Countdown to ICD-10

Follow these 10 steps to avoid the looming cash crunch.

Countdown to ICD-10

Follow these 10 steps to avoid the looming cash crunch.

By Joseph Burns, Contributing Editor

About the Author
Joseph Burns is an independent health care writer in Falmouth, Mass. His Web site is www.

ICD-10-CM, the new system for diagnostic codes, is coming October 1, 2014, and coding experts warn that practices caught unawares may suffer cash flow shortages.

But even if most practices are prepared for the increased complexity the more robust International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) requires, will system vendors and payers be ready as well? This is a question that worries practice administrators who know that being unprepared for ICD-10 could result in claims being rejected and practices running short of cash. This article reviews 10 steps practices can take to prepare for the conversion to ICD-10.

1. Prepare for the worst, hope for the best

Currently, practices submit claims to Medicare and other payers using the outdated ICD-9, which was implemented in 1979. Following the recommendation of the World Health Organization, the US Department of Health and Human Services requires practices to use ICD-10 beginning October 1, 2014. The United States is the next to last industrialized nation to make the switch; only Italy lags behind.

Preparing for the worst, ophthalmology groups are training staff, testing new coding systems, ensuring that vendors are prepared and securing lines of credit to sustain them for three months or more. Despite making these arrangements, not all practices or their vendors will be ready, consultants warn.

“The transition to ICD-10 absolutely could affect revenue if practices don’t prepare now and if physicians don’t get any training,” says Kathryn DeVault, senior director of health information management for the American Health Information Management Association. “We don’t have an estimate of how much it could affect revenue, but the point I would emphasize is that the transition to ICD-10 gives practices an opportunity to train staff on correct coding. Accurate documentation and coding lead to appropriate reimbursement.”

2. Pay attention to CMS time lines

By now, physician groups should have identified the resources they need, drafted a plan to comply with the new coding rules, named a project team, secured a budget, informed staff and contacted vendors and payers, among other preparations, says the Centers for Medicare & Medicaid Services (CMS). In the spring 2014, practices should have started monitoring vendors’ and payers’ efforts to comply and begun training staff and providers. CMS published its ICD-10 time lines and checklists on the Web (“ICD-10 Checklist,” page 29). ( ICD-10ImplementationTimelines.html).

“Yes, in a perfect world, practices should have already begun preparing,” agrees Kevin J. Corcoran, a consultant and trainer to ophthalmology practices and president of Corcoran Consulting Group in San Bernardino, Calif. “But the deadline for implementing ICD-10 has already been postponed once. That leads a lot of people to believe it may be postponed again.” In August 2012, CMS postponed the implementation date a year to October 1, 2014.

“It will not be postponed again, however,” Mr. Corcoran adds. “That’s what I believe and that’s what CMS says. But there should be some loosening of the claims processing requirements so that claims submitted on October 1, 2014, don’t fail catastrophically.

“No one wants accounts receivable to go from 30 days to six months after the change to ICD-10,” he warns. “Therefore, it stands to reason that payers will be lenient toward practices that don’t send in perfect claims in the first few weeks or months.”

3. Kill the superbill

Given that such leniency is uncertain, ophthalmology practices should at least begin educating themselves about the intricacies of ICD-10. “You have to educate providers long before October 2014, and that education involves learning a new way of thinking,” Mr. Corcoran says.

With ICD-9, ophthalmologists have relied on a one-page superbill to chart every patient visit. This one sheet accommodated most if not all of the diagnosis codes that an eye-care provider could use for a patient. But the 13,000 or so ICD-9 codes are only three to five characters in length while the 68,000 ICD-10 codes are three to seven characters long. While 68,000 codes could be daunting, ophthalmology practices will use only a fraction.

“To fit what you need for ICD-10 on a superbill would require a piece of paper the size of a sheet of plywood,” Mr. Corcoran says. “Because that won’t work, practices will need to use electronic aids for coding. This is why ICD-10 is the superbill killer. You need help to quickly and accurately find ICD-10 codes, so ophthalmologists and optometrists will rely on tablets, smart phones or laptops. They can’t use paper,” he says.

Accustomed to sitting behind slit lamps and dictating notes to assistants or taking notes on superbills, ophthalmologists may not appreciate the advantages of ICD-10, such as improved claims accuracy and greater specificity regarding diseases and abnormalities.

Instead, the disadvantages of ICD-10 may seem more obvious to providers who will need to understand the documentation changes so that coding, and ultimately practice billing, clearly reflect every patient’s condition, explains Ms. DeVault. advises. “Billing is a team sport. The chart has to be accurate and complete so the practice can get paid.”

