Medical Billing Software Update: Preparing a Blueprint for ICD-10/5010 Success

Nancy Maguire, ACS, PCS, FCS, HCS-D, CRT April 26th, 2011

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Develop your blueprint for success with the ICD-10/5010 transition in medical billing and medical billing software

Blueprint: design, diagram, draft, framework, layout, master plan, outline, pattern, plan, scheme. 

A medical practice or facility cannot just bury their heads in the sand and hope ICD-10 will go away; that will not happen.  When drafting a blueprint you have to know the purpose of the plan.  In this case, the final goal is compliance and readiness to assign ICD-10 codes on October 1, 2013.  The strategic plan will get you to this deadline.  This is a complex undertaking because there are deadlines that must be satisfied before the new codes can be transmitted to trading partners, clearinghouses, payers, etc.  Your “master plan” must weather budget concerns, resistance to change, and different personalities and opinions.

Transaction standard 5010 is a major upgrade

Similar to a blueprint for a house, the foundation must be strong and hold up under unexpected problems during the process. Remember Murphy’s Law: “If anything can go wrong, it will.”  ICD-10 codes cannot be filed electronically using 4010 transaction set.  Transaction standard 5010 is a major upgrade which will enable electronic filing using alphanumeric ICD-10 codes.  The final deadline for a successful transition to Version 5010 transaction set upgrade is only seven months away.  By December 31, 2011, providers should have completed internal testing and testing with external partners and payers.  While it’s true that full implementation of the actual codes is not until 2013, there is a final deadline for anyone that uses or submits claims electronically to show compliance to 5010 upgrade by the end of this year. Transaction standard 5010 is more than a major update, it is an organizational change.

If a practice has not started internal and external testing to ensure electronic claims are filed and received correctly using standard 5010, they are way behind schedule.  It will be difficult playing catch-up and will require focus and determination to get the job done by January 1, 2012. The fact is, providers should have started the process long ago. Every entity that sends or receives electronic transactions such as claims submissions, eligibility inquiries, claims acknowledgments and reports must upgrade to the new standards.

Providers, payers, trading partners and all involved should communicate about their transition preparations.  Not only is it important for you to make sure that you can count on them during the transition, but they are a great resource to provide details about what you need to do to comply with Version 5010 standards and ICD-10.  Follow the progress on the CMS (Centers for Medicare and Medicaid Services) web site.  Education is essential because this will foster clearer understanding of HIPAA 4010 transactions and the 5010 upgrade. Don’t assume that X12 (EDI) is just for IT staff or computer geniuses. The transition also includes business and regulatory processes, clinical data needs, and technical and front end process changes.  Add the human component to this mix and it makes for an interesting and challenging transition.

Communication is critical

Communication is especially critical to a successful transition. ICD-10 will require the involvement of physicians and non-clinical staff. Physician documentation must become more specific and granular to accommodate ICD-10 coding. If possible, enlist the help of a physician “champion” to assist in physician communication and education.  Documentation under ICD-10 detail requirements will increase for each patient seen and treated on and after October 1, 2013.  The”“i’s” must be dotted and the “t’s” crossed; the devil is in the details with the new coding classification.

The team leader should identify all organizational components that will be impacted by the conversion and then gauge the readiness to address transition for each component.  Organize your thoughts and planning, outline preparation steps and tasks, create a work breakdown structure and draft competent team members. Include team members when discussing key questions involving the plan:

  • How will success be measured?
  • What resources do you have?
  • What resources are needed? 

When communicating with physicians and staff, make sure your message is clear and understood.  Mutual respect is essential and egos are unacceptable.

Assemble a well-rounded transition team

It is imperative to put together a well-rounded transition team made up of representatives from management, coding, clinical, finance and information technology. The team should have a working knowledge of ICD-10 and how it differs from ICD-9, as well as the expected short- and long-term financial, personnel, and time impact of the transition. Failure to successfully convert will result in failed claims and halted cash flow. All Medicare billing for discharges on or after Oct. 1, 2013 will be ICD-10- based.  Sept. 30, 2013 encounters and discharges will be ICD-9 based.  There are bound to be reimbursement delays when these codes are first transmitted; the budget should allow for this delay.

Key steps to follow include:

  • Develop a plan of action and keep the focus on the compliance timelines.
  • Create deadlines with responsibilities and accountability. 
  • Link the right person to each task and do not lose sight of the goal.
  • Determine the critical path necessary but allow some slack for unforeseen events (remember Murphy). 

This process will probably take longer than you think and this must be considered.

Establish a budget for accomplishing the transition. This requires estimating the financial impact of the expected loss of productivity and disruptions in cash flow. This is particularly important given the costs associated with completing the transition.  This cost will depend on practice size and technology upgrades needed, as well as training and resource costs.

Upon completion of the planning phase, organizations should have a strategic approach blueprint that brings together all pieces of the assessment and integrates them into an outline of who and what is impacted in the individual practice or facility.  Each area of impact requires a process and action plan to achieve success.

Assess staff training needs

Staff training needs must be assessed: Who, When, How?  There are many training opportunities and materials available through professional associations, online courses, webinars, CMS web site, and onsite training by outside consultants. Because of the higher level of specificity required under ICD-10, it is important to assess clinical documentation and this can be accomplished by evaluating random samples of medical records to identify areas where documentation is lacking.  

  • Assess the diagnoses frequently used in the practice that will require a higher level of detail. 
  • Identify areas of documentation weakness and address the deficiencies prior to the transition deadline. The documentation issues should be a focus in physician and staff education.

ICD-10 is not a simple code-set replacement

The transition to ICD-10 is a BIG DEAL and not just a simple code-set replacement. Because ICD-10 is more granular and detailed, even experienced professional coders and billing personnel will require focused training to become proficient with the new diagnostic codes and documentation requirements. If electronic documentation and coding systems are not used, physicians and nurses will need training on capturing the appropriate level of information to support coding under ICD-10.  The IT staff will also need to be educated on the difference between ICD-9 and ICD-10 to determine whether current systems and interfaces need to be built or modified in any way.

Everyone must be on the same page and a Mission statement would help this goal. Describe what you’d like to accomplish and solicit ideas towards that end. In this way everyone has a voice and clear direction. This change will occur and everyone must focus on the practice blueprint and adhere to set schedules.

To learn more about how to prepare for the transition, view a recorded webinar on ICD-10/5010 featuring Nancy Maguire now.

Nancy Maguire, ACS, PCS, FCS, HCS-D, CRT, author of The Nancy Maguire GPS to ICD-10-CM Planning and Implementation Guide, is a nationally-renowned procedural and diagnostic coding instructor, bootcamp trainer, and workshop leader. She has spent more than 30 years as a hands-on coder and has authored countless coding articles and presentations. In her expansive career, she has transitioned from nursing, to coding, to practice management, auditing and consulting. Nancy served as Director of Coding and Reimbursement at UTMB in Galveston Texas for four years. She served the first two terms as president of AAPC in the early 1990s.

Note: Several Kareo customers have asked about Kareo’s preparations for 5010. We are in process with the transition and fully expect to be ready by the deadline. In addition, we have confirmed with both of our clearinghouses that they are able to translate 4010 to 5010, so our customers can expect to be covered for this change.

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