Transitioning to ICD-10

Editor’s Note

Welcome to the most recent issue of Innovations in Oncology Management, a newsletter series providing up-to-date information on current issues that are directly affecting the management and business of cancer care in the community. This fourth newsletter in the second series has been developed for oncology practice administrators, administrative staff, advanced practice clinicians, and oncology pharmacists. The current newsletter focuses on transitioning to the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedural Classification System (ICD-10-CM/PCS), referred to as ICD-10. To be compliant with the new coding system, all covered entities were required to implement the new ICD-10diagnostic code sets starting on October 1, 2015. This newsletter highlights some of the key implications for oncology practices, outlining the difference between the ICD-9-CM and the ICD-10 coding system. The information presented in this newsletter outlines key changes relevant to oncology practices as they transition to the ICD-10 codes and the impact this has on submissions of new claims for events occurring after September 30, 2015. We hope you find this newsletter to be a valuable resource for your practice. Previous newsletters have explored a variety of topics related to oncology practice administrations that can be found at www.innovationsinoncologymanagement.com.
On October 1, 2015, the US healthcare system officially adopted the International Classification of Diseases, Tenth Revision (ICD-10) for the coding of clinical diagnoses. To be compliant with the new coding system, all covered entities designated by the Health Insurance Portability and Accountability Act of 1996 were required to implement the new diagnostic code sets starting October 1, 2015.1 The Need for ICD-10 Adoption The adoption of the ICD-10 classification system is the result of concerns that the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is outdated and no longer accurately reflects the current technologies and approaches to medical treatments.2 Furthermore, the healthcare industry is becoming increasingly challenged in its ability to measure the quality of patient care by the use of ICD-9-CM, because of the lack of specificity and precision in the diagnostic codes.2 According to the Centers for Medicare & Medicaid Services (CMS), the new coding system introduced withICD-10 will allow healthcare stakeholders to better measure healthcare services and will set the stage for improved patient care and enhanced public health surveillance by various stakeholders across the country.3 The ICD-10 coding system differs from the ICD-9-CM coding system in several important ways (Figure). For example, ICD-10 uses 7 alpha or numeric digits, whereas ICD-9-CM uses a maximum of 5 numeric digits. In both systems, the first 3 characters in the code define the category for the condition under consideration, the fourth character defines the specific anatomical location, and the fifth character defines the etiology of that condition. ICD-10 provides additional detail in the sixth character by defining the laterality (left or right) for the condition. In addition, a seventh extension character allows clinicians to provide more details about the diagnosis when necessary.3,4 EHC491-4_Figure Implementation of ICD-10 As of October 1, 2015, medical claims with a date of service on October 1, 2015, or later are to be accepted by Medicare, Medicaid, and by the majority of private US payers only if they contain a valid ICD-10 code. CMS advised physician groups, hospitals, and other covered entities that Medicare claims processing systems would no longer accept claims containing ICD-9-CM codes for dates of service that occurred after September 30, 2015, nor would it accept claims that contain ICD-9-CM and ICD-10 codes for the same diagnosis.5 The ongoing transition from ICD-9-CM to ICD-10 has required considerable effort and expense, because healthcare providers and payers have prepared for an increase in the number of codes from approximately 14,000 to approximately 69,000.6 In addition, the transition from ICD-9-CM to ICD-10 has taken place during a period when provider practices and hospitals have also been dealing with increased regulations regarding federal and state quality initiatives and Meaningful Use regulations related to electronic medical records.6 Because of the lag time in submitting and processing claims, a full billing cycle will be required to assess the transition to ICD-10 codes and the success of its implementation.7 Many providers batch their claims and submit them every few days rather than submit them on a daily basis. After submission, Medicare claims take several days to be processed, and, by law, Medicare must wait 2 weeks before issuing a payment. Furthermore, Medicaid claims