October 1: point of no return

You can still beat the deadline for ICD-10.

Major changes to the way you code are coming. And, if you’re like most doctors you’ve been putting off preparations. Maybe they’ll postpone it again, or extend the deadline, right? At this point it’s looking like that would be a dangerous assumption.

As of this press date, the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) have announced that they are joining efforts to help physicians get ready ahead of the October 1 ICD-10 deadline for compliance.

This statement reiterated the deadline, specifically stating, “the Medicare claims processing systems will not have the capability to accept ICD-9 codes for dates of services after September 30, 2015.”¹ The good news is that CMS and AMA will be reaching out with education, webinars, and hotline resources to help providers prepare.

At the same time, CMS stated it would not deny Medicare claims that are coded inaccurately during the first year of transition, and ombudsman support will be supplied both prior to and after the switch.

Bottom line: You need to prepare, and helping hands are extended in your direction. What you need is a game plan.

The experts who are helping chiropractors get ready, together with CMS, suggest a reasonable schedule will break down your preparations into about seven stages. You have until October 1 to accomplish them together with your staff. This is a tight timeline, but with enthusiasm and teamwork, it’s still possible to succeed.

Stage 1: Draw up your battle plan

To begin sketching out your roadmap to ICD-10, identify those persons in your practice who currently deal with ICD-9. For most practices, this would be “anyone in the office who is hands- on with documentation, data entry, billing and follow-up, patient communications, insurance verification, and over-the-counter collections,” says Brandy Brimhall, CPC, director of education for ChiroCode Institute.

These team members will each be assigned specific roles and tasks. How you determine these will reflect your approaches to the next stages. Once personnel are assigned, set key milestones and target dates for completion next to each name.

If you haven’t started already, now’s the time to begin familiarizing yourself with the essential differences between ICD-9 and ICD-10.

“The biggest difference is the appearance of the codes,” says Evan Gwilliam, DC, CPC, vice president and director of education and consulting for the ChiroCode Institute. “They are alphanumeric and up to seven characters long. There are five times as many codes because ICD-10 includes things that were not part of ICD-9, such as anatomical details, laterality, and encounters or episodes of care.”

Still, the codes are grouped into logical chapters, separated by body system and organized into three- character categories showing related conditions. “Chapter XIII: Diseases of the musculoskeletal system and connective tissue,” is likely to feature prominently in your list of new codes to learn.

“ICD-10 utilizes up to seven characters to complete a code where ICD-9 utilizes up to five,” Brimhall says. “Diagnoses that are not coded to the highest level of specificity, not only will not accurately describe a condition but they are anticipated to be rejected from processing systems.”

She also notes that ICD-10 allows coding for laterality. That is, you’ll indicate “right hand,” “left shoulder,” etc. You’ll have separate codes for sprains and for strains, Ted Arkfeld, DC, CPC, president of Arkfeld Compliance says. “It is equivalent to speaking English now in our offices and, on October 1st, switching to French.”

CMS offers a package of documents called General Equivalency Mappings (GEMs). You should obtain these, but beware the term “crosswalks” (see “Warning on crosswalks,” Page 44). Some mistakenly believe that there’s a 1-to-1 correspondence between the old and new codes. This is generally not the case. Rather, the GEMs direct your coding staff to the appropriate section of the new codes as a starting point.

Brimhall says it can be helpful to learn about GEMs, and why they are useful, but they can’t be trusted for final code selection.

“ICD-10 and ICD-9 are fundamentally different at every level,” says Matthew Richard, CIO for Chart Talk. “The only similarity is that they are codes used to describe specific health conditions.”

Stage 2: Check with your clearinghouses

Now you are ready to determine how much support you’ll obtain from your electronic data interchange (EDI) clearinghouses. Most have been offering test run schedules for the past year.

What is a test run? Arkfeld explains: “Both CMS and other carriers have had doctors submit test claims using ICD-10, checking the results to indicate whether the carriers are ready for October 1.

According to Gwilliam, most clearinghouses will allow you to submit test claims. Either you can submit a claim with ICD-10 codes through normal channels, or visit a Web portal where you create a fake claim as a test.

As Brimhall notes, it is your responsibility to contact your clearinghouses and ask about testing schedules. This is your chance to find and fix problems before the official launch date.

