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Smaller Private Practices are Vulnerable to ICD-10

January 16, 2013

ICD-10 CodingThe most recent industry survey by CMS on ICD-10 compliance shows that 79% of providers have taken steps to implement the transition to the new coding system. 82% believe they will be compliant by the implementation deadline. Larger practices report more readiness than smaller ones. At this date, the ICD-10 transition should be on everyone’s mind, and every provider should be sure that they will meet the deadline. While professional medical billers and coders will be prepared when FY 2014 begins, providers also need to take steps to learn the documentation requirements that the transition entails.

Medical coding and billing professionals, medical billing contractors, and medical information managers already have a deep understanding of how ICD-10-CM will impact the industry. During this transition period, it is essential that coders and billers be fluent in both ICD-9-CM and ICD-10-CM. A thorough familiarity with the differences between these two diagnosis coding methodologies will make the transition seamless as long as medical records contain the information to accurately assign ICD-10-CM codes. 

All outpatient healthcare claims submitted for services performed on or before September 30, 2014 will be coded using ICD-9-CM. Claims submitted on and after October 1, 2014 will be coded using ICD-10-CM. The translation of medical conditions from one system to the other should be effortless if the necessary steps are taken beforehand. This means that everyone who has an impact on the coding process needs to be aware of what new information the codes are meant to communicate.

Coder and biller training is taking place now, and provider training should already be underway. A physician’s primary job is to provide healthcare. No one expects them to master the intricacies contained in ICD-10-CM overnight. Nor does anyone expect a physician to become an expert in ICD-10-CM soon after the transition date. The common errors produced by ICD-9 coding are one of the reasons ICD-10 is being adopted by CMS and every other healthcare payer.

Containing approximately 68,000 codes, ICD-10 will require greater specificity in the medical record in order to assign diagnosis codes appropriately. The new coding system is designed to capture the maximum amount of data in order to present an accurate picture of a patient’s medical condition. In order to submit a 100% clean healthcare claim, the medical record needs to contain requisite information to avoid “unspecified” codes.   

Ideally, the medical record should already contain the information required by ICD-10-CM. For example, some codes will require an additional character to indicate whether the patient is being seen for the first time for a condition, or if this is a subsequent visit. This should be evident in the medical record, but sometimes it is not. The documentation that follows any medical service needs to stand on its own to support medical necessity. This means that the physician progress note, consultation report, or radiology report needs to specify that the patient’s presenting problem is a first encounter or a follow-up. 

Under ICD-9-CM, the stage of a patient’s diagnosis is irrelevant to coding medical necessity.  A physician assigns the same diagnosis code at any stage in the treatment process. ICD-10-CM makes a distinction, and without that distinction being reported in the applicable code, a claim will be rejected by a payer.

The idea of an initial encounter versus a subsequent one does not refer to the first time a physician has encountered the patient. Instead, it refers to whether the patient has already been treated for the condition. A physician who picks up a patient in mid-treatment plan will not code the diagnosis as an initial encounter.

The language and specificity required by ICD-10-CM requires accurate documentation. All healthcare providers, indeed everyone who makes entries in the patient’s medical record, need to be aware of the language and guidelines that make up ICD-10-CM in order to ensure that clean claims are submitted after the transition date.


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