After a series of fits and starts, it appears that ICD-10 will take effect on Oct. 1.
All claims submitted to any entity covered by the Health Insurance Portability and Accountability Act (HIPAA) on or after Oct. 1, 2015, for inpatient discharges or outpatient services provided in all healthcare settings, must use the ICD-10 codes for medical diagnoses and inpatient procedures.
Otherwise, the claims may be rejected and providers will have to resubmit them using the ICD-10 codes, says Susan Wallace, MEd, RHIA, CCS, CDIP, CCDS, director of inpatient compliance for Administrative Consultant Services, a Shawnee, OK, healthcare consulting firm.
This means that there will be some patients who will be admitted in September but whose discharge needs to be reported under ICD-10, Wallace says.
The few non-HIPPA entities not required to use ICD-10 include workers’ compensation and medical liability in homeowner or automobile policies. But many of those agencies have also said they will be ready to accept the new ICD-10 codes, Wallace says.
The World Health Organization’s International Classification of Diseases, 10th revision (ICD-10) has been used by other countries for 22 years, reports John Zelem, MD, FACS, vice president of compliance and physician education at Executive Health Resources, a Newtown Square, PA, consulting firm. The United States will be the first country to use the coding system for reimbursement purposes. The other countries have been using it to identify and follow trends, he says.
Implementation of ICD-10 originally was scheduled for Oct. 1, 2013, and was postponed for a year to Oct. 1, 2014, to give providers more time to prepare. Then, after a push by the healthcare industry, Congress postponed implementation until Oct. 1 of this year as part of a bill dealing with the sustainable growth rate system for reimbursing physicians.
“The healthcare arena was waiting to see if Congress was going to delay ICD-10 again. Then we waited to see what Centers for Medicare & Medicaid Services [CMS] said in the Inpatient Prospective Payment System [IPPS] proposed rule. Now we know that it’s really going into effect,” Wallace says.
While ICD-9 uses five-digit numeric codes, ICD-10 is a seven-digit alpha-numeric coding system, she says. The expanded fields make it possible to track much more detailed information about the patient’s condition.
ICD-10 has 70,000 diagnosis and procedure codes, compared to 17,000 codes in ICD-9. Because the coding for ICD-10 reflects a greater level of detail, coders will need more accurate and detailed information to assign the correct code, she says.
If they haven’t started already, case managers need to educate physicians on the specificity of documentation that will be required for ICD-10 and work with them to document completely, Wallace says.
Physician education about ICD-10 and the level of documentation required is essential, Zelem says. “If physicians don’t get it right, the coders can’t produce it,” he adds.
“Typically, many physicians do not adequately document the acuity with which patients present. I’ve done a number of chart reviews and this is what I see: Physicians tend to document for other physicians and not for coders, utilization management, clinical documentation improvement, or auditors. That’s why physician education about documenting for the right audience is so important,” Zelem says.
On and after Oct. 1, if the documentation is not complete, the coder may not be able to assign a code and, depending on the hospital’s protocol, may send the case back for more specific documentation, delaying reimbursement, Wallace points out.
To make sure they are prepared for the implementation of ICD-10, some hospitals are dual coding for both ICD-9 and ICD-10, Zelem says. “Case managers and clinical documentation improvement specialists are working with physicians to improve their document to meet the new requirements for specificity. This can be significant help in ensuring that the hospitals are ready,” he says.
An example of one big change in ICD-10 is laterality. Now, there are codes for left, right, both, and neither. In the past, providers could document that a patient had a broken finger. Now, the document must specify which finger and whether it’s on the left or right hand, Zelem says.
“Laterality is simple and easy. But there is a long list of changes that aren’t so easy,” Wallace says. For instance, ICD-9 has one code for atrial fibrillation. There are four codes in ICD-10, she adds.
Surgical cases may be a source of incomplete documentation for many hospitals, Wallace says. “Surgeons are not accustomed to documenting operative reports with the specificity required by ICD-10,” she says. “There have been a lot of instances when there was not enough information in a surgical report to even assign a code,” she adds.
The documentation also needs to give details on the acuity of the disease. For instance, is the patient’s asthma intermittent, or mild, moderate, or severely persistent?
“Urosepsis is still being documented by some physicians, but that documentation does not exist in ICD-10,” Wallace says. “Therefore, those cases will have to be returned to the physician,” she adds.
If the coding is wrong because of lack of documentation, the hospital may not be paid appropriately, Wallace says.
“The list of things for case managers to work on has gotten longer. Hospitals need to have a system for concurrent documentation review so the case managers can make sure the documentation is complete and detailed so it doesn’t hold up the claims,” Wallace says.
To access the proposed rule, visit the IPPS Proposed Rule Home Page at http://go.cms.gov/1c7aU0L.