Stage 3: Train your staff

You get some good news here. Given the nationwide panic over implementation, there’s no shortage of training and resources available to you. Some come with price tags and some are free.

First, obtain the codes. These are widely available in various formats:

• Code books
• CDs, DVDs, and other digital media
• Online: gov/ICD10 and select “2016 ICD-10-CM and GEMs” to download 2016 Code Tables and Index.²
• Practice management systems
• Electronic health record (EHR) products
• Smartphone apps

“The National Academy of Chiropractic Coders has a comprehensive online study program that will prepare offices for the transition,” Arkfeld says. “And state associations are loading up an excellent lineup of speakers.”

Gwilliam points out that ICD-10 codes are in the public domain because they are maintained by the World Health Organization, and the U.S. version was created by the National Center for Health Statistics. You can purchase copies from various publishers, or access them online at sites such as FindACode.com.

But before you sign up for any courses or webinars, get the codes first. “Without this step, a DC would be like a tourist sent into a foreign country without learning the language of the natives,” Gwilliam says.

Assign a staff member now to contact your state association or society to see what seminars are available. As mentioned above, if you’re using practice management or EHR software, check whether they have training and courses, too. CMS.gov is invaluable, so take the time to explore their “Road to 10” resource page.³

When evaluating training programs, look for the following:

• A review of ICD-10 coding conventions that explains how to interpret coding instructions and understand code
• An introduction to coding Each chapter contains specific coding instructions that apply to that entire chapter. Each category and subcategory also identifies additional instructions (if applicable) that apply to those segments. Staff members who select codes must know how to interpret them and where to find coding instructions.
• An introduction to A class can’t cover the entire ICD-10 code set as it applies to chiropractic. But an introduction to some of the major codes should be included.
• Big changes you are unfamiliar with, such as adding the seventh character placeholder for those External Causes codes with ICD-10, should be
• Other special tips and instructions that will help to make ICD-10 more streamlined and manageable should be shared during online or live training
• Tips and strategies for in-office training should be offered as well to assist your practice in moving forward with ICD-10 staff

Consider this training to be your introduction to ICD-10: “Your training doesn’t stop at the end of a seminar or webinar,” Brimhall says. And Richards agrees: “Look for some sort of next step that comes after the initial training.”

According to Arkfeld, the foregoing is the easy part: “The most crucial ingredient is the clinical rationale and the documentation to support the new codes.”

Stage 4: Identify your target codes

Fortunately, as a chiropractor, your practice is fairly specialized. You may treat a broad range of conditions, but the bulk of your ICD-9 coding is likely to be in a narrow range. You’ve probably heard that ICD-10 has coding options for such things as “Crushed, pushed, or stepped on by crowd or human stampede” (W52), and “Bitten or struck by crocodile or alligator” (W58). You are unlikely to need these.

Rather, as you currently support CPT codes in the 98940–98942 range with ICD-9’s 739.1–739.5, your corresponding ICD-10 codes will be in the M99.01–M99.05 series.

Chapter XIII “M”-series codes should be immediately recognizable to you. Brimhall offers the following examples:

• 41, Lumbago with sciatica, right side
• 42, Lumbago with sciatica, left side

Those with more complex or integrated practices, however, will need facility with the new system and will likely make use of a much wider range of codes.

Stage 5: Initiate practice

Now that you’re familiar with the codes you’ll likely be using, and gaining fluency in the new system, it’s time to start working with real records. Arkfeld recommends weekly staff meetings to learn codebook navigation.

Brimhall suggests pulling three to five charts per week and converting their ICD-9 codes into ICD-10 format. This will help you and your staff gain fluency, and help you organize your resources to increase efficiency.

You can pinpoint the new codes in several ways. “The most accurate way according to Medicare,” Gwilliam says, “is to read the doctor’s diagnostic statement in the patient record, then look up the key words in the alphabetic index of the official code set.”

Based on the instructions provided there, you can then turn to the code in the tabular list and begin to research it. “It is important to browse other codes nearby, follow the in-column instructions, such as Excludes1 and Excludes2, as well as identify how many characters are necessary to code to the highest level of specificity,” Gwilliam advises.

Once complete, review the ICD-10 codes selected as well as the documentation to ensure that the records and claim forms tell the same story, Brimhall says.

