By: Allison J. Bloom, Esq., NEMSMA Board Member At-Large
By now, hopefully you have at least heard about ICD-10. But, what is it, and why is it important to not only know about it, but to also comply with its use?
Since 1979, the U.S. has been following ICD-9 coding protocols, the precursor to ICD-10. ICD-10 includes updated medical terminology and classification of diseases. However, in 1990, ICD-10 – the 10th Revision of the International Classification of Diseases (ICD) – was approved by the World Health Organization (WHO). Although it has taken 15 years, a final compliance date has been set for October 1, 2015, and no further extensions will be issued.
What ICD-10 introduces are codes which A) provide more information per code, B) better support for analytics, care management and quality measurement and C) greater ability to understand risk and severity. In short, it is a more detailed method of coding a patient’s state of health and institutional procedures than previously used in ICD-9.
There are two parts of ICD-10 that are included in the U.S. dictionary. One part is ICD-10-CM, the clinical modification of the WHO standard for diagnoses which is maintained by the National Center for Health Statistics (NCHS) specifically for use in the US, and are used for diagnosis in all healthcare settings. The other part is ICD-10-PCS, which are the inpatient procedures that are developed and maintained by Centers for Medicare and Medicaid Services (CMS), and are used for inpatient procedure coding in hospital settings.
There are a few differences between ICD-9 and ICD-10. ICD-9-CM diagnosis codes contain three to five digits, while ICD-10-CM codes contain three to seven digits. However, ICD-10 diagnosis codes are similar to ICD-9 in certain respects. The whole reason for the transition is that it requires more specific data from clinical documentation than ICD-9 does, and it is more consistent with current medical practice. ICD-10-CM for fractures, for example, captures left vs. right side of body, initial vs. subsequent encounter, routine vs. delayed healing, and non-union vs. malunion. The idea is that it will facilitate patient care coordination across settings while improving public health documentation and quality control. Meanwhile, ICD-9 is running out of capacity and cannot continue to allow the addition of codes that reflect new diagnoses and procedures.
What does this mean to EMS providers? First, all HIPAA-covered organizations must be prepared to use ICD-10 codes by October 1, 2015, or find themselves waiting to receive payments from payers, or worse, having their request for payments be rejected outright. Second, although EMS providers do not technically “diagnose,” your patient care documentation will need to be more detailed in order to show, and justify, why an ambulance was necessary, because going forward “medical necessity” will all be determined “by the numbers.”
Beginning on October 1, 2015, ICD-10 codes must be used for all services provided on or after that date. If you do not handle billing services in-house, check with your third-party billing agency to make certain they will achieve ICD-10 implementation by the compliance date. Even if you use a third-party billing agency, you will still have to take internal steps within your agency to ensure compliance.
For those of you who are already well on your way to ICD-10 compliance, congratulations! For those of you who have not yet started, the clock is ticking and it’s time to get moving!
So what needs to be done by October 1, 2015 to ensure compliance with the new standard?
- Have a plan to achieve ICD-10 implementation within your organization. This requires defining specific tasks, setting specific start and end dates for specific tasks, and determining who is accountable for the completion of each task. Don’t forget to include software and hardware testing, staff training, and development of protocols and policies, in your plan, as well.
- Make sure that senior leadership understands the extent and scope of the changes that must happen to implement the adaptation of ICD-10. The responsibility and decision making authority for managing the transition needs to be clearly understood.
- Establish an all-encompassing, and reasonable budget for the project.
- The involvement of everyone who will be affected by the changes should be expected.
- Hold in-service training for all patient care personnel, as well as any in-house billing and QA/QI staff to refresh documentation best practices and update them (especially your field personnel) on why better and more detailed documentation is important going forward. This is a critical step! Remember: if your staff’s documentation skills are subpar, it may very well mean that billing personnel will not be able to assign the proper ICD-10 code(s), resulting in delayed or rejected payments. This will in turn have a negative effect on operational cash-flow, which will ultimately affect the financial stability and well-being of the entire agency. As a result, refresher training on documentation must be done as soon as possible, and reinforced at frequent intervals.
- Finally, maintain your action plan deadlines to ensure that the October 1, 2015 compliance date is met on time and by a well-prepared agency and staff.
This article only scratches the surface. Be sure to consult with a billing and coding consultant or specialist, as well as an attorney who is versed in ICD-10 compliance, for more information and guidance.
Allison J. Bloom, Esq. is an attorney, consultant, coach and educator who works with EMS and Fire agencies. She is a nationally-recognized author and frequent lecturer on health care reform, legal, compliance, and risk management topics. She can be reached at email@example.com.