Thomas G. Dolan

On October 1, 2013, every radiology practice has to start using the International Classification of Disease 10 (ICD-10), instead of ICD-9. This will bring immense complications for radiologists in their billing and payment procedures. Is ICD-10 beneficial, a bureaucratic burden, or a bit of both? And, in any event, what are the best measures you and your staff can take to prepare?

Taking the broad view of why the arrival of ICD-10 is both good and necessary is Nancy Maguire, ACS, PCS, ECS, CRT, HCS-D, and twice president of the American Academy of Professional Coders. "By adapting these new codes, we will be able to go to different registries and different data-gathering processes to look at current conditions of a disease," Maguire says.

"We will be able to speak the same language as other countries. The Czech Republic, England, Canada and much of the rest of the world have long adopted ICD-10. The U.S. has not. We are way behind. ICD-10 requires much more specificity of detail regarding disease states. The World Health Organization uses the ICD statistics for mortality and morbidity. By bringing ourselves in conformity with this international standard, we will all be using the same diagnoses which will lead to greater efficiency in case management and decision making. For instance, whereas an ICD-9 code might indicate diabetes, ICD-10 will zero in on diabetes with retinopathy."

Elizabeth Woodcock, principal, Woodcock and Associates, Atlanta, agrees that ICD-9, 30 some years old, is obsolete, and can't contain the detail for the more comprehensively detailed diagnoses today. And she agrees that ICD-10 is a good thing in that "it's better for quality monitoring, research, and population management."

But she also says, "I don't think the government took into account the impact of ICD-10 on physical payment and overhead costs. I think all practitioners are concerned about this."
Woodcock points out that the number of codes from ICD-9 to ICD-10 has grown from 14,000 to about 69,000. "Under the present system, a radiologist taking an order from a doctor can manually flip through one- or two-inch thick books. But now visualize his facing five volumes of codes. I truly believe a radiologist won't be able to do it. It will take too much time."

Maguire adds, bluntly, "Because of the documentation required, the practitioner will see fewer patients."

It's not only the sheer volume, but also the accompanying complexity which will make this a trying chore, says Betsy Nicoletti, consultant, Medical Practice Consulting, Springfield, VT. "The number of digits [in each code] from ICD-9 to ICD-10 has grown from three to seven."

Since the digits are a mixture of letters and numbers, even this can lead to error and confusion. "If you use the letter o instead of the number 0, or mix up the letters i and 1 you can get into trouble."

Also, continues Nicoletti, "Before you could designate a code for knee pain, but the new codes specify you detail the imaging is for either the right or the left knee. Or any part of the body of which there are two sides. You can say, 'Of course, I know what side I imaged.' But this will have to be in the code billing the payer, which wasn't required before." 

More detail is required for any particular condition. "It's not enough to just code asthma, but whether it is mild, moderately persistent, or serious," Maguire says.

In addition, Nicoletti explains, the new coding requires not just specifying a condition, such as a torn ligament, but whether the first encounter, a normal follow-up, or a later complication. The increase in the number of digits is designed to provide this specific detail.


 
Resolving these complexities is, of course, necessary for getting paid. "I think that for the radiologist in particular, the issue is coverage determination and the payment policy from the insurance company. Potentially there will have to be a matching between the procedure and the diagnostic code. The insurance company will want to make sure what it is paying for is supported by the diagnosis," says Woodcocock. “If not, they will deny the claim, stating a medical necessity denial. The payer is saying we do not agree with you that this was an authorized procedure. And this decision is driven from the ICD diagnostic code system. The billing office will have to manage these denials. It can affect cash flow, and be a very challenging time."

Add to this, Woodcock continues, what happens when a physician typically calls in an order to the radiology center. "The center may have the diagnosis, but it is not detailed enough," Woodcock relates. "This will be a challenge for the scheduler in the radiology practice. He'll have to ask for more detail. This can put a burden on the interaction between the doctor's office and radiology center. The diagnosis of a low back pain will not be enough. Today that claim would be paid. But under ICD-10, low back pain could mean a lot of things. You'll have to pick from one of a dozen codes, or you won't get paid."