Continue practicing and look for what Brimhall calls “gaps” such as inconsistencies or missing components with your current documentation. As your practice sessions progress, your documentation will improve, and you’ll gain coding efficiency and comfort.

Stage 6: Prepare your tools

Update your hardcopy and online forms, e.g., CMS 1500. Ensure your software is ready to support the new system. And check that your clinical documentation supports the new key concepts:

• Laterality: left versus right
• Initial or subsequent encounter for injuries
• Trimester of pregnancy
• Details about diabetes and related complications
• Types of fractures

The deadline is right around the corner, so you’ll have to make every day count. Continue practicing with the new codes and give your coding and billing staff whatever tools and support they need.

Call your software and billing vendors, third-party payers, and clearinghouses (if you haven’t done so yet), and confirm their ICD-10 readiness. Ask if they have the codes loaded in their systems, Arkfeld says. “Be very careful here; you cannot rely on your vendors to do this job for you. They can only provide the systems to submit the codes, so you must code with the highest level of specificity and documentation.”

Ask about testing opportunities if you haven’t already done trial runs submitting data with them. “If the vendor is a software company, it would be good to ask them if they have incorporated the entire ICD-10 code set or just a basic mapped crosswalk,” Brimhall says. If there are any glitches or pitfalls between you and your vendors, you want to find them now—not after October 1.

Stage 7: Test your readiness

You’re almost there. As the doctor, you should have a copy of the codebook, and your front desk should have one too, to help with billing. “After several months of experience, it can probably be replaced with a shortcut list,” Gwilliam says. He warns that starting out with a shortcut list will likely lead to coding errors.

Brimhall says if you use a printed coding manual, use page tabs and a highlighter to mark those pages and sections of the manual that are frequently visited. “This is a huge time saver,” she says.

Make a checklist and verify that you and your staff are as prepared as possible. Confirm the following:

• The office has participated in various types of training (CD, webinar, self- study)
• You have participated in testing with key vendors
• In-office training and review sessions show your documentation is clearly supporting the ICD-10 codes selected
• Risk management systems have been evaluated such as post-ICD-10 strategies for efficient claims follow-up, monitoring of accounts receivable, etc.

The last thing you’ll need to confirm is that your billing software is able to code claims in ICD-9 for all claims submitted up to September 30, and then able to submit in ICD-10 thereafter. Some software packages will allow for dual coding to facilitate this process.

Those using EHR systems now will likely find this stage to be easier going, as most systems have this functionality built in.

“The practice’s billing service should have a plan in place for addressing risk areas post-ICD-10,” Brimhall says. “The practice cash flow and statistics would certainly be impacted if a solid strategy is not in place.” This applies to your in-house staff, too. If you lack confidence with your in-house billing, consider outsourcing to a professional firm.

Stage 8: The finish line

If you made it this far, the final steps are to batch and submit claims on the last business day of September. This isn’t mandatory, but Gwilliam suggests clearing out the ICD-9-coded claims on Wednesday, September 30, so you can start on October 1 with a clean slate.

Arkfeld strongly warns against delegating ICD-10 preparation to a staff member: “This is a team effort. Training and education has to start now if you have not done so already.” Offices waiting until the last moment could face severe reimbursement issues in mid-October and into November.

But if you and your team have trained, practiced, tested, checked, prepared, logged your progress, and checked off completion of the essential milestones, then October 1 should be business as usual with minimal drama. Take a victory lap with your staff—you earned it.

Daniel Sosnoski is the editor- in-chief of Chiropractic Economics. He can be reached at 904-567- 1539, dsosnoski@chiroeco.com, or through ChiroEco.com.

References

¹ CMS. “CMS and AMA Announce Efforts to Help Providers Get Ready For ICD-10.” http://cms.gov/Newsroom/MediaReleaseDataba se/Press-releases/2015-Press-releases- items/2015-07-06.html. Published July 2015. Accessed July 2015.

² CMS. “2016 ICD-10-CM and GEMs.” http://cms.gov/Medicare/Coding/ICD10/2016- ICD-10-CM-and-GEMs.html. Published September 2014. Accessed July 2015.

³ CMS. “Road to 10: The Small Physician Practice’s Route to ICD-10. http://roadto10.org. Published Jan 2014. Accessed July 2015.