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Avoid payment delays by ramping up for ICD-10

September 2, 2014
by Joanne Sammer
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ICD-10 begins October 2015

Some providers are hedging on whether the transition from ICD-9 to ICD-10 will actually occur on October 1, 2015. After all, the deadline has already been postponed twice.

The federal government has stated the reason for the delay to 2015 was that small providers were not ready. Unfortunately, the 12 months of extra prep time might not do much to make providers any more prepared for the change.

“Providers think if it has already been delayed once, it could be delayed again,” says Jacqueline J. Stack, director of ICD-10 training and education for the American Academy of Professional Coders (AAPC). “If you give providers five more years, will they be any more ready than they are today? And the answer is: probably not.”

Change is difficult under any circumstances. However, the start-and-stop nature of ICD-10 preparation has not helped matters.

“The constantly changing deadline for ICD-10 implementation has largely caused a loss in momentum,” says Mary Givens, product manager of healthcare reform at Qualifacts Systems, Inc. “With healthcare reform creating so many other priorities for providers, including integrated care, outcomes measurement, and meaningful use, most organizations decided to focus their time and resources on other projects with harder deadlines.”

Moreover, many behavioral healthcare organizations have come to see ICD-10 implementation as a moving target. For many chronically underfunded behavioral healthcare organizations, the lack of a firm deadline has forced them to focus attention and resources on more pressing matters. While it is still possible that ICD-10 implementation will be postponed yet again before next year, behavioral healthcare organizations cannot reasonably assume that they can put off implementation indefinitely. Instead, the best approach is to act as if implementation will occur as planned.

There are compelling reasons to be ready for ICD-10 implementation by next fall. For example, consider the financial consequences of not being prepared, which translates into delays in receiving reimbursement for claims that do not include appropriate ICD-10 codes or paid claims that are flagged during payer audits. It could wreak havoc on cash flow. In short, if behavioral healthcare organizations have not begun seriously preparing for the changeover to ICD-10 coding, they need to begin doing so now because the process isn’t a simple switch. Rather, many providers will spend six months or more from preparation to adoption.

Changing culture

The International Classification of Diseases, 10th Revision (ICD-10) is the system developed by the World Health Organization (WHO) that all healthcare providers must use for coding diagnoses, symptoms, and procedures. After two postponements, the Centers for Medicare and Medicaid Services (CMS) has announced that the changeover to ICD-10 will occur starting on October 1, 2015, for the United States.

One of the key difference between ICD-9 and ICD-10 is the number of codes used. While some diagnoses will have fewer codes under ICD-10, most will have more. Another difference is the greater specificity required by ICD-10 in coding and documentation.

In fact, if there is any guiding principle in using ICD-10, it is the need to be as specific as possible in diagnoses and documentation.

For example, “bipolar disorder uses a typical diagnostic of bipolar disorder or bipolar unspecified,” says Stack. “ICD-10 requires more specific coding, such as hypomanic or depression with bipolar.”

Similarly, when diagnosing depression, ICD-10 requires codes based on severity, whether in remission (full or partial), any psychotic features and so on. The documentation accompanying the code must be similarly specific and, most important, match the code provided. Therefore, providers must not only choose the appropriate code but understand what documentation is required to support that code.

“People may hear this and assume that the system will make more work,” says Stack. “However, it is just adding a few more words. If we know depression is mild/moderate/severe, now we can pull a more specific code.”

For behavioral healthcare organizations, the changeover to ICD-10 is also likely to require a shift in mindset among providers. Technology is an asset in the coding process, but it merely provides a structure. The clinician’s experience and education is needed to marry the diagnosis with the right code. In essence, they must think in terms of ICD-10 to optimize their reimbursement.

“Most mental health practitioners do not understand that they need to use the ICD-10 moving forward,” says Lisette Wright, executive director of Behavioral Healthcare Solutions. “They are beholden to their DSM and they don't think that ICD-10 applies to them. They don’t realize that in some regards they have been using ICD-9 codes that have aligned with the Diagnostic and Statistical Manual (DSM) IV-TR codes.”

The confusion arises because some payers use both: DSM for clinical documentation for preauthorization and utilization review, and ICD for billing.

Wright notes that the issue has deep roots in the profession. For example, graduate schools in the fields of mental health and substance abuse tend to teach the DSM and not ICD coding.

“The number one priority is to educate your staff on the relationship between the ICD and the DSM,” she says. “But before you can do that, you have to understand it yourself.”

This is not to say that the DSM will be obsolete.

“Although behavioral healthcare organizations will face new terms that are not included in ICD-9, ICD-10 is designed to work side by side with DSM-5, which should help with the transition,” says Melanie Endicott, senior director of coding and CDI products development at the American Health Information Management Association (AHIMA).