11/13/2013    Neil H Hecht, DPM

ICD-10, a Recipe for Disaster?

I am concerned that the overwhelming specificity
required by ICD-10 will compromise my ability to
actually provide a diagnosis code in a timely
manner. Further, working in several hospitals and
my private practice as well as 2 outpatient wound
centers, I now utilize four (4) different
computerized electronic health record systems.

If my documentation is not absolutely accurate to
match the specificity of the ICD-10 diagnostic
coding, any audit would result in either non-
payment of claims or a multitude of refund
requests. I am not optimistic about the adoption
of ICD-10 in regard to the viability of continuing
practice for any private doctors in the United
States.

I understand that preparation for this conversion
has been touted as necessary, however when one
considers the specificity of the ICD-10 versus the
actual charting done at the time of
treatment/consult/rounds, how could I know if I
have covered ALL of the specific elements found in
EACH diagnosis? This is especially true with my
hospital and wound care patients who have multiple
diagnoses. Could any training be that in depth for
all of the myriad diagnoses of these sick
patients? Is the readership confident that they
can actually master this?

ICD-10 requires much greater detail on location of
ailments, cause and type, and complications or
manifestations compared with ICD-9. For example,
diabetes will have many separate codes that each
incorporate different complications. And asthma is
listed as "mild," "mild intermittent," "mild
persistent," "moderate persistent," or "severe."

I would appreciate specific comments especially
from those doctors who have commented previously
in the positive regarding this conversion.

Neil H Hecht, DPM, Tarzana, CA,
drhecht@drneilhecht.com

Other messages in this thread:

---

11/22/2013    Joseph Borreggine, DPM

ICD-10, a Recipe for Disaster? (Neil Hecht, DPM)

With the recent failed OBamacare roll-out for the
health insurance exchanges I would like PM news
readers to ponder the following:

With the way the new ICD-10 changes will affect
healthcare delivery next year when it goes into
effect Oct 1, 2014, I would like some to comment
positive or negative on how it will affect the
profitability of all medical practices across the
country due to the coding complexity and increased
medical record management.

I believe, this coding change, in turn, could
cause longer wait times, inability to see their
physician at appropriate times and even possibly
not at all because their physician may just leave
the practice of medicine due.

The potential ill-preparedness of CMS and other
insurance companies when we switch from ICD-9 to
ICD-10 is a mounting storm on the horizon. I opine
that no one in the general public is currently
aware of this looming disaster at this moment in
time.

This observation of another impending healthcare
reform debacle can be solely based on how the
government has handled the Obamacare roll out. So
far, under the leadership of HHS Secretary,
Kathleen Sebelius, healthcare reform's stellar
moment has been dulled unnecessarily.

Being that this transition is a just a short 10
months away will everyone be ready? The medical
profession does not seem to think so. Scary
thought if they are not.

Truly, doctors and hospitals will not continue to
work if they can't get paid because of the pending
change to ICD-10 coding along with all of it
idiosyncrasies and potentially
difficulties during its transition.

Most physicians are being told that they should
have at least 3-6 months cash or credit reserve of
operating expenses since it could take up to 120
days to get initially paid after the ICD-10 roll
out.

I also would like for someone to comment on the
current HIPAA privacy guidelines which are quite
stringent as of Sept 23, 2013 as they relate to
the Healthcare.gov site.

Now, any business or healthcare provider will be
fined heavily when privacy breaches occur and are
reported. Fines upwards of $1.5 million can and
will be levied.

It has happened already with Affinty Healthcare as
reported by CBS news:
http://www.hhs.gov/news/press/2013pres/08/20130814
a.html

How is that the Healthcare.gov website does not
have to follow these same HIPAA privacy protection
guidelines? With all the recent potential hacking
and privacy breaches going on with
healthcare information, doesn't the the federal
government who created HIPAA have to abide by
these laws?

Just some interesting issues that I believe the
unsuspecting public should know about in light of
recent news regarding the failed Obamacare roll-
out.

Joseph Borreggine, DPM, Charleston, IL,
footfixr@consolidated.net

---

11/21/2013    Pam Thompson

RE: ICD-10, a Recipe for Disaster? (Neil Hecht, DPM)

ICD-10 has adverse financial consequences well
beyond those concerned with preparation for the
transition. A Canadian hospital study of ICD-10
implementation reported physician productivity
losses of 50% in the first month. A year later,
the loss continues, at 19%. It is unlikely that
the change-over in the U.S. will fare much better.