can take up to 30 days to be submitted and processed by states.7 Although there were reports that nearly 25% of physician practices would not be ready to implement theICD-10 codes by the October 1, 2015, deadline, large health insurers have reported few problems in the early stage of the transition to ICD-10.8 For example, Humana reported that only 0.03% of inbound calls from providers regarding benefits, claim status, spanning date of service, and authorization in the first week of the transition were specific to ICD-10 codes.9 In addition, UnitedHealth Group, the nation’s largest health insurer, indicated that claims are being paid and call volumes from providers have been typical, with only a slight increase in claim denials.9 CMS Announced a “Grace Period” CMS released guidance that allows for flexibility in the claims auditing and quality reporting processes to help ease the transition to ICD-10 for providers.5 According to CMS, for 12 months after the implementation of ICD-10, Medicare review contractors will not deny claims from providers that are billed under the Medicare Part B Physician Fee Schedule through automated medical review or through complex medical record review based only on the specificity of the ICD-10 diagnosis code, as long as the provider uses a code from the correct family of codes. However, a valid ICD-10 code is required on all claims starting October 1, 2015.5 For all quality reporting completed for the 2015 program year, Medicare clinical quality data review contractors will not hold providers to the Physician Quality Reporting System, Value-Based Payment Modifier, or Meaningful Use penalties during any primary source verifications or auditing that are related to the additional specificity of the ICD-10 diagnosis code, but the provider must use a code from the correct family of diagnoses.5 Furthermore, providers will not be penalized if CMS cannot easily calculate the quality scores for the Physician Quality Reporting System, Value-Based Payment Modifier, or Meaningful Use because of the transition to ICD-10.5 CMS also stated that it would not deny any informal review request based on the 2015 quality measures if it is found that the participating healthcare provider’s only error(s) is/are related to the specificity of the ICD-10diagnosis code.5 Furthermore, CMS announced that a communication and collaboration center will be set up to monitor the implementation of ICD-10. This center will quickly identify and initiate the resolution of issues that arise as a result of the transition to ICD-10.5 Advance Payments CMS stated that if Medicare Contractors are unable to process claims within the established time limits because of administrative problems (eg, contractor system malfunction or implementation problems), an advance payment may be available under certain conditions.10 To apply for an advance payment for a fee-for-service Medicare claim, healthcare providers should submit their request to their appropriate Medicare Administrative Contractor.10 If there are Medicare systems issues that interfere with claims processing, CMS and the Medicare Administrative Contractors will post information on how to access advance payments. Advance payments are only available if the healthcare provider has submitted a valid claim for the services rendered.10 Implications for Oncology Practices Should delays occur in claims approval and payment, it will be incumbent on the practice to determine the reason for the delay. Roberta L. Buell, MBA, a well-known expert in oncology drug coding and reimbursement, indicated that practices must figure out whether delays or rejections in reimbursement are the result of actual ICD-10 coding (miscoding) in the practice or whether claims processing and payment systems are unable to keep up with the transition to ICD-10.11 Each claim must be carefully examined before and after billing to ensure that problems are resolved quickly. Overall, 2 coding systems—ICD-9-CM for dates of service before October 1, 2015, and ICD-10 for dates of service starting October 1, 2015—will have to be in place for approximately 1 year beginning on October 1, 2015.11 On the positive side, Ms Buell notes that some prior authorizations may be avoided with more specific lateral coding for breast cancer and other solid tumors.11 In addition, ICD-10 offers more specificity in coding for certain tumor types, such as lymphoma, and in this case, practices will be able to see more detailed information regarding the type of lymphoma treated in the practice and the drugs used to treat it. Furthermore, oncology practices may have an easier time learning the new ICD-10 codes than some other specialties, such as orthopedics, where a large proportion of the ICD-9 codes have changed or have expanded.11 On the negative side, Ms Buell mentions that in oncology, the