ICD-10-CM Q&A: State of the Industry

As part of our February issue on ICD-10, Today’s Wound Clinic recently spoke with Laurie Aloi-Zabel, CHC, CHPC, CPC, director of coding and compliance at MedSafe, Wellesley, MA, about her perceptions on the rate in which the wound care industry has successfully absorbed ICD-10 post-implementation.  

Today’s Wound Clinic (TWC): From what you can ascertain, how well have providers in the outpatient wound clinic setting converted to ICD-10-CM versus their peers?

Laurie Aloi-Zabel (LAZ): “While we do not yet have any published information on this, if providers in any setting have not yet converted to ICD-10, they are not receiving any reimbursement for their services. If we are looking at the providers’ ability to find and select the correct ICD-10 code for the services they are providing, those utilizing an electronic health Record (EHR) have had assistance through the transition to that system. Most EHR vendors were prepared for the transition and have created easy crosswalks and mappings to the ICD-10 codes. In many instances providers have had the ability to create ‘customized’ lists of their most commonly used ICD-9 codes that are then converted to ICD-10. While there may be a learning curve for utilizing these new systems, providers are able to easily search out the codes needed.” 

TWC: Based on coding and billing habits that you’ve observed among providers since the conversion to ICD-10, what would you say have been the most common causes of difficulty/confusion among those in the outpatient wound clinic arena?

LAZ: “Thus far, the area creating the most difficulty is ICD-10 code selection within the EHRs. Each EHR vendor has set up a process to be utilized by the providers in selecting the appropriate code(s) for billing services and for updating of patient problem lists. In turn, providers and their practices have had to make adjustments to their workflows during the transition and providers are also adapting to the new features within their EHRs. Where the difficulty may lie is in instances where there are multiple ICD-10 codes to replace one ICD-9 code. This requires that the provider review each of the options available and then select that code that reflects the diagnosis to the highest level of specificity.”

TWC: Did the delay of ICD-10 implementation help the overall transition for healthcare providers? Why or why not?

LAZ: “From my experience of working hands on with providers in the last few years, I do not think the delay had much of an impact either way. When ICD-10 was delayed from October 2014 to October 2015, it gave providers and their practices another 12 months to update their systems and workflows, as well as to attend training sessions. However, what I found most often was that providers and practices waited in hopes there would be another delay or that ICD-10 would be put off indefinitely. Of course this was not the case. Even once it was confirmed in the spring of 2015 that there would be no delay, many practices and providers still waited until about July to begin training for providers. Many felt that it was best to wait so that information was still fresh in the providers’ minds. Practices also worked with their EHR vendors to have both ICD-9 and ICD-10 available within their systems and viewable by the providers.”

TWC: How would you compare the general state of ICD-10 compliance among healthcare providers with the rate at which providers maintain HIPAA compliancy?

LAZ: “This is an interesting question. The impact of noncompliance with either of these regulations can be costly to a provider/practice. But I believe, to providers, the financial impact of noncompliance with ICD-10 is more easily seen and felt. Since Oct. 1, 2015, any claim with a date of service of 10/1/15 or later that is not submitted with an ICD-10 code will be rejected — meaning the claim will not be paid. For a provider/practice to be providing services to their patients and not receiving reimbursement for those services would be costly to any practice. They would not be able to continue to pay any of their expenses long-term in this scenario. With regards to HIPAA noncompliance, providers/practices have vendor-supplied EHRs that come with assurances that they are HIPAA compliant — meaning they are properly encrypted and the electronic protected health information is protected, or they have secure paper charts within their offices. Although every practice is concerned about their ‘risk’ of a breach, they have taken many steps in an attempt to lower that risk and, in turn, lower their risk of any financial penalty.”

TWC: Assuming that few (if any) providers in the outpatient wound clinic space have made a seamless conversion to ICD-10, how much revenue would you say the average wound clinic could have lost (or be losing) due to inaccuracies related to ICD-10 coding and subsequent billing and payment?

LAZ: “At this time there should not be any loss of revenue. That will change after October 2016, when the grace period is over. Although there was no ‘extension’ in going live with ICD-10, ‘flexibilities’ have been put into place for 12 months. This flexibility allows providers to submit claims that may not provide the most specific ICD-10 code on their claim, yet the claim will not be pended or denied. Carriers will pay these claims. For example, if the provider is treating a patient living with a stage II pressure ulcer of the left elbow, the most specific ICD-10 code would be L89.022 - Pressure ulcer of left elbow, stage II. At this time, if the provider would submit the claim as ‘L89.02, pressure ulcer of left elbow,’ without the specific stage, the claim would not be denied or pended. In October 2016 this claim would be denied or pended for additional information.” 

TWC: Can providers in the outpatient wound clinic industry expect to be audited more regularly due to the challenges that have come with ICD-10? Why or why not?

LAZ: “At this time, I would say ‘no,’ they should not expect to be audited for ICD-10 reasons. There are, of course, many other audits being conducted and they may be audited for other documentation and coding reasons, but not for ICD-10.”

TWC: From what you’ve seen, has the average rate of claims denials increased or decreased for outpatient wound clinics since the switch to ICD-10? Please provide feedback to support either assertion.

LAZ: “Again, at this time, there does not seem to be any impact on claim denials due to the flexibilities that have been put in place.”

TWC: For claims denials, are there any in particular that have been more common with outpatient wound clinics?

LAZ: “At this time, there is no information on this and there should not be any denial. Once the flexibility period has ended, I am sure that there will be denials due to lack of specificity in the ICD-10 codes submitted.”

