As 2014 moved into its fourth and final quarter, the one-year hourglass turned on ICD-9, and no one on the exhibit floor at the Radiology Business Management Association’s 2014 Fall Educational Conference, Oct. 19–21 in Seattle, expected another reprieve.

In fact, no one expects mercy either. “I think if we would have had ICD-10 in place in 2014, we would have seen most payors relax their edits,” said Robert Kebbekus, president and COO, Integrated Medical Partners (IMP), Milwaukee, Wis. “In 2015, I don’t know if they are going to be as lenient.”

How have billing companies used the extra year to prepare clients? Cheryl Loper Fimreite, VP of coding and compliance, IMP, is coding a section of each client’s work in ICD-10 to create a database that can be analyzed by physician, by hospital location and by technologist to locate areas of weakness.

“In January, we will give the initial feedback,” Fimreite said. “We’ve used this time to make sure systems are up to date, enhance coder education and identify the physicians’ top 25 to 50 unspecifieds.”

Key areas of focus in ICD-10 are laterality and specificity, Fimreite said. “A lot of times the physicians will say, ‘I have all of this in the PACS from the admitting clerk, I didn’t know you needed it,’” she said. “We are saying, ‘More is better, give us everything you’ve got.’  The good news is that the hospitals are doing this too, so they will be pushing the techs.”

By the numbers

With a total of 70,000 codes, more is imperative. Presenting on “Driving Financial Performance Before and After ICD-10,” Mark Morsch, Optum 360, said laterality is a huge driver in the increase in codes in ICD-10. “There are more than 24,000 distinctions associated with laterality, particularly in the injury chapter,” he said.

Another major factor in the increase in codes is encounter type, which accounts for 20,000 of the 70,000 codes in ICD-10. Radiologists must record whether this is an active/initial treatment versus routine/subsequent care for an illness or injury, he said. “It defines the seventh character for a good number of fracture codes,” Morsch said. “The requirement is really important, especially for follow-ups, because bills will be coded differently.”

Jesse Moniz, Affiliated Professional Services (APS), Wareham, Mass., said APS has offered clients the option of running reports through software from 3M (which acquired CodeRyte), which generates a report on how each physician is performing under the more specific reporting requirements for ICD-10.

“Ninety percent of our clients are taking advantage of this,” Moniz reports. “In addition to a report card, the software provides a breakdown on what the financial impact will be.”

If a client is doing poorly, APS meets with hospital registration and intake people to see how they are collecting the specific how, why, where that ICD-10 requires from the radiologist report.

APS did an initial assessment in 2014 and will do a secondary assessment in 2015.

“Radiologists are at the mercy of the hospitals,” said Bo Trotter, president, Management Services Network, Columbus, Ga. Trotter said it’s a mistake to assume that hospitals know that they need to send the radiologist the reason for the exam. “We’ve heard some hospitals say they’ve forgotten the radiologist needs it,” he said.

A feedback loop

Zotec used the reprieve year to develop a feedback loop between physicians and its coders, which it calls its Request for Information (RFI) portal. “A dictation comes through to the coder and it is not optimally dictated,” Steve Collins explained. “The coder sends an email to the radiologist with a recommendation—please include documentation for fistulogram and specify vessels treated for angioplasty.”

Zotec also is working with Coding Strategies to develop ICD-10 videos and crosswalk tables to load into the RFI portal. “A key feature of RFI is that we track the information flow,” Collins says. “Radiology practices can look at who is creating the RFIs, who is causing them and who has responded to them.”

Nonetheless, be prepared for a slowdown in the revenue cycle, Collins advised: “There is a strong belief in the marketplace that payors are going to use this to slow payment to providers. I think they need a line of credit.”

Radiology gets high marks for ICD-10 readiness, from Melody Mulaik, president, Coding Strategies, but she said those outside of radiology are not as prepared. “Find out where the greatest return on investment is,” she recommends. “CT and ultrasound are where practices are having some of the biggest problems with clinical indications.”

“Be able to quantify the problem—10% of the time that this ENT practice orders CT, we are not getting good clinical indications,” she adds. “I would argue that this is going to tee in well to the next thing coming—clinical decision support.”