and.timelines.are.being.met.

4. Seek additional resources.

Your.vendors.and.payers.will.all.likely.have.many.resources.available,.from.training.to.timelines..Seek.them.out.early..

For.general.but.still.detailed.advice,.CMS.has.many.resources,.including.an.excellent.56-page.implementation.guide.for.small.and.medium.practices.

ICD-10 ACTION GUIDE FOR MEDICAL PRACTICES

PAGE 11

The.AMA.has.the.following.resources.available.for.purchase:

ICD-10-CM Mappings 2014, linking ICD-9-CM to All Valid ICD-10-CM Alternatives

Principles of ICD-10-CM Coding Workbook

Principles of ICD-10-CM Coding

Advanced Anatomy and Physiology for ICD-10-CM/PCS.(Note:.All.coders.will.need.to..understand.anatomy.due.to.the..increased.specificity.of.ICD-10)

5. Prepare for potential cash-flow problems.

Consider.setting.up.or.expanding.an.existing.line.of.credit.to.mitigate.any.cash-flow.interruptions.that.may.occur..

6. Prepare a Plan B if any vendors or partners look like they may not make the deadline.

Don’t.wait.for.them.to.fail.before.coming.up.with.your.alternate.plan..Missing.the.deadline.is.not.a.realistic.alternative.for.your.practice..The.inability.of.any.vendor.or.partner.to.smoothly.make.the.transition.to.ICD-10.could.be.a.warning.sign.about.their.overall.competence..

ICD-10 ACTION GUIDE FOR MEDICAL PRACTICES

PAGE 12

7. Consider likely financial impacts of ICD-10 reimbursements.

Most.payers.will.continue.with.current.reimbursements.schemes.for.now..However,.at.some.point,.it.is.likely.that.many.will.start.to.reimburse.at.a.higher.rate.for.more.complex.treatments.and.at.a.lower.rate.for.less.complex.treatments,.where.previously.these.treatments.may.have.reimbursed.at.the.same.rate.when.both.were.covered.under.the.same.ICD-9.coding..

Note:.This.is.not.an.issue.for.traditional.CPT-.or.HCPCS-based.reimbursements,.since.these.codes.are.not.part.of.ICD-10.and.will.not.change.

8. Assess your staff’s ICD-10 proficiency after implementation.

Consider.changes.in.workflow,.additional.training,.software,.or.other.resources.to.address.weaknesses.or.inefficiencies.

It.is.strongly.recommended.that.the.practice.have.a.

line..of.credit.with.its.banking.institution.prior.to.the.

implementation.of.ICD-10..It.is.very.likely.that.cash.

flow.will.be.impacted..Establishing.a.new.line.of.credit.

normally.takes.four.to.eight.weeks.to.set.up,.so.don’t.

put.this.off..

Share on:

ICD-10 ACTION GUIDE FOR MEDICAL PRACTICES

PAGE 13

Conclusion

The.transition.to.ICD-10.won’t.be.cheap.or.easy..A.widespread,.comprehensive.implementation.of.a.new.diagnosis.code.hasn’t.been.done.in.more.than.a.generation.of.physicians..While.it’s.key.to.modernizing.the.way.physicians.practice.medicine,.the.process.can.place.a.great.deal.of.stress.on.you.and.your.practice.if.you’re.not.properly.prepared.

The.Cooperative.of.American.Physicians,.Inc..(CAP).has.supported.California’s.best.physicians.for.nearly.40.years.with.outstanding.medical.liability.coverage..Our.supplementary.services.are.designed.to.help.you.and.your.practice.thrive..That.way,.you.can.focus.on.what.really.matters.–.quality.patient.care.

This.guide.to.ICD-10.is.part.of.our.effort.to.support.physicians.like.you.with.resources.that.address.their.everyday.needs..We.hope.you’ve.found.it.useful.

Like.what.you’ve.read?..

Let.your.colleagues..

know.about.our..

ICD-10.Action.Guide.

Share on:

ICD-10 ACTION GUIDE FOR MEDICAL PRACTICES

PAGE 14

ICD-10 Transition Checklist

Follow.the.steps.in.this.checklist.for.a.smooth.transition.to.ICD-10.

.❏ Identify.and.establish.an.ICD-10.team.and.team.leader.for.your.practice.

.❏ Collect.information.on.current.use.of.ICD-9.and.a.list.of.staff.members.who.need.

ICD-.10.resources.and.training

.❏ Perform.an.impact.assessment.and.identify.potential.changes.to.existing.workflow.

and.business.processes,.including.the.effect.of.ICD-10.on.other.planned.or.ongoing.

projects.(e.g.,.HIPAA,.EHR.adoption,.etc.)

.❏ Contact.systems.vendors,.clearinghouses,.and/or.billing.services.to.assess.their.

readiness.for.ICD-10,.timelines,.and.cost.estimates

.❏ Estimate.and.secure.a.budget,.including.all.costs.associated.with.implementation,.

such.as.software.and.software.license.costs,.hardware.procurement,.and.staff.

training.costs.

.❏ Identify.training.needs.and.resources

.❏ Seek.additional.resources.as.needed.

.❏ Determine.a.business.and.technical.implementation.plan.

.❏ Determine.and.communicate.timeline

.❏ Develop.a.tracking.system.to.monitor.progress

.❏ Consider.financial.implications.of.transition

.❏ Prepare.for.potential.cash-flow.issues.(if.applicable)

.❏ Prepare.a.Plan.B.for.any.partners.or.vendors.who.falter

.❏ Complete.system.design.and.development

.❏ Educate.and.train.staff.on.workflow.changes,.ICD-10.system,.and.impacts

.❏ Conduct.internal.testing

.❏ Complete.external.testing.with.vendors,.payers,.billing.services,.and.clearinghouses

.❏ Transition.ICD-10.systems.to.production

.❏ Go.live.on.October.1,.2015

.❏ Evaluate.staff.proficiency.and.workflow.post-implementation..Make.adjustments.

and/or.provide.additional.training.as.needed.

For.additional.information.about.ICD-10,.please.visit.http://www.cms.gov/ICD10.

ICD-10 ACTION GUIDE FOR MEDICAL PRACTICES

PAGE 15

About CAP

The.Cooperative.of.American.Physicians,.Inc..was.established.in.1975.by.a.group.of.California.physicians.to.manage.the.escalating.cost.of.medical.professional.liability.coverage..Two.years.later,.CAP.formed.the.Mutual.Protection.Trust.(MPT),.which.has.earned.an.A+.(Superior).rating.from.A.M..Best.since.2006..CAP.now.supports.nearly.12,000.of.California’s.finest.physicians.through.offices.in.Los.Angeles,.San.Diego,.Orange.County,.Sacramento,.and.Palo.Alto.

Special Thanks

CAP.would.like.to.express.its.appreciation.to.June McKernan, COO of Patient Preferred Dermatology Medical Group, Inc.,.and.Mary Jean Sage, CMA-AC of The Sage Associates.for.their.valuable.contributions.and.expert.review.of.this.important.guide..

Learn more: 800-356-5672

www.CAPphysicians.com

Share on:

333 S. Hope Street, 8th Floor Los Angeles, CA 90071 800-252-7706 www.CAPphysicians.com

San Diego | Orange | Los Angeles | Palo Alto | Sacramento

A.publication.of.the.Cooperative.of.American.Physicians,.Inc..©.Copyright.2/11/2015