TWC: How has the switch to ICD-10 impacted providers’ use of EHRs, from what you’ve seen?

LAZ: “I have worked with many providers and many different EHRs through this transition, and the EHR vendors I have worked with have all transitioned to ICD-10. Some have made the navigation through selecting the most specific ICD-10 codes easier than others, but each EHR has given providers a way to select the correct code. As with any change, it will take some time to get used to and develop workflows that make this change easier. Providers have not only had to select the correct ICD-10 code for documentation and coding purposes within their EHRs, they have also had to take the time to update problem lists within their EHRs. Contained within each office note in an EHR is a list of problems that the patient is being treated for and the corresponding ICD-9 code that went along with that problem. Once we converted to ICD-10, all of these problem lists needed to be updated with the appropriate ICD-10 code when the patient was seen. This is a daunting task for providers who may already have a limited amount of time to see patients and keep up with administrative tasks. In a majority of the practices I worked with and provided training to, changes in workflow were required to assist with updating this information. In reviewing chart documentation now, it seems that the providers and their practices have made the necessary adjustments and have a comfort level with their EHRs.”

TWC: Do you think the switch to ICD-10 has positively or negatively impacted the collaboration between physicians and healthcare staff? Please explain.

LAZ: “I believe that, in the end, the impact is neutral. I have been working in the healthcare field for more than 25 years, and from my experience providers and healthcare staff learn who works well with whom. Providers try to surround themselves with a team that assists them in the day-to-day struggles. Many providers and practices utilized their healthcare staff to assist with the updating of the problem lists, converting those from ICD-9 to ICD-10, and this probably put more pressure on the staff doing additional work. But just as the providers begin to adjust to the new system, so does the staff.”

TWC: What do you see as being the overall impact of ICD-10 moving forward related to reimbursements received in outpatient wound clinics?

LAZ: “Once this ‘flexibility’ period is over, claims must be submitted with an ICD-10 code that provides the utmost specificity of the diagnosis. If claims are submitted with nonspecific codes, they will be pended or denied. If a claim is submitted with the most specific code, there will be no impact on reimbursement. While providers and practices have this additional time, they should be conducting audits to ensure the providers are documenting the specificities required to support the ICD-10 code and that they are selecting the correct ICD-10 code. This process will help to ensure their claims are not pended or denied and their reimbursements are not impacted. In the example I gave earlier, if a provider submits a claim in October 2016 with the ICD-10 code L89.02, this claim may be denied or pended for further clarification on the staging of that pressure ulcer. The provider would need to provide a copy of a chart note and a corrected ICD-10 code to support the staging on that pressure ulcer.”

TWC: Regardless of how successfully or unsuccessfully any program managers in any outpatient wound clinics see their experience with ICD-10 conversion, please discuss what anyone can do to improve documentation.

LAZ: “The important thing to remember about documentation as it relates to ICD-10 is that it must support the selected code. When L89.022 is billed, the documentation within the note must state the same information. Within the note there must be documentation by the provider that states he/she is treating a pressure ulcer of the left elbow that is stage II. With ICD-9, we did not have a code with that specificity. There was a code for a pressure ulcer, stage II (707.22), but this code did not specify where exactly the ulcer was located (and left or right). Through my experience, with auditing many chart notes, in most cases, providers were already documenting the specific information necessary. If I were to have audited a chart note in which ICD-9 code 707.22 was billed, the provider would have documented in his/her note that the pressure ulcer was located on the left elbow. There are only a few specialties that I have worked with where there may need to be additional information documented than they previously would have to support the ICD-10 code selected. In these instances, what I stressed to providers during trainings is that when selecting ICD-10 codes in the ‘assessment and plan’ (A&P) of their notes, the verbiage that went along with the code always appeared, and at this point they should review the verbiage to ensure they have documented that specific information within the note. So, when I am in my EHR note and I get to the A&P section, I select ICD-10 code L89.022 and the verbiage ‘pressure ulcer of left elbow, stage II’ appears. This would act as a trigger or reminder to me to ensure that this information was documented within my office note.”

TWC: On a scale of 1-10 (with 10 being the best), how would you rate the healthcare industry’s overall rate of conversion success to ICD-10 and why? How does this compare to those in outpatient wound clinics?

LAZ: “I think I would rate the overall conversion at a ‘7’. It has been my overall experience working with many practices that they have all converted to ICD-10 to the extent that is needed to submit claims and receive reimbursement. I believe that there is still some improvement needed in selecting the ICD-10 code to the highest level of specificity that will be needed and then ensuring that the documentation supports the code selected. As for the comparison to outpatient wound clinics I believe they may be ahead of the game when compared to other specialties in that the specificity required in their documentation to support the code selected is a level that has always been included in their documentation. Wound care providers as a whole document the laterality (left or right) and the stage of the wound. These are the important elements that are now included in the ICD-10 code.”

TWC: Please discuss a few of the biggest infractions you’ve seen regarding providers’ ICD-10 billing and coding practices since conversion without naming any provider or facility specifically.

LAZ: “What I have seen in ICD-10 audits that I have conducted is that, in some instances, the providers are not currently selecting the ICD-10 code to the highest level of specificity available, nor does their documentation include the level of specificity to support the ICD-10 code. I recommend providers and their practices take advantage of the flexibility that is available to them and conduct chart audits specifically for ICD-10. ICD-10 is not going away and all providers and their practices need to ensure they will not face any delays in reimbursement in October 2016.”