4. Use the coding team

“Rule number one is the biller can’t code what’s not in the chart, and the corollary to that rule is the biller can’t read the doctor’s mind,” Mr. Corcoran advises. “Billing is a team sport. The chart has to be accurate and complete so the practice can get paid.’

For example, ophthalmology practices initially coding ocular trauma may need as much as 30 minutes due to the increased complexity of ICD-10, Mr. Corcoran estimates.

ICD-10 resources for ophthalmologists

Among the organizations that offer information to physicians, payers and vendors implementing ICD-10 are the Centers for Medicare & Medicaid Services. CMS has an extensive list of resources including implementation time lines, conversion guides, and answers to frequently asked questions. Here’s the link:

Other organizations offering resources include:

American Health Information Management Association:

American Medical Association:

Blue Cross Blue Shield Association:

Workgroup for Electronic Data Interchange:

“The added time for ICD-10 compounds every day until the billing department gets the process down to two or three minutes,” he cautions. “That’s why we recommend that physicians and billing staff get educated now.” In Mr. Corcoran’s classes, trainers time each exercise so that attendees can practice coding quickly and accurately. “We provide a variety of ways to code, including ICD-10 books, mapping files, laptops, and cell phone apps. Then it’s a race to see how quickly the students can do it and get it right,” he says.

Practices must also recognize that while physicians ultimately are responsible for providing the necessary information for claims filing, they should not spend time looking up codes, Mr. Corcoran adds. “The ophthalmologist is the most expensive human resource in the practice,” he says. “It would be ideal if the biller doesn’t have to help the physician fill out the chart or return to the physician with questions.”

Northwest Eye Surgeons in Seattle, a practice of 183 employees (including 19 physicians), six offices and four surgery centers, assigned the task to a team with experience. “We have a team that includes staff from information technology, operations, compliance, coding and the controller’s office that has worked on other system transitions such as the conversion from the old electronic data interchange standard 4010 to the new 5010 in January 2012,” says Maureen Tipp, executive director.

Will ICD-10 cause staff to quit in frustration?

Personnel issues may be the most difficult to solve if a practice finds staff quits in frustration in the middle of converting from ICD-9 to ICD-10.

Physicians, support staff and other seasoned professionals may be more inclined to retire and seek jobs in other fields rather than contend with another challenging conversion from one way of operating to another, advises Lisa Asbell, RN, president of coding consulting and training company In recent years, ophthalmology practices have converted from HIPAA 4010 to HIPAA 5010 and many have implemented EHRs. Now, they’re transitioning from ICD-9 to ICD-10, she says.

“We know practice productivity slows way down for six months or so when converting to new systems,” she says. “That slow down is frustrating and often requires to work extra hours, cancel vacations or time off for holidays. Some practices work Saturdays or cancel vacation time.

“That’s why anyone age 50 to 60 or more may already be thinking about retiring. If they don’t want the hassle, they may just give their notice or quit outright,” she says. “Replacing someone in the middle of conversion will be challenging.” If possible, it might be a good idea to plan ahead by having some temporary staff on call if necessary, she advises.

“Another idea is to use a third-party billing company, at least for the first year,” Ms. Asbell says. A third-party biller would be fully responsible for filing claims and so such a move would shift much of the responsibility from the practice to a vendor. If the vendor is fully prepared for ICD-10, the staff could spend the time learning how to file claims using ICD-10, she adds.

5. Learn the new codes

Lisa Asbell, RN, president of trainRX, a coding consulting and training company in St. Petersburg, Fla., recommends ophthalmologists use flashcards to convert ICD-9 codes to ICD-10. “Once ICD-10 is required, you have to move quickly and flashcards do just that: speed up your thinking,” she says.

Practices should be careful not to overwhelm physicians, Ms. DeVault advises. “They don’t need to know the ICD-10 book,” she says. “A specialty physician practice will code a limited section of the book, based on specialty. So, practices should make the training specific to what physicians need to know based on the documentation changes from ICD-9 to ICD-10.”

Adds Mr. Corcoran, “That’s why we train coders and physicians, but training alone is not enough. You have to practice over and over. Just like riding a bike, you learn by doing it.”

