ICD-10 phase II: What you should be doing now

You may recall that in our article, “ICD-10: Different codes but identical guidelines," we encouraged all to take a breath in preparing for ICD-10. We are now 6 months past the ICD-10 go-live date, and the most common description we hear from practices relative to the change is that the entire process reminded them of Y2K. The Medicare statistics in the table demonstrate that the initial transition was smoother than most expected.

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As you may recall, we also indicated that eventually payers would begin to tighten the rules and requirements for diagnosis specificity. That time is now. We do not see that these changes are going to be implemented quickly, but we do see changes beginning to impact practices in several states. In response to the changes, we have a few suggestions to tackle phase II of ICD-10 coding.

It’s time to let go of ICD-9. Many practices are still using crosswalks to select codes from ICD-10. If this is a part of your EHR, you will likely have to change a few settings to begin working with ICD-10 directly instead of picking the ICD-9 code and then using the crosswalk to ICD-10. You should still be able to use short cut language or abbreviations within superbills or the EHR system to assist in coding appropriately. Make sure that your codes and altered descriptions are accurate.

Phase out all “unspecified” codes. Although there are appropriate circumstances for unspecified codes, the circumstances are limited and these codes should be avoided where possible. As with any change, it is usually not feasible to stop where you are, go back, and change all your codes at the same time. We would recommend that you first tackle high-volume diagnosis codes for your practice.

You will also need to tackle those codes that are causing denials. Some groups are eliminating rarely used unspecified codes from short lists or superbills. If they are needed in a rare instance, they can be communicated via description or looked up in the broader look-up feature within the EHR.

Next: Check payer bulletins and payment posting

Check payer bulletins and payment posting. While this process should be a part of everyday life for every practice for both CPT and ICD-10 coverage, a stepped-up approach may be required over the next few years. Local Coverage Policies for Medicare and other payers are slowly tightening. A recent example is urinalysis  payment by some carriers. New policies have been introduced that no longer allow “C67.9 Malignant Neoplasm Bladder, site unspecified” as a covered payment option.

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As we all know, Medicare does not always take a clinical approach to changing payment protocols. ICD-10 changes are no different. While we do see that changes are being implemented at a reasonable pace, we also see that some diagnosis codes that should be considered clinically valid for payment are being moved to non-covered. If you see this happen, you should contact your local Urology Carrier Advisory Committee representative to have the policy revised.

Actively monitor all claims and remove diagnoses that are no longer valid. Practice management systems often carry over a diagnosis assigned to a patient to the next visit. This feature has resulted in many patient billings reflecting patients with symptoms that no longer exist. We have seen some patients with gross hematuria that has persisted for many years. This does not help your profile, nor does it help you get paid for your services. Make sure that your office protocol requires that urology diagnoses not checked for that date of service are removed from the bill that is submitted.

Diagnosis codes should tell a story of the patient’s health. Removal of symptom codes as soon as a diagnosis that includes the symptoms is available is one step in making sure the ICD-10 codes that are assigned to a bill demonstrate a plan of care that is addressed to the patient problem and is medically sensible. Break old habits relative to cancer diagnosis and move those patients without active disease to the “history of” category. Move patients who no longer complain of lower urinary tract symptoms to codes reflective of the patient’s condition on that date.

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All of the above suggestions are targeted to the conditions that you actively manage in a urology practice. These are likely your primary diagnosis codes assigned to the services you provide. Again, these changes should be taken on in a manner that allows for implementation in the daily practice setting. These will likely require that the clinician clearly document and communicate the diagnosis and the CPT code for the services provided.

Next: Expand diagnosis capture

Expand diagnosis capture

For your longer term payments under the value-based modifier (VBM), Physician Quality Reporting System, and eventually the new Medicare incentive-based payment system, your diagnosis capture will have to expand. Adding diagnosis(es) of comorbidities will become very important when Medicare starts assigning cost of care through new alternative payment models. The added comorbidities may prevent you from being credited with cost of care that should be assigned to others, preventing you from getting the appropriate payments. These programs affect payment to the practice 2 years after you have submitted the service charge.

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Claims allow up to 12 ICD-10 codes per claim. Your urology-specific codes and those required as the assigned diagnosis for the CPT code provided that day should be managed as above. The remaining problems that your patient may present could extend well beyond 12 diagnoses and if taken to the full degree possible will overwhelm virtually any practice. Keeping up with only a few can overwhelm some. Therefore, we are going to recommend that you implement some simple protocols within the practice to address these requirements.

Consider what is really important to patient care and marry these clinical concerns with what the payers are measuring, particularly Medicare. From a clinical perspective, you should focus on diagnoses that may change your treatment recommendations or pathways. From a payer perspective, the following represents a list of those disease processes that are addressed broadly by PQRS and likely to affect your VBM payment:

• chronic kidney disease

• hypertension

• heart disease/failure

• COPD

• osteoporosis

• rheumatoid arthritis

• cancer

• BMI-obesity

• diabetes.

Some of these conditions have multiple ICD-10 codes and, of course, collecting information on all of these issues will potentially take time away from urology patient care.

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We are seeing many different approaches to this issue, from ignoring the problem and hoping it will not affect the practice to increased patient physician interview and documentation for every visit. Here, we will outline a couple of the most practical approaches that we have seen to date.

Next: Integration with PCP records

Integration with PCP records

Perhaps the easiest approach we have seen requires some integration with primary care provider records. While this does have some potential for failure based on issues out of your control, it is likely that payer monitoring will be partially based on the diagnosis submitted by other providers; therefore, your baseline coverage should be accurate from the payer perspective.

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The second approach we have identified within urology practices will require that your patient intake form be adjusted to collect information in the Review of Systems and Past Medical History, requiring the patient to provide you with active diseases from the categories listed above. Asking the right question is key in this regard. For example, does the patient questionnaire ask, “Do you have diabetes?” and stop, or do you add questions attempting to further define the type and severity of the problem? We would recommend that you keep it simple and higher level, stopping at the first question unless you need more information to determine appropriate care paths in the beginning and increasing your accuracy as you improve your processes.

Once the patient intake form is altered to reflect these needs, the second step relies on implementing a protocol for data entry into the EHR by an assistant that requires those diseases that are active to be added to the problem list communicated to billing. This may require some training for those working in this capacity to prioritize diagnosis and will require review by the physician or non-physician provider when adding urology-specific and treatment codes to make sure that you are submitting accurate and appropriate data.

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Once these processes are implemented, we have found that practices can integrate a reasonable patient flow and minimize the impact to administrative time.

Next: Medicolegal responsibility

Medicolegal responsibility

Of course, any time we bring these issues to practices we work with on implementation, the question of medicolegal responsibility comes up. Typically, we have seen that ignorance of a condition is not a viable defense. Simply not recording these issues is not an option that will protect you. You will have to add to the protocol at least a clear recommendation that the patient seek diagnosis and/or treatment as necessary for the disease or symptoms, or document that he or she is being treated by another physician. Again, first-line advice and documentation of this issue can be moved to the patient intake personnel and non-physician providers, with review by the provider with minimal extra effort.

ICD-10 phase II will require some additional changes in your practice. With time and some upfront effort, you will be able to handle these changes without having to memorize the ICD-10 codebook. But you need to start.

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The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

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