majority of the documentation included in the electronic medical records, such as staging, histology, functional status, or previous therapies, are not coded in ICD-10.11 In addition, many of the genomic tests do not have codes. As a result, data enhancement is limited for oncology compared with other specialties.11 What Happens Now? It will take some time for physician practices, institutions, and payers to become accustomed to the new ICD-10 codes. During the first 6 months, mistakes and deficiencies will become more apparent, underscoring the need for remedial education. In addition, during this period, practices and institutions will begin to understand how payers process the more specific ICD-10 codes. To ensure success, ongoing coder training will be essential for long-term compliance.12 There are several strategies that practice administrators and coding managers can use to ensure ongoing coder training in ICD-10.12 The first strategy is the development of a training plan that addresses coding errors in real time. Quality assurance staff should be assigned to track and trend coding errors as they occur, giving priority to errors or omissions that affect reimbursement. These errors should be directed to management and to the individual coder for immediate education. Coding errors or omissions can be caused by deficits in ICD-10 knowledge, or because of a general deficit in coding knowledge; the necessary remedial education can be guided by examining the root source of the error.12 The examination of denied claims can also provide valuable insight about coder deficiencies.12 Denial management staff should focus on the root cause of the claims denial to decipher whether remedial coder education is necessary, or whether the denial was triggered by a documentation issue that requires a physician’s attention.12 Not all coding education must be provided in a remedial setting.12 Opportunities for learning must also be available on an as-needed basis as coders are coding each claim. Anatomy and physiology references can be valuable sources of information in this regard, and physician practices and institutions may benefit from an investment in clinical resources so that healthcare claim coders have sufficient, accurate information at their fingertips.12 References 1. American Health Information Management Association. Setting the facts straight about ICD-10: what physicians need to know about the transition. 2014. http://bok.ahima.org/PdfView?oid=300625. Accessed October 7, 2015. 2. American Health Information Management Association. ICD-10 for physicians and clinicians: why ICD-10 matters. www.ahima.org/topics/icd10/physicians. Accessed October 7, 2015. 3. Medicare Learning Network; Centers for Medicare & Medicaid Services. ICD-10-CM/PCS: the next generation of coding. June 2015. www.cms.gov/Medicare/Coding/ICD10/downloads/ICD-10Overview.pdf. Accessed October 7, 2015. 4. American Academy of Dermatology. ICD-10 documentation requirements. www.aad.org/members/practice-and-advocacy/coding-resources/icd-10-center/documenta tion-requirements. Accessed October 8, 2015. 5. Slavitt AM; for the Centers for Medicare & Medicaid Services. Letter to Medicare providers. July 7, 2015. www.cms.gov/Medicare/Coding/ICD10/Downloads/Medicare ProviderICD-10.pdf. Accessed October 11, 2015. 6. Ray W, Norbeck T. ICD-10: the clock is ticking. Forbes. June 5, 2015. www.forbes.com/sites/physiciansfoundation/2015/06/05/icd-10-the-clock-is-ticking/. Accessed October 11, 2015. 7. Cavanaugh S. Welcome to ICD-10. Centers for Medicare & Medicaid Services Blog. October 1, 2015. http://blog.cms.gov/2015/10/01/welcome-to-icd-10/. Accessed October 7, 2015. 8. Workgroup for Electronic Data Interchange. WEDI ICD-10 survey results: industry nearing readiness but physician practices lagging behind. Press release. August 3, 2015. www.wedi.org/news/press-releases/2015/08/03/wedi-icd-10-survey-results-industry-near ing-readiness-but-physician-practices-lagging-behind. Accessed October 7, 2015. 9. Japsen B. Smooth rollout for new ICD-10 medical codes, insurers say. Forbes. October 13, 2015. www.forbes.com/sites/brucejapsen/2015/10/13/so-far-smooth-rollout-for-new-icd-10-medical-codes-insurers-say/. Accessed October 11, 2015. 10. Centers for Medicare & Medicaid Services. CMS and AMA announce efforts to help providers get ready for ICD-10: frequently asked questions. www.cms.gov/Medi care/Coding/ICD10/Downloads/ICD-10-guidance.pdf. Accessed October 11, 2015. 11. American Society of Clinical Oncology. Three questions with: Roberta Buell, MBA, OnPoint Oncology. www.asco.org/file/28781. Accessed October 13, 2015. 12. Strafer P. ICD-10 education shouldn’t end after October 1, 2015. ICD10monitor. October 12, 2015. www.icd10monitor.com/enews/item/1511-icd-10-education-shouldn t-end-after-october-12-2015. Accessed October 18, 2015.