6. Verify the EHR vendor is ready

Not all practices will be able to use EHRs for charting. A survey published online in the June issue of Ophthalmology showed that only 32% of responding ophthalmologists had already implemented an EHR, 15% had implemented or were implementing EHRs for some physicians, and 31% had plans to do so within two years.1

For practices without EHR at this point, they may want to consider buying and installing systems this year so that they can train to use ICD-10 codes in time for implementation next fall, Mr. Corcoran suggests.

Even practices with EHR must ask if their EHR vendors will be ready. This question worries Ms. Tipp at Northwest Eye Surgeons. “For ICD-10, our planning and roll out are not transpiring the way we would like,” she says. “We don’t have the software in place, for example, because we’re waiting for an upgrade from our system vendor, so we don’t know if our claims will be accepted. And our clearinghouses have yet to run tests using the new codes. So they don’t know either,”

Ms. Tipp expects the vendor to install an update in the coming weeks that will include both ICD-10 and the requirements to comply with the federal meaningful use rules for EHRs. Once the software is in place, she estimates it will take four months to rewrite and test practice work flows before introducing the new codes to the providers and other staff, which she hopes to do by March 2014.

7. Verify the clearinghouse is ready

“We’re good about sticking to our plans, but I’m concerned that the claims won’t even process once they will hit the clearinghouse and then the insurers,” Ms. Tipp says.

Candace Simerson, president and CEO of Minnesota Eye Consultants, in Minneapolis, has similar concerns. She expects the practice to be ready, but unprepared vendors could cause problems. The practice has 250 employees, including 11 physicians and 12 optometrists working in six locations, three of which include surgery centers.

“We began looking at ICD-10 about a year ago. Then in February we installed an EHR and practice management system. Now, we’re trying to figure out how to introduce ICD-10 and what resources we need to deploy,” she says. She hopes to implement the required software and then start training in the next few months.

8. Train the coding team

Another practice gearing up for training is Ophthalmic Consultants of Boston (OCB), where compliance officer Ellen Adams expects the practice will be ready by next fall. “We’re in good shape,” she says. “We have a team of people in billing and other departments who will become experts in ICD-10 coding and they will train the rest of our practice. We have successfully tested our computer systems and we have scheduled visits with our vendors.”

OCB is not following CMS’s timeline exactly. “They think training should start this year, but we disagree. When we did our EHR roll out, we started training three months prior to go live and were fine. We don’t want to train the staff now and have them forget their lessons,” she says.

The Medical Group Management Association criticized CMS in July after it said it would not do end-to-end testing as it had proposed earlier. Physician practices need such testing to ensure that the transition goes smoothly, MGMA said.

ICD-10 checklist and time line

These are steps the Centers for Medicare and Medicaid Services recommends for implementing ICD-10:

Actions to take immediately:

Review ICD-10 resources from CMS, trade associations, payers, and vendors

Inform your staff/colleagues of upcoming changes (1 month).

Create an ICD-10 project team (1-2 days).

Identify how ICD-10 will affect your practice (1-2 months).

How will ICD-10 affect your people and processes? To find out, ask all staff members how/where they use/see ICD-9.

Include ICD-10 as you plan for projects like meaningful use of electronic health records.

Develop and complete an ICD-10 project plan for your practice (1-2 weeks).

Identify each task, including deadline and who is responsible.

Develop plan for communicating with staff and business partners about ICD-10.

Estimate and secure budget (potential costs include updates to practice management systems, new coding guides and superbills, staff training) (2 months).

Ask payers and vendors — software/systems, clearinghouses, billing services — about ICD-10 readiness (2 months).

Review trading partner agreements.

Ask about systems changes, a timeline, costs, and testing plans.

Ask when they will start testing, how long they will need, and how you and other clients will be involved.

Select/retain vendor(s).

Review changes in documentation requirements and educate staff by looking at frequently used ICD-9 codes and new ICD-10 codes (ongoing).

CMS also recommends the following timeline moving forward:

• October 2013 – January 2014:

Begin testing claims and other transactions using ICD-10 codes with business trading partners such as payers, clearinghouses, and billing services (10 months minimum).

• January 1, 2014 – April 1, 2014:

Review coder and clinician preparation.

Begin detailed ICD-10 coding training (6-9 months).

Work with vendors to complete transition to production-ready ICD-10 systems.

• October 2014 - Complete Transition/Full Compliance:

Complete ICD-10 transition for full compliance.

ICD-9 codes continue to be used for services provided before October 1, 2014.

ICD-10 codes required for services provided on or after October 1, 2014.

Monitor systems and correct errors if needed.

