By Oct. 1, 2014, insurance claims should all be displaying the International Classification of Diseases, Tenth Revision (ICD-10), replacing the 30-year old ICD-9 coding system all neurologists currently use to ascribe diagnoses to patients. The transition is taking place, experts say, because the prior numerical groupings produced limited data about patients' medical conditions and the system restricted the number of new codes that could be created. ICD-10 will expand the number of diagnostic codes from 13,000 or so to around 68,000.
Figure. THE CONVERSI...Image Tools
“Part of the reason that there are so many more codes is that laterality is added, along with more specific anatomical locations, more specific pathophysiology, and new designations for type and severity of encounters,” explained former Medical Economics and Management Committee (MEM) Chair Laura B. Powers, MD, who has been leading the neurology ICD-10 effort for the past 15 years.
While doctors may question the need for such detailed descriptors like the codes related to injuries from macaws, parrots, geese, ducks, turkeys, and chickens, (nine for each bird!), insurance companies will no longer have to speculate about how a patient got hurt when they see ICD-9 code 919.8 (other and unspecified superficial injury of other, multiple, and unspecified sites, without mention of infection). In addition to the multiplicity of codes for animal-related conditions — mice, rats, squirrels, cows, pigs, raccoons, alligators, crocodiles, snakes, turtles, lizards, dolphins, sea lions, sharks, and even orcas — there are codes for myriad places of occurrence, including the barn (Y92.71), the chicken coop (Y92.72), the farm field (Y92.73), the orchard (Y92.74), and nine locations inside and around a mobile home.
There is a virtual cornucopia of codes for accident scenes, including a variety that apply to recreational and sports activities, public buildings (no need to fret, the opera house is covered), streets and highways, and every conceivable room in any type of home, in case, say, you need to code for wounds sustained in the garage of a boarding house one day (Y92.044).
Indeed, the range of oddities has attracted some buzz spawning competitions like that in Healthcare IT News — see the article, “Ten Most Outlandish Kinds of ICD-10 Codes.” Examples included code V0001XD — pedestrian on foot injured in collision with roller-skater, subsequent encounter; V91.07XA — burn due to water-skis on fire, initial encounter; Y92146 — swimming pool of prison as the place of occurrence of the external cause (prompting the question “Prisons have swimming pools?”); T7501XD — shock due to being struck by lightning, subsequent encounter; and my personal favorite: V9542XA — forced landing of spacecraft injuring occupant, initial encounter. Really, we need a code for astronauts? Should someone alert NASA?
WHAT WILL IT COST?
While the level of specificity may excite actuaries, statisticians, and a few health insurers, physicians are likely to be dismayed to discover that implementation is not only onerous, but expensive. Adoption of ICD-10 is estimated to cost around $83,000 for a small practice and as much as $2.7 million for a large group practice, according to a June 5 story in the American Medical Association e-newsletter, AMA Wire. In addition to the direct costs of software upgrades, training, and conversion; disruptions in payer processing may cause delays that will cripple neurology practices that already run on thin margins.
Medical Group Management Association research released this June revealed ominous findings regarding practice readiness for ICD-10. Responses from more than 1,200 medical groups, which included more than 55,000 physicians, indicated that more than 52 percent had not yet heard from their practice management system vendors as to when changes would be available to the practice. Only 5.9 percent of respondents reported that internal software testing had begun or was completed with their practice management software vendor and only 4.7 percent with their EHR vendor. Just 11.9 percent of respondents reported that external testing with their clearinghouse had started or was complete. Almost 60 percent reported that they had not even heard from their clearinghouse regarding a testing date. Only 8.6 percent had started or had completed testing with their major health plans, with 70 percent stating that they had not heard from their major health plans.
HOW TO GET READY
So, what should you do to get ready? To avoid a panic attack (soon to be referred to as F41.0), David A. Evans, chair of the Practice Management and Technology Subcommittee and chief operating officer of Texas Neurology, advised: “Neurologists need to have an action plan in place including key milestones with associated timelines — including their electronic health record/practice management/clearinghouse vendor readiness (both internal/external systems testing), staff training, billing processes, and ‘crosswalk’ development (mapping designed to provide equivalents between ICD-9 and ICD-10).”
In many cases, one ICD-9 code will translate to several ICD-10 codes due to the greater specificity of the new system. In general, there will be crosswalks available through various resources, some which may be purchased for a fee, said Evans, who anticipates that the expanded options will call for a provider, or a coder to have expanded clinical knowledge in order to accurately select an ICD-10 code based solely on a crosswalk. “I would suggest that neurology practices perform a preliminary review of their top codes to develop their own crosswalks, which may help them in determining if there are internal skill set and/or system gaps and whether an external resource should be identified,” he said. Any software programs purchased for the purposes of performing crosswalks should be vetted by a nationally recognized coding society such as the American Academy of Professional Coders or their respective specialty or sub-specialty society, he cautioned.
Evans also suggested that practices review their payers' medical coverage policies as they are updated with ICD-10 codes to ensure that members of their staff are aware of coverage limitations. Claims with incorrect ICD-10 codes may not be paid. “Review your managed care agreements and their bulletins which relate to ICD-10 transition, dates, delays, etc.,” he added. Ideally, practices should consider creating an implementation team — including a physician, coder, biller, administrator, and IT personnel — to oversee implementation, he advised.
‘EMBRACE THE CHANGE’
Jeffrey R. Buchhalter, MD, PhD, director of the Comprehensive Children's Epilepsy Centre at Alberta Children's Hospital, and a member of the Coding Subcommittee who has been engaged in ICD-10 education, added: “Neurologists should embrace the change to ICD-10 as more specific coding allows patients to have much more accurate diagnoses and has profound implications for allocation of public health resources and clinical research.”
The greater accuracy of the ICD-10 codes provides a better description of the complexity of neurological patients and therefore our value as care providers, explained Dr. Buchhalter, who had previously practiced pediatric neurology in the United States for 25 years prior to his position in Canada. “If you work in a very large, hospital-based, clinic-based practice, it will be handled on the administrative level, but if you are responsible for the management of office flow, it will require a significant investment of time and effort,” he forewarned.
Recognizing that this is yet another change imposed upon us during a period when we are inundated by new regulations, former MEM Chair Laura B. Powers, MD, added, “Don't get mad, get ready.”
Dr. Avitzur, a neurologist in private practice in Tarrytown, NY, holds academic appointments at Yale University School of Medicine and New York Medical College. She is an associate editor of Neurology Today and chair of the AAN Medical Economics and Management Committee.
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