Rheumatology Practice Management February 2014 Vol 2 No 1 — February 28, 2014

San Diego, CA—The first issue of Rheumatology Practice Management looked at the 4 phases for im­­­plementing the new International Clas­sification of Diseases, Tenth Revision (ICD-10) code sets. At the 2013 meeting of the American College of Rheumatology, Shelly Cronin, CPC, CPMA, CPPM, CANPC, CPC-I, Director of ICD-10 Training at the American Academy of Professional Coders, Salt Lake City, UT, outlined practical strategies that practices can execute as the transition approaches.

Practice managers and physicians must understand that the Centers for Medicare & Medicaid Services will not postpone the implementation of ICD-10 again. The new codes will go into effect October 1, 2014. “If you are not ready, it is not business as usual—you will not get paid,” Ms Cronin warned.

ICD-10 codes will allow for greater specificity in documenting clinical diagnoses, but it will also mean that practices will need to make significant changes. “Practices must prepare now,” she said. “Thinking you’ll be able to prepare for this transition in a couple of months is not rational. It affects too much to leave it to the last minute.”

Practices must first determine the areas in which diagnosis codes affect a practice. “You need to track anywhere an ICD-9 [International Classification of Diseases, Ninth Revision] code is in your practice,” Ms Cronin said, including a review of laboratory request forms, policies, administrative functions, contracts, and documentation.

Because ICD-10 codes have a much greater specificity than ICD-9, the transition will not be as simple as learning a new code for a condition. ICD-10 codes require more notes, including information about anatomical location.

An internal audit of the documentation that is currently used in the practice should be conducted and evaluated to determine if it is sufficient to choose an ICD-10 code. Insufficient information could lead coders to rely on unspecified codes. Using unspecified diagnoses will lead to difficulty in getting paid, and their overuse may trigger audits.

“Look at your documentation carefully,” Ms Cronin said. “See what is required for ICD-10 and determine if your current documentation allows you to choose a specified code. If it doesn’t and you can’t assign a code or can only assign an unspecified code, you need to say why.”

Learning how to avoid unspecified codes now will help with the transition to ICD-10. Ms Cronin suggests doing an audit using 10 charts and coding them according to ICD-10. Start with the most frequently used diagnosis, and review at least 10 records per quarter for each provider.

A Hypothetical Case
An example of insufficient documentation for ICD-10 would be the following hypothetical case. A 77-year-old Hispanic man with rheumatoid polyneuropathy and arthritis of the lower extremities comes in for a follow-up appointment. The patient is feeling much better with the prednisone that he is taking, 10 mg twice daily. The patient had his laboratory work and x-rays done and wants to go over the results with his doctor. He feels better since his last visit.

In this hypothetical case, the anatomic location is not specific enough, Ms Cronin said. The ICD-9 diagnostic codes of 714.0 rheumatoid arthritis and 357.1 polyneuropathy in collagen vascular disease could convert to several ICD-10 codes as follows:

  • M05.561 Rheumatoid polyneuropathy with rheumatoid arthritis of right knee
  • M05.562 Rheumatoid polyneuropathy with rheumatoid arthritis of left knee
  • M05.569 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee
  • M05.551 Rheumatoid polyneuropathy with rheumatoid arthritis of right hip
  • M05.552 Rheumatoid polyneuropathy with rheumatoid arthritis of left hip
  • M05.559 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip
  • M05.571 Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot
  • M05.572 Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot
  • M05.579 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot.

Similarly, for gout, the ICD-9 code 530.81 sarcoid arthropathy is ready for the ICD-10 transition (D86.86), but to allow for proper assignment of the ICD-9 code 274.9 for gout in ICD-10, the documentation needs to include the type of gout, and the location affected.

Medical Contracts
Medical contracts will need to be modified, Ms Cronin said. Practice managers should identify contracts in which reimbursement is tied to particular diagnoses, and contact payers to discuss potential changes to existing contracts. The timing of contract negotiations should be determined, and agreements should be modified as needed. Contract changes should be communicated to the appropriate staff.
Insurance coverage determinations also may change, and practices may need to develop written educational materials to assist patients. This will be a time-consuming process, Ms Cronin warned.

What You Should Do Now
Ms Cronin suggests that in preparation for the switch, practice managers should engage heavily with vendors and determine if hardware and/or software updates are needed. Ask the vendor when it will be tested, “and ask if you can be included in the vendor’s testing,” she said. Start budgeting for changes now.

Devise a training plan. “Every single person will need some level of training,” she said. Coders must brush up on anatomy and physiology to make ICD-10 code assignment easier. “Coders need an in-depth understanding in order to assign codes appropriately,” Ms Cronin said. They will need to work with clinicians, because clinical documentation will be crucial.

Clinicians must be aware that clinical documentation will need to adhere to ICD-10’s higher level of specificity, and that unspecified codes may cause a loss in revenue. The additional documentation that will be necessary may affect productivity, as will the long code descriptors that will take time to read and assign for electronic medical record use.

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