ICD-10 Is Coming: How to Ensure an Optimal Transition

Once again, there is an official implementation date for ICD- 10: October 1, 2014. In some circles, there is still much discussion as to whether this date, too, will be moved. While no one can predict the future in the ever-changing healthcare regulatory environment, it is highly unlikely that the date will be pushed further into the future, given that CMS (arguably) overstepped its bounds by pushing it out to 2014. Responses to the one-year extension for implementation have been mixed. Many hospitals and vendors have stated that they would have been ready on October 1, 2013, so they are using the additional year to expand their preparations—with the goal of an even smoother transition. Physicians, in many cases, tell a different story, with some still choosing to delay preparation while others embrace the opportunity to prepare their practices better for the expected impact on the coding process. Many radiology practices have either dedicated staff or a supporting billing company to help them through the transition. Radiologists could be in a better position than many other specialists in terms of what steps they must take in order to be 100% ready for ICD-10 implementation. ICD, the International Statistical Classification of Diseases and Related Health Problems, is a list maintained by the World Health Organization and used throughout the world to report clinical information for a variety of purposes. The United States is the only country that also uses ICD, in the form of the US Clinical Modification (ICD CM), for reimbursement purposes. This creates many operational challenges. In imaging, ICD CM codes are used to report either definitive findings or the patient’s signs/symptoms (if no definitive findings are present). The current US version, ICD-9 CM, has been in place since 1977; it is limited in terms of the number of codes used, as well as in its ability to describe modern care and to communicate important details about the patient’s condition. This is one of the many reason that the United States is joining the rest of the world with the implementation of ICD-10. A Whole New World With ICD-10 CM, the number of diagnosis codes increases from approximately 13,000 to 68,000, and with this increase comes much greater detail in diagnosis-code descriptions, along with the creation of diagnosis codes that combine conditions, manifestations, and complications into a single code. With the overall increase in the specificity of diagnosis codes, the level of detail provided by both the ordering physician and the interpreting radiologist becomes crucial. Currently, an order for a lower-extremity duplex study for deep-vein thrombosis might be received with the diagnosis of leg pain, which is coded as limb pain in ICD-9 CM. In ICD-10 CM, limb pain has been further divided into specific anatomic sites (upper limb: axilla, finger, forearm, hand, or upper arm; lower limb: foot, lower leg, thigh, or toe), along with laterality designation (left or right). In order to assign the most specific diagnosis code, the treating physician now needs to indicate that the pain is lower-leg pain occurring in the left leg, right leg, or both legs. Keep in mind that although the diagnosis code is assigned based on the findings in the final report, when the results are not definitive (or are negative), the code is assigned based on the diagnosis provided on the order. If the information provided on the order is too general or unspecific, assigning a diagnosis code for the procedure will be difficult. It is likely to require additional staff time to contact the treating physician and research the medical record. Greater specificity will also be needed in radiology reports to assign diagnosis codes to the findings. For example, a patient might be sent for radiography of the forearm for a suspected fracture of the ulna. The requisition simply states ulnar fracture due to motor vehicle accident. The radiology report documents that the fracture is in the shaft of the ulna. With the current ICD-9 CM codes, this information is enough to assign the specific diagnosis code, but in ICD-10 CM, more information is required. Not only is the location of the fracture necessary, but also the type of fracture and the side involved (right or left). For example, the radiologist needs to indicate whether the fracture is greenstick, oblique, spiral, comminuted, or segmental, along with the side involved. There are three main areas about which radiologists need to be concerned, when it comes to implementing ICD-10 CM: increasing the level of specificity documented in the radiology report, ensuring that referring physicians provide sufficiently detailed information, and having good staff or partners to address all the IT challenges associated with the implementation and ongoing maintenance. Radiology Specificity The issue that radiologists have the greatest control over is the documentation provided in their radiology reports. The radiology report is the beginning and the end of the audit trail; therefore, it must support all the diagnosis codes that are assigned for a patient encounter. There is much greater specificity in the ICD-10 CM codes, so radiologists will be required to provide more information than was previously needed with ICD-9 CM. Clinical-documentation improvement is the process of reviewing patient records to locate opportunities for the provider to improve the documentation of the services that are provided to the patient. Clinical-documentation improvement has a definite place in radiology as we prepare for increased documentation requirements. From a radiology perspective, clinical-documentation improvement can be used to identify where radiologists will need to improve or expand their documentation so that minimal clarifications or rework will be required. There is no one right way (nor one solution) to accomplish this task; clinical-documentation improvement has been accomplished through a manual review of radiology reports or by using a tool within an existing computer-assisted coding program. Regardless of the method, the goal should be the same—clear, concise, and complete documentation to determine the correct ICD-10 code(s) accurately. Practices should identify radiologists who will need to enhance their documentation in preparation for the transition to ICD- 10. Training should focus on the specific changes needed in their documentation and on the areas requiring additional information to assign diagnosis codes correctly and limit payment delays. Radiologists evaluate and diagnose many medical conditions, but no area is more affected in ICD-10 CM than injury/trauma. In particular, the ICD- 10 CM trauma codes allow capture of a much greater amount of detail than the ICD-9 CM codes can. Currently, we have separate codes for open and closed fractures of the same bone, but in ICD-10 CM, we will also have separate codes to show whether the fracture is displaced, as well as specific codes for fractures that are transverse, oblique, spiral, comminuted, segmental, or torus. In the case of open forearm fractures, there will be specific codes for the different Gustilo classes, so the