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On October 1, 2013, diag-nosis coding as you cur-rently know it willchange dramatically. Justwhen you think you have

it down pat, this change will haveyou starting all over again. It willalmost have to be tackled with a “door die” attitude, the changes are thathuge. Fortunately, ophthalmologyhas great physicians and allied staffwho have good drive and attitudesand will be able to weather thestorm. Ophthalmology practices alsohave access to some of the bestadministrative tools in the industrythanks to the American Society ofOphthalmic Administrators.

Why tell you about the changesnow when the actual ICD-10 diagno-sis code set will not be effective untilOctober 1, 2013? It’s because themere magnitude of the conversionfrom ICD-9 to ICD-10 will requiresignificant changes in your practice,including hours of training forphysicians and staff. Budgeting forthe new diagnosis code changes willalso be a big challenge, particularlyin smaller practices.

BackgroundThe current diagnosis coding systemin the United States is theInternational Classification ofDiseases, Ninth Revision, ClinicalModification, which is the U.S. ver-sion of ICD-9 developed by theWorld Health Organization (WHO).ICD-9 was originally developed toclassify mortality statistics (causes ofdeath) and was later expanded toclassify morbidity (presence of illnessor disease). ICD-9-CM has become

obsolete, and many of the clinicaland procedural concepts are nolonger able to meet today’s demand-ing healthcare data needs. In addi-tion, outdated software and equip-ment are no longer supported by theWHO and cannot be modified tomeet current and future needs.

ICD-9 vs. ICD-10ICD-9 has outgrown the level ofspecificity for diagnosis coding. It nolonger reflects advances in medicaltreatment. There are only five levelsof specificity in ICD-9; ICD-10 hasseven levels of specificity. There arevery few unassigned codes remainingin ICD-9 for adding new diagnoses,and many of the current codes donot accurately describe the diagnosesthey are assigned to represent. Also,many countries around the world are

already using ICD-10, so it is difficultto compare U.S. data to the rest ofthe global community. The WHOonly supports ICD-10 now becauseICD-10 codes are more precise andwill give healthcare providers theability to code more accurately.

ICD-10 will require improvedchart documentation from physi-cians and other healthcare providers.It will provide greater coding to sup-port more accurate payments forhospitals, physicians, and healthplans.

There are currently about 14,000ICD-9 diagnosis codes. ICD-10 willcontain more than 68,000 diagnosiscodes. The good thing is that themajority of ophthalmology codes arenow in one chapter. The new ICD-10codes have greater specificity andexpanded detail for identifying

Preparing for ICD-10-CM—Possibly the BiggestChallenge Facing Ophthalmology to DateE. Ann Rose

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injuries, diabetes, post-op complica-tions, and alcohol/substance abuse.An expanded use of combinationcodes will need to be learned, andinjuries are grouped by anatomicalsite rather than type of injury. ICD-10 contains additional characters toallow for identifying body system,root operation, body part, approach,and devices involved in a procedure.The differences are show in Table 1.

The Centers for Medicare andMedicaid Services (CMS) has posted2011 diagnosis code crosswalkscalled GEMs (General EquivalenceMappings) on their website atwww.com.gov/ICD10/. Both ICD-9to ICD-10 and ICD-10 to ICD-9crosswalks are listed on the website.Practices are encouraged to reviewthese comparisons to become famil-iar with the coding differences. Justbe aware that these GEMs will beupdated annually to cover new diag-nosis codes.

Feeling the ImpactICD-10 will impact all healthcareproviders, payers, software vendors,clearinghouses, and third-partybillers. Key areas to consider initiallyinclude• Staffing• Vendor software• Computer technology issues• Clinical systems and forms• Information management• Impact on cash flow

In addition, electronic claims arecurrently submitted using theVersion 4010 transaction code set.This version must now be convertedto the new Version 5010 and VersionD.0. computer systems that submitclaims, receive remittances, and

exchange claim status or eligibilityinquiry, and responses must beupdated to the new Version 5010effective January 1, 2012. CMS doesnot expect a delay in this implemen-tation date, so it is important forpractices to confirm with their com-puter vendor that they have met theVersion 5010 requirements.

