The date of the implementation of the International Classification of Diseases, Clinical Modification (ICD-10-CM, henceforth “ICD-10”), has come and gone, and we have survived what is arguably the most significant change for providers in the history of reporting healthcare services. As the dust settles, a postimplementation assessment is recommended. This is a time to acknowledge the success, reward the hard work, and ensure that you did more than merely survive. But, was it really that easy? Did we miss some detail that will haunt us in the future? Did the months or, in some cases, years of preparation finally pay off?
It’s Not Over Yet
The first observation is that the implementation of ICD-10 is not over. The “go-live” date was a single event, but the actual integration of the new code set into the healthcare system will continue for several years. We must accept that payment today does not necessarily mean payment tomorrow. Many insurance companies were very up-front about accepting unspecified codes and/or not implementing all the payment edits on day 1, recognizing the need for a transition into the new code set for both sides.
Continue inching toward providing the most complete clinical history appropriate for the patient’s service date. Revise the templates for the progress notes to leverage the electronic health record without imposing unnecessary clicks on the provider or “note bloat” on the final report. As more data are available to determine the outcome of specific treatment regimens for a distinct combination of conditions, healthcare policy will change. We need the mind-set to continue to adapt to the environment.
Diagnosis codes are the primary tool used to communicate the medical necessity of services rendered. Data analysis begins with codes. First step—the payer will compare the procedure codes to the diagnosis codes. If the clinical makeup of your patient supports a high level of complications, such as multiple malignancies and comorbidities that affect treatment, the review will typically end. If your clinical demographics, however, show a large number of “unspecified codes” and single conditions, the review will move to step 2—requesting medical records. This is counterproductive for your practice and for the payer. If the payer expends the resources to perform a chart audit, it is likely to find a reason for recoupments.
Next, coding is a key communication tool in every practice. The coders need to be comfortable determining the appropriate primary diagnosis code, and when to assign a “personal history of” code or a “surveillance” code, despite its impact on reimbursement. Too many diagnosis codes are assigned based on what “pays,” not on what is appropriately documented in the medical record. ICD-10 has raised many questions about when to report a follow-up code versus an after-care code, and when to note “use additional code.” Before ICD-10 implementation, many practices ran a frequency report to determine the volume of unspecified diagnosis codes, which needs to be repeated and sorted by the provider. Behavior modification is not fully successful overnight, and a tendency to return to shortcuts can occur as time moves on.
Remember that diagnosis codes are updated on an annual basis. The last regular annual updates to the diagnosis code set were made on October 1, 2011; very limited updates were subsequently allowed through 2014. It has been 4 years since routine updates were available for diagnosis codes; we can therefore anticipate many changes to the 2017 edition. New codes will be available for review in July 2016, and they should be promptly examined for any changes that will affect documentation within your practice.
Today's Data Impact Future Payments
Finally, it is important to analyze the relationship between the new code set and the overhaul of physician reimbursement models. The year 2018 may be 2 years away, but the data used for the reimbursement adjustments in 2018 will be gathered in 2016.
Every diagnosis code placed (or not) on an insurance claim form today will impact the reimbursement database used to determine the new reimbursement models. “Quality,” “severity,” and “value-based” are terms that are building the replacement for the Medicare Physician Fee Schedule. One way these terms are measured is in outcomes that are evaluated by a patient’s condition before and after their treatment for conditions that are described by diagnosis codes.
We have only begun to scratch the surface of implementing ICD-10.