Anticipation of claims processing interruptions,
coding errors and other FUBAR'd but heretofore
unknown issues, are estimated to result in at
least 5 percent physician income loss, and up to a
30 percent short-term cash flow loss. Of course,
income loss is money you'll never see again.

CMS estimates that claim denials will increase 100
– 200 percent. Days in A/R (how long it takes to
pay you) will increase 20–40 percent. Claim error
rates will increase 6–10 percent based on improper
coding.

The cash flow loss could extend for three to six
months. Do you have operational capital to cover a
5 percent income loss and a 20-30 percent cash
flow loss for three months? Six months? It will be
of great benefit to prepare for the attendant
revenue interruption.

Is it possible that this will not occur? That
payers will reimburse you just like they always
do, promptly and correctly, with no untoward
delay, underpayment or calls for additional
information? That they won't take advantage of an
opportunity to use ICD-10 "problems" to advantage
themselves at physician expense?

I've recommended that my clients focus as much on
increasing revenue and decreasing costs as they do
directly preparing for the Oct 1st transition. A
healthy credit line would be helpful.

Pam Thompson, Guerrilla Podiatry,
pamthompson@guerrillapodiatry.com

---

11/21/2013    Michael L. Brody, DPM

ICD-10, a Recipe for Disaster? (Bryan Markinson, DPM)

At this point, I believe that is important to
point out that this 'extra work' in documenting
the findings and determining the correct ICD-10
code only needs to be done when you are adding a
new ICD-10 code to a patient's problem list.

Yes, it will be very time-consuming when we first
have to convert to ICD-10 and 'update' all of our
patients' charts. But once we have documented our
findings to substantiate the correct ICD-10 code,
we do not have to repeat the process each and
every visit.

We will have to repeat the process when a patient
presents with a new diagnosis and we need to
establish the documentation to support the new
ICD-10 code. With implementation of EHR
technology, we had to expect productivity
decreases for about 6 months (on average) I
believe that there will be an initial period of
productivity decreases with the implementation of
ICD 10 but after our 'break in period' we will
become familiar with the requirements of the
coding system and will be back up to speed.

My advice is come October 1, 2014, adjust your
schedule to provide yourself with more time to
document your findings, and complete the
documentation at the time of the visit wherever
possible so that you can examine the patient and
document the additional details necessary for the
proper ICD-10 code. Once the patient has left the
office, if you do not know the answer to a detail,
you may be in for a lot of frustration.

, Commack, NY, mbrody@tldsystems.com

---

11/20/2013    Bryan C. Markinson, DPM

ICD-10, a Recipe for Disaster? (Joshua Kaye, DPM)

I am the podiatry ICD-10 Champion of my hospital
network. Don't confuse the word champion to mean
any proficiency at the moment. I am just the
interface person between hospital administration
and the podiatrists and residents who must learn,
adapt, and implement the new system. They "train"
me, I train "them."

The ICD-10 system is a more exacting detailed
description, that among other things must include
severity, laterality, and, general health of the
patient. Anyone who thinks that a drop-down menu
with 35 more choices to scan though will not be
more time stealing has another thing coming. I do
believe that Dr. Kaye is correct that when we get
down to it, maybe the most common things we do
will be easy to crosswalk, but the diabetic with
no primary care physician who walks in without
pulses and frank gangrene, where you must pick the
perhaps yet undiagnosed type of atherosclerosis
they have, is another matter.

Additionally, the ICD-10 conversion on the
insurance side is completely dependent on chart
auditing, which will skyrocket as the details
required will be increasing and more apt to be
deficient. Add to that the OIG warnings on cloning
notes, and the note-bloat endemic with most EMR
systems users, I would find it miraculous that
providers who do not pay attention (most already
admit they wont be ready) will find themselves
under a mountain of denied claims, as well as
requests for notes, then money.