Stakeholder Perspective

ICD-10: A Coding Expert’s Perspective After years of delay, ICD-10 Clinical Modification/Procedural Classification System (ICD-10-CM/PCS), generally referred to as ICD-10, finally took effect on October 1, 2015. As healthcare providers and payers are transitioning to the use of the new code sets in all new claims, Innovations in Oncology Managementspoke with Susanne Talebian, CHBC, CUA, CPC-I, CCS-P, RMM, CMOM, PCS, CEO and Senior Consultant, Health Business Solutions, Ltd, who has more than 30 years of experience in practice administration, financial analysis, budgeting, and compliance. Ms Talebian is a well-known national speaker and an American Health Information Management Association (AHIMA)-certified ICD-10 trainer. Q: What has been your experience with the implementation of ICD-10 so far? Susanne Talebian: The transition has been relatively quiet so far. As of October 21, we have had 14 official business days in claim processing. By law, that is how long Medicare must wait before releasing claims. We should start seeing how Medicare is processing claims very soon. I have seen a few claims processed through commercial carriers, and there have been very few problems. It is a relatively small batch of claims, but I have not seen any red flags yet. Physician practices should keep in mind that any claims resubmitted with a date of service before October 1 must be in ICD-9-CM format, using ICD-9-CM codes. Sometimes, that can be tricky for the specific practice management software that some practices are using. Q: For how long do you anticipate that practices will need to maintain ICD-9-CM information in their software systems? Ms Talebian: The top performing accounts receivable departments will require 3 months to clean up old claims, but I think some practices will require up to 6 months. Q: Have most medical practices and/or hospitals been adequately prepared for the transition that took place on October 1? Ms Talebian: Overall, the larger hospitals, health systems, and physician groups are better prepared forICD-10 than smaller groups, primarily because they have the staff, the time, and the money to get ready. Many of these organizations set up planning committees and were able to develop their infrastructure well in advance of the implementation date. In my experience, some of the smaller providers and physician groups have not been adequately prepared for the transition to ICD-10. This perception is supported by the data. According to AHIMA’s June 2015 report on ICD-10 readiness, only 29% of smaller physician groups (with less than 10 physicians) and hospitals with less than 100 beds reported testing their systems for ICD-10 interchange, whereas larger groups of 30 or more physicians and hospitals with more than 300 beds reported a testing rate of 68%. Testing was viewed as a key indicator of ICD-10 readiness.1 A later study by the Work Group for Electronic Data Interchange reported that approximately 75% of hospitals have begun testing as of July 2015 compared with only 20% of physician groups.2 This aligns with what I have been seeing in my seminars on coding throughout the country. Q: Are private practices facing similar coding challenges as hospitals and hospital-owned health systems, or are their coding challenges different? Ms Talebian: Hospitals all have electronic medical records (EMRs), so they are one step ahead of the game. They are larger, so they tend to have more resources. Hospitals and private practice physicians are required to implement ICD-10-CM, the clinical modification for diagnosis coding, but the hospitals are also required to implement ICD-10-PCS, the procedural classification system, using the codes for inpatient surgery and medical procedures. However, hospitals should be well-prepared, because their diagnosis-related groups are already based on services and diagnosis codes. Q: Why is it important for physicians and other clinicians, as well as coders and administrative staff, to be fully trained on the ICD-10 codes? Ms Talebian: It is imperative for them to understand the coding changes, because coding is the responsibility of the provider. Choosing the correct ICD-10 code at the level of specificity required by the new coding system will decrease the time it takes for claims to be submitted. Remember, a claim cannot be submitted without the proper documentation, which means the billing staff will be querying the physicians and providers, and these delays will cost the practice money. The best thing is to train your providers. Give them guide sheets, and have them understand the codes. It will make everyone’s job easier. The time for preplanning is over, but we can modify the existing templates to drive the providers to the necessary questions to select the correct diagnosis code. For example, for breast cancer, is it the left or the right breast? In which quadrant of the breast does the tumor reside? Answering these questions will help coders to select the proper ICD-10 code for breast cancer. Q: Should billing and coding staff coordinate more closely with the clinical staff during this transition period? Ms Talebian: Billing and coding staff and clinicians should always have open lines of communication. When claims are denied, unless billing staff are clinically trained, they do not know if a denied claim is appropriate for the appeal process. They should always go back to the provider and let them determine whether the denial makes sense from a clinical perspective. Then the practice can make an informed decision of whether to appeal the claim. That said, I think it is even more