I was recently addressing a group of health care providers to overview the impending transition from ICD-9 to ICD-10 from an operational perspective, and to speak about the various processes, staff resources and impact areas affected by the changeover within the physician practice setting. It occurred to me that even though the audience was familiar with ICD-9, they couldn’t quite “wrap their arms around” the anticipated impact of ICD-10. So I kept the overview simplistic, needing to remember that many practices are just getting started down the path to transition, a circuitous path impacting not only clinical and administrative talent directly involved in the day-to-day activities of providing services, but numerous other health care peripheral resources with skill-sets in information technology/information systems (IT/IS), finance and accounting, staff augmentation, etc. I started from the beginning, describing how ICD-9-CM diagnosis codes are currently generated, applied and reported by the typical physician practice, dovetailing that information to what’s anticipated for ICD-10-CM.
ICD-9-CM codes, representing the clinical reason(s) for the office visit, are usually generated by a face-to-face visit with a health care provider. The migration of the patient through the physician practice begins at the check-in desk and ends with his/her departure from the office, although the visit data continues to be handled, assessed, processed and ultimately reported for reimbursement. There’s even an “afterlife” for this data if the initial claim is not reimbursed or is paid at a suboptimal rate due to denial, insufficient or incorrect information, or fee schedule error.
Presently, the basic office systems and internal resources involved in the generation and application of ICD-9-CM diagnosis codes are:
- Practice management IT systems including scheduling modules and electronic medical records [eMR] (or manual systems for non-computerized offices)
- Staff resources, e.g., providers, coders, billers, collections staff, data entry resources, etc.
- Coding/billing IT systems for claims generation (or manual tools for non-computerized offices)
With the advent of ICD-10-CM, it is important to consider that numerous provider offices are not yet computerized. While some might have electronic laboratory ordering and lab results-retrieval capabilities, this doesn’t necessarily mean the office is fully or even partially computerized. And even at this stage of modernization with government initiatives such as the Electronic Health Record Incentive Program (more commonly referred to as the “meaningful use” program because of the criteria required to obtain available federal subsidies), there are multitudes of medical practices not yet transitioned to eMR. On a positive note, many partially computerized practices are leaping into eMR with ‘meaningful use’ assistance and are coalescing the disparate practice systems or e-modules into one, fluid system able to handle practice management functions (scheduling, superbill generation, patient demographics), eMR capabilities and coding/billing functions.
Following ICD-9-CM Code Generation for the Typical Office Visit
Step 1 – Check-in/Registration. A patient presents for an office visit. In preparation for the visit, the practice receptionist generates an encounter form, commonly referred to as a superbill or fee ticket. This is the primary charge capture tool utilized by most physician offices. For practices on eMR, this “document” might remain in an electronic format accessed on monitors or touch screens positioned at various service points within the practice or by using hand-held palm pilots, or it might be simply screen-printed to paper for facile use. Using the practice management system, the superbill is generated from each provider’s daily schedule of patients. When billing or eMR modules are involved in generating the superbill, the data used for this document may be dovetailed to data entry done from the patient’s prior visits, specifically utilizing demographic and clinical information already embedded in the coding/billing system. One way or another, even if hand-completed, a superbill is generated. Currently, the majority of IT systems allow the superbill to be generated with the most recent “set” of ICD-9-CM codes associated with that particular patient. ICD-10-CM codes, when implemented, will likewise be initially accessed at this point.
Step 2 – The Provider (SOAP) Encounter. While in the treatment or exam room, the patient will be asked for subjective (S) information about his/her condition (which might be coded), will be objectively (O) evaluated and provided an overall assessment (A) that when documented will be punctuated by diagnostic statement(s) (which will be coded), and is finally provided a care plan (P) or treatment regimen. During this process, the patient might undergo various testing and studies, e.g., glucometry, hemoccult, EKG, CXR, etc. All of this activity is substantiated by the confirmed diagnoses abstracted from the diagnostic statement(s) or by the documented signs/symptoms gleaned from the chief complaint and subjective data, e.g., the diagnostic statement “Rule out appendicitis” in a patient with abdominal pain and vomiting will be coded using ICD-9-CM codes representing the abdominal pain and emesis only, not the suspected appendicitis. This data is required to substantiate the medical necessity of the patient encounter as well as any laboratory or other tests/studies performed or ordered. The information is subsequently entered into the eMR-superbill or onto the paper superbill. In the ICD-10 milieu, all of this activity will likewise occur. Because ICD-10-CM codes are embedded with more clinical data, the MR documentation must be on par with this coding system and be conducive to its application. Clinical documentation improvement (CDI) steps may need to be undertaken.