In my hospital, we are going live well in advance
of the implementation date to get a sense of how
it will flow, but already we have been advised
that coders will be asking us very often if we are
sure of certain things we have written in the
notes. To that end we are creating extremely
detailed templates as best as we can to address
all the key points that could be brought up by our
choice of code (and don't forget your LCD
guidelines). That these changes will cost me 5-10
visits a day on top of what EMR has already cost
me is a certainty.

Our coders in the network is somewhat of a safety
net before the claims actually go out. For those
in private practice, your office manager and coder
for the last 20 years has to get seriously trained
in this implementation, or the first level of
screening of your claims will be at the insurance
company.

Bryan C. Markinson, DPM, NY, NY,
Bryan.Markinson@mountsinai.org

---

11/19/2013    Keith L. Gurnick, DPM

ICD-10, a Recipe for Disaster? (Joshua Kaye,, DPM)

I believe that Dr. Kaye's current conclusions
about concern for accuracy of ICD-10 coding will
prove over time to have been naive.

When medical records are audited they are done so
to insure accuracy of diagnosis, to determine if
services are medically necessary, and allowable or
covered and coded properly for level of service
and type of service and site of service.
Coding errors caused by the new increased
specificity of coding diagnoses, when audited will
definitely trigger payment recoupments, when the
services billed for and the diagnosis provided
with ICD-10 coding are not born out by the
medical records submitted for an audit.

Remember that almost all of the audits and reviews
of medical records are done by employees, agents,
subcontractors and consultants hired by the
insurance companies, and paid for by the money
they save insurance companies.
These auditors include nurses, doctors, coding
experts and even nationally recognized podiatrists
who do their best to help us, advise us and teach
us how to properly code at their seminars and
their on-line services. But remember who pays
their salary when they are at work for the
insurance companies!

With EMRs and direct deposits of payments from
many insurance companies including Medicare and
with their direct access to your bank accounts, it
has never been easier to recoup overpayments, for
those services they deem not-medically necessary
or "where the diagnosis code is inconsistent with
the submitted medical records". Typically, the
doctor is wrong until they can prove they are
correct and that becomes very complicated and time
and labor intensive after the money has been taken
away, or taken off another patient's payment as an
"offset".

Keith L. Gurnick, DPM, Los Angeles, CA
keithgrnk@aol.com

---

11/18/2013    Joshua Kaye, DPM

ICD-10, a Recipe for Disaster? (Neil H Hecht, DPM)

In reading through various articles and blogs
regarding the October 1, 2014 looming date for the
conversion to ICD-10, it is beginning to sound
like the fears during 1999 considering Y2K.
Unless I am very naïve or missing the point, the
complexity of the transition appears to be
exaggerated. There are two distinct components to
the transition. One part is the upgrading to the
new ICD-10 code number which contains two or more
digits than ICD-9. The second part is strictly a
software change, involving both the EMR and the
billing software. So let’s take a look at these
two components.

ICD-10 requires a greater level of specificity for
a diagnosis and the increase of the number of
digits of the diagnostic code will demonstrate
that specificity. So if we have a patient with an
ankle sprain, for example, ICD-10 will require
determining whether the injury occurred while
playing soccer or as a result of a car accident.
That doesn’t seem so difficult.

If the upgraded EMR, interface program and billing
software is appropriately written, if the ICD-9
code is entered, that should trigger a selection
of appropriate ICD-10 choices. Once the
appropriate ICD-10 choice has been determined, the
increased software field size should then allow
the upgraded code to be digitally transferred to
the billing software and on to the insurance
company or Medicare. Assuming that the software is
written in a user-friendly manner, we would not be
concerned with that portion of the new process.

There may be tens of thousands of new codes with
ICD-10, but realistically, as with any medical
specialty, we would likely only use a tiny
fraction of those new codes.

Using the above example of the ankle sprain, of
all the different ICD-10 codes, I don’t believe
one code will result in a greater payment than
another for the same injury. The level of patient
care will not improve or change. And if an error
in the selection of the precise ICD-10 code is
made, I don’t believe that will result in an
audit. ICD-10 was designed for the bean counters
of the medical world. Honest errors in ICD-10 code
selection will be rampant during the early stages
of the conversion.

Putting future changes of healthcare into
appropriate perspective, ICD-10 conversion will be
one of our smallest concerns.

Joshua Kaye, DPM, Los Angeles, CA,
jk@joshuakaye.com