important for open communication and coordination during the transition, because of the increased complexity of the ICD-10 codes, and because everyone is getting accustomed to using them in the real-world setting. Payers have modified their medical necessity requirements to reflect the new codes. The failure of practices to submit proper codes may result in claim denials or delays in receiving payment. Q: How can coders and billers remain as productive as they were before processing the same number of claims when you have so many new codes? Is it possible? Ms Talebian: Initially, it will not be possible to maintain the same productivity, because coders are now entering alphanumeric characters. Therefore, the actual time it takes to enter the codes is a little bit longer. The second issue is that it takes time to become intimately familiar with the code sets, especially the fifth, sixth, and seventh digits, which were not necessary with ICD-9-CM. As a result, there will be a slowdown in productivity in terms of data entry. If EMRs are linked correctly to the billing and practice management software, it will likely mitigate most of the reduced productivity in terms of data entry. But not all software is created equal, and some are better equipped to push diagnosis, procedure, and drug codes from the EMR to the billing software. In oncology, there are many expensive drugs and high-dollar claims, so many practices have invested in high-quality electronic systems. Q: Are any providers having issues with claims that have service periods that straddle the October 1 implementation date? Ms Talebian: Medicare has been very helpful in providing guidance on this issue. I refer providers to the article “Medicare Fee-For-Service (FFS) Claims Processing Guidance for Implementing International Classification of Diseases, 10th Edition (ICD-10)” of the MLN Matters series, which provides very specific guidance about what providers need to do for claims that span the ICD-10 implementation date.3 Q: Are oncology groups and institutions encountering any unique challenges because of the new codes? Ms Talebian: Yes. In oncology, it is important to document whether the neoplasm is benign, malignant, or of uncertain histologic behavior, or unspecified, to choose the correct code. It is also important to know whether the neoplasm is a secondary metastatic site. There are several rules on the principal diagnosis being used in the treatment of cancer. For example, if a patient’s hospital admission or office visit is solely for the administration of chemotherapy—an immunotherapy, or radiation therapy—we would assign the appropriate Z code as the first diagnosis code, which is the encounter for such treatment. In this case, the diagnosis of cancer will be sequenced as the second diagnosis code. Another example is when anemia is associated with a malignancy. If the treatment is for anemia only, the appropriate code for the malignancy is sequenced as the first-listed diagnosis, and then followed by the appropriate code for anemia, such as ICD-10 code D63.0 (anemia and neoplastic disease). I would encourage oncology providers and coders to review the relevant cancer-related codes frequently until they learn all of the differences in the ICD-10 codes. Q: Why is ongoing and/or remedial training important for ICD-10, and what resources are available? Ms Talebian: Ongoing training is important, because it takes time to create a new habit. We have been coding ICD-9-CM for nearly 30 years. To be familiar, confident, and up to speed with ICD-10, we have to continue the education process. Repetitive use and education will result in the successful implementation of ICD-10 and will minimize the disruptions in cash flow that occur from claim denials and claims that cannot be processed. Of course, remedial training is critical during the transition period. As soon as a claim comes back with an error, we need to stop the process, fix the claim, then educate the coder and clinical staff about the proper procedure for documenting the information or assigning the code. If remedial training does not take place in real time, the same error may repeatedly occur, resulting in claim denials and payment delays. There are plenty of good online sources for information about ICD-10 support. My go-to sources are the Centers for Medicare & Medicaid Services (CMS; cms.gov), AHIMA (ahima.org), and the American Academy of Professional Coders (aapc.com) websites. Many EMR and practice management software vendors offer useful information as well. In addition, CMS has appointed an ombudsman, William Rogers, MD, to address issues related to ICD-10, who can be reached via e-mail at This email address is being protected from spambots. You need JavaScript enabled to view it.. References 1. AHIMA/e-Health Initiative. 2015 ICD-10 readiness: survey results. http://bok.ahima.org/PdfView?oid=300936. Accessed October 25, 2015. 2. Workgroup for Electronic Data Interchange. WEDI ICD-10 survey results: industry nearing readiness but physician practices lagging behind. Press release. August 3, 2015. www.wedi.org/news/press-releases/2015/08/03/wedi-icd-10-survey-results-in dustry-nearing-readiness-but-physician-practices-lagging-behind. Accessed October 7, 2015. 3. Centers for Medicare & Medicaid Services. Medicare Fee-For-Service (FFS) Claims Processing Guidance for Implementing International Classification of Diseases, 10th Edition (ICD-10). www.cms.gov/Outreach-and-Education/Medicare-Learn ing-Network-MLN/MLNMattersArticles/downloads/MM7492.pdf. Accessed October 26, 2015.

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