Nicoletti adds that practitioners can suffer financially not only if they fail to be in compliance with the new standards. "Physician and radiologist practices can only hope that all the major payers are ready as mandated by law. If they do not upgrade correctly, your correctly submitted claim will be denied. It means a potential cash flow problem which might necessitate your securing a line of credit for payment problems and delays."

Still another problem, Nicoletti continues, "is the [vendor and physician] software is not ready. Even if it was…upgrading won't help, for ICD-10 can't be used until the start date of October 1, 2013."

In agreement is Michael R. Mabry, executive director, Radiology Business Management Association, Fairfax, Va. "There won't be a transition. When ICD-10 goes into effect, you'll have to switch over all at once. I believe ICD-10 has implications which haven't really been appreciated. You're going to have to train your coding and billing staff to make sure these claims are adequately processed. Billing and coding financial systems have to be upgraded to accept this new coding. This hasn't been done yet.

"Then there's the issue of integrating all of these changes into the electronic health records. There are still lots of moving parts that practices are trying to grapple with."

Why all of this uncertainty and confusion? Especially when, as Mabry relates, "ICD-10 was mandated at the tail end of 2008. It was one of the last acts of the Bush Administration to put ICD-10 into place. The lawmakers knew that the transition would take time. But it was thought that five years was sufficient time to put the new system in place."

"There were a lot of starts and stops," says Nicoletti. She explains that various political considerations were responsible. Now, however, both Democrats and Republicans are fully behind implementing ICD-10. But now the deadline is closing in, and not much has actually been done. "People are worried about it," Nicoletti says.

If, as indicated above, mastering the new law and implementing it into a workable form is too overwhelming a task for the physician or radiologist, especially in the context of their full-time jobs, then, as suggested above, these tasks should go to their staffs.

But this involves training. No simple matter. "Now's the time to think about a budget for training," Nicoletti says.

"This involves a big demand of taking somebody away from his regular office job. I don't know whether it's true or not, but I've heard it takes 40 to 60 hours to train a coder. That's a big demand." Add to that the number of people who may need to be trained, depending on the size and the organization of the practice. Involved might be front desk staff, the person who pre-authorizes studies from all physicians, the billing department, a coding specialist, and so on.

There are a number of educational resources already in place and more will be likely to come to the fore in the coming months, says Mabry. For instance, he relates that "

 designed to help radiologists make the transition."

At first it might seem that the larger practices, with the staff in place to handle administrative details might be better off, while it is the smaller practice that might suffer. But this is not necessarily true, says Nicoletti. "A four person imaging group, with a specialty in mammography, would not have a lot of trouble, for the number of codes would be narrowly focused. If you're offering full-service imaging, however, you will have to make a lot of changes."

One preparation larger practices can make, recommends Maguire, is to pick your most repeated exam, look at the coding required for ICD-9, then the additions needed for ICD-10, and do what you can to understand those changes. Then go to your next most repeated procedure, and so on. This will put you in a better position to deal with the changes that will directly affect you, with a correspondingly lesser need to address changes further removed from your practice.
Maguire recommends also that you either hire one outside expert or have an in-house person expertly trained in ICD-10.

This expert, in turn, can train your staff on the particular aspects of ICD-10 that he or she needs to know. Also, says Maguire, since the ICD-10 codes go through updates every year, there is no point in starting the intensive training and adjustment until January 2, 2013. This will cut back on the time and expense involved, and should still be enough time to make the overnight transition.
As a final note, Maguire points out that just as not being ready for ICD-10 on time can result in delays in payments, the opposite is true if you are ready. "By providing more detailed and higher quality data you should decrease the number of your denied claims and increase the speed of payment for all your accepted claims."
 

Thomas G. Dolan

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The Impending Arrival of ICD-10: How Can You Cope?