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ICD-10: Keep the Transition Concurrent With 5010

By now, every healthcare facility in the country should be aware that two major conversions are imminent. The transition to the 5010 electronic transaction standards must take place by January 1, 2012 and is the first required step in the transition to ICD-10. The transition to the ICD-10-CM (diagnosis) and ICD-10-PCS (hospital procedure) code sets must take place by October 1, 2013.

With the 5010 conversion looming more immediately on the horizon, attention understandably has been diverted away from ICD-10. Even in times of stretched resources, however, it’s important to try to tackle these transitions as concurrently as possible.

Fortunately, the bulk of the 5010 transition will be the responsibility of healthcare IT vendors such as clearinghouse, EHR, practice management, and other software product providers. It will be largely up to these vendors to make sure their products comply with the new data standards. However, it is up to physician practices to verify that their vendors are ready for the transition. Otherwise, practices risk claims rejections by insurance companies—and resulting cash flow interruptions.

In addition, 5010 supports ICD-10, so it is essential that practices make sure that their HIT vendors are prepared to transition. More information about what practices should ask their HIT vendors can be found in the white paper, How 5010 Will Enhance Practice Profitability: A Preparation Guide for Physician Practices.

In contrast to the 5010 transition, the ICD-10 transition will rest more heavily on physician practices. This is more than a mere technical update. It is something that will affect a practice from front office to exam room to back office.

Remember, the differences between ICD-9 and ICD-10 don’t only begin with the numbers: nearly 70,000 ICD-10-CM codes compared with the current 14,000 codes in ICD-9-CM—roughly an 80% increase. Other important differences to investigate, if you haven’t already, include: code length (up to seven characters instead of five); code format (alphanumeric instead of primarily numeric); clinical organization (e.g., injuries in ICD-10 are grouped by anatomic site, rather than by type of injury); and clinical terminology (e.g., “caesarean section” is called “extraction of products of conception” in ICD-10).

Fundamental differences such as these mean that every part of a medical practice will be affected in some way by ICD-10. Front-end eligibility. Back-end coding, claims and payment processing. Clinical documentation processes. Nearly every manual and automated clinical and administrative process will be affected.

Of course, with the capacity for more codes and more specificity comes the possibility of improved care quality, safety, and efficacy, as well as the potential for better claim and payment processing systems. But it all takes preparation.

Regardless of size, every practice should be preparing an inventory of all software, paper forms, staff, and processes that use diagnosis codes in any way. Use the inventory to prepare an action plan for transitioning all policies and procedures affected indirectly or directly. I encourage forming a joint team of both clinical and administrative personnel to conduct the assessment of where and how diagnosis codes are used.

Ask software and IT vendors questions such as: What are you doing to prepare for ICD-10? How much will it cost me, and will I need training? Will I need to test with you? Most healthcare IT systems will need updating to accommodate the ICD-10 format changes.

And don’t forget that continued processing of older claims after the implementation date will require a period of using both ICD-9 and ICD-10 codes. Make sure IT systems are able to accommodate both ICD-9 and ICD-10 codes simultaneously.

Mapping tools such as the CMS General Equivalency Mapping (GEM) files can aid preparations. But, it’s important to recognize that these tools cannot always reliably translate all code values. After all, if there were 100% direct mapping, there would be no need to move to ICD-10!

For later education efforts, analysis of codes frequently used in your office—both in terms of quantity and reimbursement—is a good idea. The level of specificity in clinical documentation, of course, will be critical. So, review of current clinical documentation specificity would be prudent. Start training clinical administrators and coders not too far before Oct. 1, 2013, so that knowledge is not lost from lack of use, but not so close that training is rushed and perhaps incomplete.

Many experts suggest that ICD-10 may be a good time to assess current knowledge of medical terminology, biomedical sciences like anatomy, physiology, and pharmacology for either refreshers or additional education. Correct coding based on clinical documentation is the only sure way to protect your revenue stream.

Successful implementation of ICD-10 depends on a successful implementation of 5010, because 5010 supports the use of ICD-10 codes. So, be sure to follow vendor and payer recommendations for both of these important transitions.