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 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
11/21/2013 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.
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