Step 3 – Check-Out, Claims Generation and A/R Management. At this point the patient officially signs out of the office, typically accompanied to the check-out point by the superbill. The receptionist reviews the encounter data, adds up the various services and collects the patient’s co-pay, co-insurance and/or deductible amounts. The patient departs and the receptionist, among other activities, performs a quick final scan of the encircled or entered ICD-9-CM codes in/on the superbill. Internal tools such as ICD-9-CM “cheat-sheets” complete with the most frequently used codes may be accessed at this juncture (often, these tools are likewise used in the coding/billing department as well as by collections staff). At this point questions, comments or concerns about superbill entries together with the MRs are routed back to the providers’ assistants, scribes or directly to the providers themselves for clarification. If a paper MR and hardcopy superbill are used, the finalized superbill is then separated from the MR (which may be filed or sent to transcription), and the superbill is then sent to the coding/billing department. If the practice utilizes a professional billing company, the batched superbills from the day’s patients will be sent to the billing company for processing.
In the coding/billing area, assigned personnel perform another check of the superbill to ensure all appropriate ICD-9-CM codes are documented for services performed (i.e., ICD-9-CM code linkage) as well as enter the visit data into the billing system. Often when coders are involved in the visit processing work, a comparison of the service and diagnosis codes is done against the actual MR documentation or eMR screens; just as often however, no MR reference or final check is made against the chart notes at all. The superbill, then, may stand as the sole document utilized as the vehicle for accurate and appropriate coding and billing for the patient encounter.
At this juncture, the ICD-9-CM code “libraries” or IT data files are accessed during input of the encounter data into the billing system by coding/billing personnel or data entry staff. Currently those data files hold the ICD-9-CM code library; soon enough, they will house ICD-10-CM data. Further, there will probably be an estimated 3-6 months of overlap time, during which the practice coders/billers may simultaneously utilize ICD-9-CM and ICD-10-CM data, reporting both sets of information to the various payers with which the practice participates.
Once the patient’s encounter data is entered into the billing system and in many cases after a claims scrubber program has been run, a CMS-1500 claim form will be generated to submit to the patient’s insurer (e.g., Medicare, Medicaid, BCBS, Aetna HMO, etc.). This can be a weekly duty but more than likely, claims generation is performed in busy medical offices several times a week. For practices utilizing third parties for their billing functions, i.e., a claims clearinghouse, the e-files containing the pre-submission billing data are transmitted to the clearinghouses for final formatting and claims scrubbing. The claims are then officially reported to the various payers.
After the patient’s reimbursement is received from the payer together with the remittance advice or explanation of benefits, a review is performed to ensure appropriate reimbursement. For denied, underpaid or suspended claims (e.g., for additional information to substantiate medical necessity), the ICD-9-CM code data may be at issue. To resolve these issues, personnel assigned to accounts receivable (A/R) management and claims follow-up are usually responsible for knowledge of ICD-9-CM coding, experience in evaluating and correcting initial claims errors, and in constructing correspondence with third party payers (including federal/state payers). These personnel will access the patient accounts, verify disparate parts of the patient encounter in question, make claims corrections if necessary, generate updated claims and resubmit the CMS-1500 claim forms or remit necessary additional MR documentation to get the services appropriately paid.
Various clinical and administrative personnel working in the physician practice will be affected by the transition from ICD-9-CM to ICD-10-CM including the providers, necessitating education and training (E&T), updated internal tools as well as access to updated IT systems. In this short article, we have provided a high level overview of these personnel and their internal functions. In operational order they are:
Medical Office Staff
|Receptionists||Check-in; Check-out||–IT systems–Internal tools–ICD-10-CM E&T (functional)|
|Providers||Treatment areas||–IT systems–Internal tools–ICD-10-CM E&T (provider-level)
MR documentation overview, such as CDI
|Ancillary Clinical Staff||–Treatment areas–Laboratory–Nurse’s/Scribe’s Stations
|–IT systems–Internal tools–ICD-10-CM E&T (provider-level or functional)|
|Coding/Billing Staff||Coding/Billing Dept.||–IT systems–Internal tools–ICD-10-CM E&T (in-depth)|
|Coding/Billing Staff||Third Party Interface||IT systems|
|A/R Mgmt. & Collections||Manager; Collections||–IT systems–ICD-10-CM E&T (in-depth)|
|IT/IS Interface||Manager||IT systems|
Touch-points in the physician’s office anticipated to be affected by the transition to ICD-10-CM will vary, but there are sure predictions that can be made: at the very least, the above-listed personnel will need to have knowledge of ICD-10-CM coding to some degree. Some staff will need in-depth knowledge of ICD-10-CM codes, while others will only need operational familiarity with the new code system. Various internal tools and office systems (IT and manual) will require revision and updating in the change from ICD-9-CM to ICD-10-CM. Office efficiency in administrative operations, clinical operations, coding/billing functions and A/R management will likewise be affected until all parties are proficient in ICD-10. IT systems including scheduling and demographic modules, coding/billing systems, third party and clearinghouse interface(s), and practice eMR systems will require new data files and ICD-10 functionality, updated linking (especially if concurrent ICD-9 and ICD-10 systems will be run for a time), staff training on the revised systems, and the ability to generate claims in the 5010 format versus the current 4010 format. All of these activities should be considered when contemplating at which touch-points, and to what degree, ICD-10-CM will operationally impact the physician office.
Michael Calahan, PA, MBA, is an ICD-10-CM/PCS AHIMA-Approved Trainer.