Preparing for ICD-10

October 1, 2013, ushers in a new era in coding. That is when health-care providers in all categories will be required to submit claims to CMS using the new ICD-10 codes. These codes must be used for all HIPAA transactions, including outpatient claims with dates of service—as well as on inpatient claims with dates of discharge—on and after October 1, 2013. Claims on which the codes do not appear may be rejected; providers will then be required to add the codes and execute a resubmission of the documents, resulting in delays and other possible negative effects on reimbursements. Moreover, providers will be forced to grapple with a far larger number of codes than in the past. The diagnostic-code count will increase from 16,000 to 69,000; the procedure-code count, from 3,800 to 72,000. The changes wrought by the advent of ICD-10 get underway even earlier than two years from now. On January 1, 2012, standards for electronic health-care transactions transition from version 4010/4010A1 to version 5010. These electronic health-care transactions include such functions as claims, eligibility inquiries, and remittance advice. Unlike the current version 4010/4010A1, version 5010 accommodates the ICD-10 codes, and it must be in place before the changeover to ICD-10. The version 5010 change occurs well before the ICD-10 implementation date to allow adequate version 5010 testing and implementation time. CMS has publicly noted that if providers do not conduct electronic health transactions using version 5010 as of the January date, they will almost certainly encounter delays in claim reimbursement long before the fall of 2013. With this in mind, private practices and hospitals alike have begun their preparations for ICD-10 and version 5010. For its part, Advanced Radiology Services, Grand Rapids, Michigan, plans to upgrade its billing system to handle the new codes. Specifics have not yet been ironed out; vendors advocate such upgrades as integrated electronic health record components. These could assist physicians with the extra documentation required by ICD-10 (as well as with selecting the correct codes), while simultaneously affording billers instant access to the patient records they need to check before submitting claims. Training will constitute an equally significant step on the preparation front: Team members will be educated to grapple with the new codes, in part, by asking patients more specific questions about specific conditions, while physicians will (for example) be made more aware of the subtle differences between multiple diagnostic codes for seemingly identical conditions. Bill Ziemke, JD, LLM, CPA, MBA, who serves as CEO of Strategic Administrative and Reimbursement Services (STARS), LLC, the billing and management company for Advanced Radiology Services, concedes that paving the way for ICD-10 will cause some temporary inefficiencies. “Obviously, in the short run, our costs will increase,” he says, “and the organizational improvement process will continue.” Similarly, Desert Radiologists (Las Vegas, Nevada) has held ICD-10 training sessions for on-site billing personnel. It has also initiated discussions with physicians about how the codes are evolving and what they personally will need to do in order to help the practice weather the change, according to Pat Harms, MBA, CPA, FACMPE, CFO. For example, they will have to understand which of several similar diagnostic codes should be assigned to any given condition. “We are also communicating with outside resources, such as referrers and hospitals, regarding the information they gather and how it fits into coding, so that there can be a seamless transition,” Harms concludes. “Without cooperation, it won’t work.”