O&P Preparation for the Transition to ICD-10

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By Maria St. Louis-Sanchez

All entities covered by the Health Insurance Portability and Accountability Act (HIPAA) will be required to transition to the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) by October 1, 2014. While the transition to the revised, mandatory medical coding system is a year away, some leaders in the O&P industry worry that many practices are not aware of the impact the revision will have on the profession and will not be ready for the change unless they start preparing immediately.

The tenth version of the diagnostic coding system is a dramatic change from the previous system. According to the Centers for Medicare & Medicaid Services (CMS), there are about 13,000 ICD-9 codes for all types of healthcare diagnoses. With ICD-10, there will be about 68,000 codes, more than five times as many. The new codes have been expanded from three to five digits to three to seven digits and will allow for much more specificity in the diagnosis. For example, the codes will allow for descriptions that include laterality, precise definition of an anatomic site, and devices used. In addition, terminology has been modernized and made consistent, and some codes will combine diagnoses and symptoms, thus necessitating fewer codes to be reported.

Mark Ford, director of business development for OPIE Software, Gainesville, Florida, says he doesn't think many O&P practices understand the full impact of the coming change. The OPIE staff has been working to ensure the software is ready for the change, but in other parts of the O&P world many are not even aware of it.

"When I do state and regional presentations, I ask the audience if they know about [ICD-10], and in a room of 50, maybe five to ten people will raise their hands," he says. "I don't think a lot of O&P offices realize that they will have to do this documentation change next year."

Don Hardin, director of government affairs and payer relations for Ottobock HealthCare, Minneapolis, Minnesota, says many practice owners tend to be more focused on the patient side of their business than the paperwork side. "They care more, and should, about taking care of their patients," he says. "Paperwork is not always a priority for them. Unfortunately, in this current environment we are in, it needs to be more and more of a priority."

While these new codes will primarily impact the prescribing physician, Ford says that O&P providers should know the new codes thoroughly themselves and not rely on the physicians to always get it right. "Physicians are supposed to assign the diagnosis code; it's their job," Ford says. "But we also know they don't always do it. My fear for the profession is that the O&P practices will try to determine the codes on their own, and if they get it wrong, they aren't going to get paid."

To help prepare for the switch, Ford and Hardin offer this advice for O&P practices: Develop a plan early, set aside time for training and testing, and be prepared for the worst.

Start Preparing for the Transition Immediately

CMS documentation recommends that providers should already be working toward ICD-10 implementation. This includes ensuring that practice leaders understand the full scope of the changes and create a transition team, prepare a budget for potential expenses such as training needs, and develop a timeline to ensure that the practice is ready well before the deadline. A suggested timeline released by CMS states that practices should have their plan in place now.

For those who might not be so prepared, the good news is that there are several ways for practices to stay on top of the latest news regarding the changeover to ICD-10. O&P providers can sign up through the CMS website to receive e-mail updates to get the latest news or even follow the CMS twitter account, @CMSGov, which regularly provides ICD-10 updates. (Editor's note: To access the CMS ICD-10 webpage, visit www.cms.gov/Medicare/Coding/ICD10/index.html.) CMS has released video lectures on its website, for both small and large practices, and has posted articles with recommendations for practices about implementing the change. CMS also hosts conference calls occasionally to explain the changes that providers can expect. Hardin says there are even smartphone applications where O&P providers can look up the new codes.

Ford says that practices should also be on the lookout for training sessions at O&P conferences as well as webinars that are provided for the entire healthcare profession. "You should start to learn about it, at least the basics, sooner rather than later."

Set Aside Time for Training and Testing

Training for the new system will take time, Ford says. "There were previously a fairly narrow set of diagnosis codes. The O&P profession is very comfortable and knows and understands them. This new ICD-10 system drastically increases the number of codes. There will obviously be a learning curve with that." Part of the problem is that many people become familiar with codes over time, working with them day in and day out, he says. This revised system will start in a single day so the staff members dealing with the switch have to be prepared to use the new codes immediately. They should test whatever billing software, computer system, or billing service they plan to use well in advance to ensure that everything runs smoothly, CMS documentation recommends.

Training staff members may also mean that practices should be prepared to adjust the schedules of the employees dealing with the codes and possibly adjust their budgets to reflect any training costs. "Any time you are doing training, you are taking staff members away from the revenue-generating operation, but there really is no option to learning about this new piece of the documentation and billing equations," Ford says.

Be Prepared for the Worst

CMS documentation clearly states that claims submitted with incorrect coding, including previous codes, will not be paid. Hardin says practices should be prepared for that and ensure that everything is ready for the change by the deadline. "It's a no-brainer," he says. "If these policies are put into place, and the policies require the use of these ICD codes, and the billing entity doesn't include that, then claims will get denied. It's that simple."

Hardin and Ford both say they do not know yet if CMS will allow practices to resubmit claims with proper coding if mistakes are made. To be on the safe side, O&P practices should not expect any leniency, they say. If practices can learn anything from the Recovery Audit Contractor (RAC) audits that have recently forced O&P practices to pay back identified overpayments, it is that they should not expect any tolerance from CMS, Ford says.

The worst-case scenario, he says, is that CMS may originally pay a claim and then come back and demand the money back from the practice.

"We don't know for sure if that will happen yet...," Ford says. "We have to assume from what CMS is doing on every other documentation topic that including an incorrect ICD- 10 code may fall into the same category. For practice owners, this is definitely one of those situations where it is better to be safe than sorry."

Maria St. Louis-Sanchez can be reached at