radiologist can indicate whether the patient has a class I fracture (a small wound with minimal soft-tissue damage) or a class III fracture (a high-velocity or crushing injury with extensive soft-tissue damage). To make the coding process even more challenging, the ICD-10 CM trauma codes require the provider to indicate whether this is the patient’s initial encounter for the injury, a subsequent encounter with routine healing, or a subsequent encounter with a complication (such as delayed healing, nonunion, or malunion). ICD-10 fracture codes have a seventh character to indicate the encounter. For example, radiography might be ordered for a patient who broke her left forearm four weeks earlier. The radiologist documents that the oblique fracture of the shaft of the left radius is healing satisfactorily. The correct ICD-10 code for this subsequent encounter is S52.332D (displaced, oblique fracture of the shaft of the left radius, subsequent encounter, for closed fracture with routine healing). The initial emergency-department visit would be coded with a seventh character of A. Areas besides trauma are affected by ICD-10 CM. In order to determine where your opportunities lie, you must first determine which practice areas within radiology will be most affected by the changes. Once you have ascertained this, you should compare the radiologists’ documentation against new coding methods in these key areas to identify where changes are required. As much as it is strongly recommended to have highly detailed radiologist reports, some unspecified codes will continue to exist in ICD-10 CM. Along with all of the extremely detailed codes, ICD-10 CM also includes codes for vague and/or poorly documented diagnoses. Providers will still be able to assign a code for a fracture of the radius, even if the physician doesn’t document that it was a closed, non-displaced torus fracture of the upper end of the patient’s right radius. Although there is a nonspecific code available in such instances, however, that does not guarantee payment. Once ICD- 10 is in place, payors will tend to be more specific in their coverage policies. For example, a patient with varicose veins and stasis dermatitis of her right leg (I83.11, varicose veins of right lower extremity with inflammation) might come to a facility’s vein clinic. If the physician documents only the varicose veins and does not mention the stasis dermatitis, the facility will have to submit code I83.91 (asymptomatic varicose veins of right lower extremity). When the patient has an ablation procedure, which of those codes is more likely to get the facility its reimbursement for the procedure? The Referring Physician’s Role The Balanced Budget Act requires the referring physician to provide the diagnostic information to the testing facility at the time the test is ordered. This requirement has not been strictly enforced by CMS, but the referring provider must supply the diagnostic information, signs and symptoms, or diagnosis code on the order for it to be valid. Orders received without any clinical indications (or with rule-out conditions) are not considered valid orders for Medicare beneficiaries. It is critical— not only from a clinical perspective, but also from a compliance and coding perspective—that this information be documented. Just as the implementation of ICD- 10 CM will require greater specificity in radiology reports, it will also require more details for many of the orders. Given how great the challenge is today for many radiology practices to get complete information on patient orders, imagine how dramatically ICD-10 will amplify that problem. Medical necessity becomes a big concern with the implementation of ICD-10. For example, there is still a coding option for an unspecified malignant neoplasm in ICD-10; however, it is not anticipated that claims submitted with this code will result in payment. Clearly, we will not know for sure until after October 1, 2014, but based on information provided by payors, this is a reasonable assumption. To ensure correct code assignment for neoplasms, the radiologists and referring physicians must clearly document the specific location of all neoplasms. Simply stating breast cancer or lung cancer will not be sufficient for many payors. To prepare for correct neoplasm coding in ICD-10, it is recommended that you review the amount of detail that your referring physicians, as well as your radiologists, provide for all neoplasms. For neoplasms that require more detail regarding location, it would be best to require this level of detail today, instead of waiting for the implementation of ICD- 10. Examples include reports involving neoplasms of the colon, lung, breast, and brain. Having physicians expand their level of detail will take time, but it will be well worth the effort. There is great value, even two years before ICD-10 implementation, in addressing any order difficulties that you have today with your referring physicians and their staffs. Many practices shy away from addressing this because they are afraid that the referring physicians will send their patients elsewhere if they request additional information. On the other hand, how many exams can any practice afford to perform for free? In our increasingly regulated environment, we should not apologize because we are following the rules and trying to do what is best for the patient. I would argue that not having complete and accurate clinical information on the front end potentially jeopardizes patient care. How, then, do you address incomplete orders? Perform an internal assessment to determine which referring practices show an opportunity for improvement. Once you have identified these practices, prioritize your list and begin making contact with the appropriate personnel in their offices. These conversations might be challenging, and change might be slow, but this is another reason to begin the process now (instead of waiting until problems erupt during ICD-10 implementation). Remember that it is always better to have specific examples (not general, negative statements) to communicate. For example, state that there were 12 orders from the referring practice last week that did not identify the reason for the exam requested; don’t state that the practice never sends you the information that you need. Try a positive approach based on documented facts. IT is possibly the least stressful area of ICD-10 implementation for radiologists who are not actively involved in maintaining and updating this function, even though IT is not likely to be the least stressful part of implementation as a whole. Other staff and/or business partners, such as the billing company and clearinghouse, should be working hard to assess the IT challenges and to implement the plans necessary to ensure compliance on October 1, 2014. There are many things that we can definitely begin to prepare for now, but unfortunately, since the United States is the only country that truly uses ICD for reimbursement, we don’t have a model that we can use from other countries. We must recognize that this will be a work in process: There is no one way to accomplish a good result, and we must be nimble and flexible in our approaches.