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Claims and Coding

What ICD-10 means for doctors

The 2013 coding update may lead to revenue loss if physicians are not prepared. By Janice Jacobs, CPA , CPC, CCS, ROCC, CPCO


enters for Medicare & Medicaid Services is fi rm that the go-live date for ICD-10 implementa- tion is Oct. 1, 2013. There will be no further delays, nor will there be a grace period. Every person touching a medical claim form will be affected, including physicians.

There has been a wealth of information available on the

Janice Jacobs, CPA, CPC, CCS, ROCC, CPCO, is director, regulatory compliance, IMA Consulting.

For more information on IMA Consulting solutions:

ICD-10 initiative. However, many physicians still believe that this is strictly a “coding” issue. Therefore, it will not affect them in their daily rou- tine, nor will they personally have to undergo any prepara- tion in advance of the go-live date. Most seem to under- stand that this transition can result in a loss of revenue if they do not ensure that their

coders are properly trained in the new code sets, but physi- cians who do not fully understand the far-reaching effects of ICD-10 implementation will face a signifi cant revenue loss if they themselves are not adequately prepared. While ICD-10 moves us from 17,000 diagnosis codes to 140,000, the ability of the coder to appropriately as- sign those new codes and use the new coding methodology relies heavily on the physician’s clinical documentation to complete the process.

It may be true that physicians do not have to actually learn to code. However, under ICD-10 physicians will now have to document at a level of specifi city not required in ICD-9. Absent thorough documentation of diseases, disease processes, accident details and external causes, coders will have no choice but to return records to the physician for clarifi cation and addendums. Large volumes of medical re- cords returned to physicians on Oct. 1, 2013 will no doubt result in a loss of productivity for both the physician and the coder as well as an ultimate loss of revenue for the practice, particularly if physician training is delayed. To further complicate matters for the physician, ancil- lary order forms on Oct. 1, 2013 must include the correct ICD-10 diagnosis code or a patient will not be able to have diagnostic studies done at hospitals and clinics. Again, the

diagnosis now must be specifi c to the patient disease or injury and will require appropriate documentation in the medical record. Hospitals and health clinics will have no choice but to turn the patient away until such time that he/she can return with an appropriate order form. In the case of electronic orders, a patient may present for stud- ies only to fi nd that their physician ordered them with an outdated ICD-9 code or an incorrect ICD-10 code, again being turned away, perhaps after a night of fasting depend- ing upon the study.

So how can physicians prepare for this change of monu- mental proportions? Physicians are actually in a better position to learn ICD-10 coding requirements early than the coders themselves. Coders stand to lose knowledge by 2013 if they are not using the new code sets daily, but enhanced clinical documentation has no downside while ICD-9 is still in effect. To determine how an individual physician’s documenta- tion measures up to future ICD-10 standards, a small sample of his/her charts should be reviewed and a gap analysis per- formed comparing the current state to the required future state under ICD-10. That way, physicians needing more training can be identifi ed and training structured to indi- vidual needs. After the initial training, further monitoring of a few charts per week should be performed. The coding staff also can provide their input as to what elements con- tinue to be missing from clinical documentation to further reinforce documentation requirements.

While the majority of physicians have never seen require- ments in clinical documentation change this dramatically in their careers, the change is manageable with proper planning, training and timing. Breaking the initiative down into smaller components such as understanding HHS’ fi nal rule, learning the required specifi city, understanding the application of codes and developing an auditing and monitoring program is more effective than trying to eat the elephant in one bite. Ad- ditionally, after all of the road bumps are worked out, better documentation will lead to more effi cient coding and more specifi city on insurance claims, which will result in fewer denials and manual reviews, which equals faster payments at a lower cost.


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