Compliance timelines for theVersion 5010 conversion were pub-lished by CMS (see Table 2).

Documentation and TrainingIncreased documentation will also be required to support the new ICD-10 codes. Specificity of diagnosis will be more important than ever.

Practices should begin now to formulate a needs analysis to prepare for ICD-10 implementation, effective October 1, 2013.

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Physicians and staff must understandhow to rewrite clinic notes, andcoders will need specificity fromclinic staff in order to code properly.Improperly coded claims could resultin claim denials or payment rever-sals. Documentation will be requiredto support the diagnosis or proce-dure and ensure the service is consis-tent with patient symptoms.

Extensive training will berequired for physicians, clinical staff,coders, billers, front office staff,managers, administrators, and audi-tors/reviewers. The learning curvemight be quite steep, especially insmall- to medium-sized practices thatdo not employ certified professionalcoders. CMS initially thought 4 to 10hours of training would be adequate,but now believes one day might notbe enough. Other studies suggest 24to 80 hours for coders and 10 to 12hours for physicians and nurses.Coders will now need to understandanatomy and physiology moreextensively; this understanding isnot required in ICD-9.

There are currently many typesof training tools available such ascourses, workshops, seminars, web-based training, printed materials,and audio conferences. It is impera-tive that practices take advantage ofthese training tools in order to beprepared for the transition, and thatmeans physicians, too. CMS suggeststhat staff trained too early will forgetmuch of the information by October1, 2013. If trained too late, staff willbe overwhelmed with training andthe final steps implemented all atonce. Approximately 1 year prior tothe “go-live” date of October 1, 2013is considered an appropriate windowfor optimal training. While that datemay seem far away, providers should

now begin working toward imple-mentation of the new ICD-10 codes.

Preparing for ICD-10Potential impact on reimbursementis suggested to be about 10–25% of apractice’s productivity, due to slowerpayments for 3 to 6 months. Thiscould be caused by queries fromcoders to clarify documentation inthe medical record, increased billinginquiries by payers, and an increasednumber of adjustments and pendingor suspended claims. Hiring addi-tional trained staff might be requiredbecause of an increased need toreview charts and encounter formsor superbills for compliance.

The Medical Group ManagementAssociation (MGMA) has projectedthe potential costs, in dollars, ofimplementing ICD-10: about$27,000 for a solo practice; $83,000for a small practice (three to fivephysicians); and $285,000 for amedium-sized practice (10 physi-cians).

Take these steps into considera-tion when preparing for ICD-10:• Work with your computer vendorand billing clearinghouses tomake sure they are 5010 compli-ant and tested as such.

• Be prepared to change encounterforms and superbills.

• Modify pre-printed chart sheets.• Upgrade EMR/EHR chartingrequirements.

• Identify staff to be trained.• Test claims submission with trad-ing partners, payers, and clearing-houses.

• Budget for implementation costs,expenses for system changes,resource materials, and training.The biggest obstacle a practice

will have to overcome could be

resistance to change, resulting instaff turnover.

Start NowThe change to ICD-10 will affectevery aspect of healthcare forproviders and practices, includingquality measures, documentation,medical coverage, payment policies,productivity, and more. BecauseMedicare payment to physicians isdriven by coverage and reimburse-ment policies, coverage decisionswill be based not only on proce-dures, but also on medical necessity,interpreted from the new diagnosiscodes. There could be paymentdelays, either due to CMS processingor to having submitted incorrect orold codes, resulting in a rejection ofyour claims and other transactions—so providers are encouraged to stayupdated on new medical policychanges to ensure reporting correctICD-10-CM diagnosis codes.

The bottom line is thatproviders cannot afford to take thischange lightly. Practices shouldbegin now to formulate a needsanalysis to prepare for ICD-10 imple-mentation, effective October 1, 2013.Taking the high road now and (toborrow a phrase from the BoyScouts) “being prepared” for thisastronomical conversion will be yourbest defense to avoid claim denialsand slower reimbursements. AE

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E. Ann Rose (800-720-9667;results@roseandassociates.com) is president of Rose &Associates in Duncanville,Texas.