9. Get a line of credit

Practices are taking steps to ensure they avoid cash flow disruptions if claims do not process so smoothly after October 1, 2014. For OCB, Medicare is the primary payer, and Ms. Adams is confident about CMS’ ability to accept ICD-10 claims, adding, “It is highly unlikely we will suffer a complete loss of payment.” To date, OCB’s costs for compliance have been minimal because the practice management system had ICD-10 upgrade costs built in, although Ms. Adams is prepared with a line of credit if needed. Also, she is investigating whether business interruption insurance would cover any lost revenue.

Likewise, Minnesota Eye Consultants and Northwest Eye Surgeons have arranged lines of credit. At the latter, Ms. Tipp is ensuring that the practice has a line of credit to sustain payroll and operations for at least three months. Adds Ms. Simerson at Minnesota Eye Consultants: “We will be ready and I believe our vendors are big enough players that I can’t imagine they won’t be ready. But we always have a line of credit in place for blips in cash flow, and 60 to 90 days worth of cash should be enough.”

Where EHR vendors stand with ICD-10

Compulink is launching its Advantage Version 11 software that will support automatic determination of the correct ICD-10 and CPT codes based on the EHR entered for the patient. Advantage users will also be able to process claims using either ICD-9 or ICD-10 throughout the transition period.

First Insight recently launched its “ICD-10 Resource Center” on the “For Customers” Web site to help MaximEyes customers prepare for the transition to ICD-10. There, the “Preparing for ICD-10 Guide” provides a checklist on how to perform a risk analysis and documentation review in MaximEyes as well as how to use the ICD Code Review Utility.

Ifa EMR is ICD-10 ready, drawing on its experience of using ICD-10 codes in 18 of the 20 countries in which it operates. It’s ICD-9 to ICD-10 Conversion Study has been available in the United States since 2012.

IO PracticeWare says it expects to complete all necessary changes to support ICD-10 by the spring 2014.

ManagementPlus includes ICD-10 along with tools to assist users in choosing the proper ICD-10 code. The company has started providing webinars and educational material to its users along with surveys to assist clients in their preparedness for ICD-10.

MD Intellesys has already integrated ICD-10 coding into its software, and has placed systems in Canada, where ICD-10 codes have been in use for years. The changeover from ICD-9 to ICD-10 should work like “flipping a switch,” according to the company.

MedFlow says it will be ready with ICD-10 by the deadline and will also be incorporating an optional tool into the product that will allow a doctor to cross reference ICD-10 and SNOWMED with ICD-9 codes and terminology.

MedInformatix says it has taken strides to adopt the code set across the breadth of its application modules and has been participating in industry-wide testing programs.

NextGen Healthcare has completed the ICD-10 conversion for its 5.6/8.3 release. The vendor has been certified by ONC for MU2. It provides the ICD-9/ICD-10 Comparison Utility, which helps convert ICD-9 to ICD-10 codes, free to current clients.

10. Prepare to pay more for staff and upgrades

Significant personnel costs may be a concern, however. “We anticipate higher personnel costs because we have to assign trainers for the physician staff and to do that we have to take staff out of their usual roles,” Ms. Adams adds. “We also will staff out for training.”

Laurie K. Brown, administrator for the three-physician practice of Drs. Fine, Hoffman & Sims in Eugene, Ore., also is confident. Being a small practice helps keep the level of complexity lower than it would be at a larger operation, she says.

The practice uses an EHR and practice management systems and has installed all the required upgrades to date, and is preparing for the changes required for ICD-10, she says. The system costs for ICD-10 were included in the software maintenance budget, she adds.

This fall the practice will incorporate an upgrade that will allow the practice to use ICD-10 codes alongside those for ICD-9 so that it can produce claims for one or the other as needed. “We went through the conversion from 4010 to 5010 with this vendor, and knew that if a payer can’t get a claim paid with 5010, we could revert to 4010. We expect to do the same type of work around with ICD-10 and ICD-9,” she explains. “If a payer goes to ICD-10 before the deadline we can send it that way, or if a payer is prepared, we can downgrade to ICD-9.”

Practices seeing patients who have workers’ compensation or auto insurance claims will need to be able to file claims with ICD-9 or ICD-10, because those insurers are exempt from complying with ICD-10, Ms. Asbell says. And being able to code with both ICD-9 and ICD-10 is a good way to provide some protection against cash flow problems. OM


1. Boland MV, Chiang MF, Lim MC, et al. Adoption of electronic health records and preparations for demonstrating meaningful use: An American Academy of Ophthalmology Survey. Ophthalmology. 2013;120:1702-1710.