On Oct. 1, the United States became the last industrialized country to transition to the new International Classification of Diseases for medical conditions and procedures.
The transition from International Classification of Diseases (ICD)-9 to ICD-10 has been postponed twice since its initial announcement and has been tested extensively through the CMS coding system. O&P practices, along with all health care facilities, must use ICD-10 codes for all claims with a date of service after Sept. 30, 2015 for all Health Insurance Portability and Accountability Act (HIPAA) entities.
New codes, new look
ICD-10 codes are bringing major change to health care due to the increased volume of codes and the increased specificity of each code. While ICD-9 contained about 13,000 diagnosis codes, ICD-10 has more than 68,000 codes — a 55% increase. Additionally, the four- or five-digit numeric codes in ICD-9 are now four- to seven-digit alpha-numeric codes. The new code structure places the category of the diagnosis in characters one through three; the etiology, anatomic site, severity and other clinical detail in characters four through six; and extension in the seventh character.
All of these changes are in place for one reason, according to Don Hardin, consultant with Don Hardin & Associates: “Specificity. More specificity.”
“It really goes along with having more technology available,” Linda Collins, director of Market Access for Össur, said. “The codes are expanded so they allow for more clarification of diagnosis.”
Guidance from CMS and the American Medical Association supports this statement. According to a joint press release from the two organizations, “The medical codes [the United States] uses for diagnosis and billing have not been updated in more than 35 years and contain outdated, obsolete terms.”
The most obvious example of this increased specificity related to O&P codes is the addition of lateral codes that distinguish between right and left sides of the body. Whereas in the past, a physician would code for osteoarthritis of the lower limb, for example, now the physician would have to choose a code for the right or left knee.
Additionally, the new codes group injuries by anatomical site rather than type of injury. ICD-10 codes also indicate whether an encounter was the initial or subsequent encounter or the sequela (an abnormal condition resulting from a previous disease or injury), which means that a different code will most likely be used for each visit. Other changes include a flexibility for adding new codes and the ability to add up to 12 codes on a claim form, whereas the ICD-9 limit was four codes.
“This is not a punitive action on the part of CMS,” Hardin said. “This is an action for more clarity on the part of CMS, so it is in the best interest of the practitioner to participate and to comply as much as possible.”
Impact on O&P
Lesleigh Sisson, CFom, owner of the Prosthetic Center for Excellence and consultant for O&P Insight, estimated a typical O&P practice probably used between 80 and 100 ICD-9 codes for 75% of their claims, but in the new system, she believes the number of commonly used diagnosis codes could increase to more than 500. Additionally, according to Rebecca J. Hast, chief compliance officer for Hanger and president of Linkia LLC, the paper version of the code manual has increased in size from one book for ICD-9 codes to five books for ICD-10.
“Although O&P practitioners do not diagnose patients, most of the practitioners that I have worked with have diagnosis codes they use most often memorized or they have a ‘cheat’ sheet with the codes listed on it,” Sisson told O&P News. “For decades the O&P profession has used a fairly narrow set of O&P codes [but] with the implementation of ICD-10 that set of codes will be much broader. Confirmation of the diagnosis code with the ordering physician’s office is imperative.”
While sources were in agreement that the brunt of the impact from the changed codes will fall directly on the shoulders of physicians, Hast said O&P facilities should not underestimate the importance of the change for O&P professionals.
“One of the things I have heard in the industry is that it does not really apply much to us, that it is a physician issue,” Hast said. “If you determine that you are just going to slap a diagnosis code on a bill, you may end up getting paid for it. But if you have to appeal that claim, you are not going to stand much of a chance if the diagnosis does not tie to the physician’s clinical notes. So it is an important change … and ultimately there may be more changes that will build on this one, e.g. payer medical policy guidelines.”
Staff at Children’s Healthcare of Atlanta (CHOA) have a unique viewpoint on the transition due to the mixture of physician and other medical staff.
“We tackled the ICD-10 system-wide transition by breaking the organization into 10 different focus areas, each with an assigned leader and identified integration points.,” Andrea Cameron, MPH, manager of Transformation Projects, said. The organization includes a Pediatric Center for Orthotics and Prosthetics.
The organization has appointed physician leaders to help lead the transition and specialty champions to help engage staff. In addition, CHOA hired ICD-10 trainers like Delinda Doss, PMP, CPC, CPC-H. Doss said a situation she often uses as an example when training O&P practitioners is that of a pediatric patient with clubfoot and cerebral palsy. The patient’s documentation should include a code for clubfoot but could also have a secondary code for cerebral palsy.
“If [the practitioner] has a valid diagnosis on the order then they can use that, but we have also trained them in situations of when they should be using additional secondary codes,” Doss said. “So this is an example where an underlying condition like cerebral palsy could also be indicated. So [the practitioner should be] referring back to the documentation and what is actually coded. The two of them have to match, basically.”
Doss emphasized the importance of accurate documentation over knowledge of codes.
“We just tell them it is all about what is being documented first, and then coding comes second,” she said. “If they have good documentation practices and they have this information documented in the medical records, then the coding should report that. It paints a complete picture of what that specific encounter is for.”
Some concerns were difficult to address before seeing how implementation would play out.
Janet Lombardo, CPO, LPO, MBA, manager of Orthotics and Prosthetics and Scoliosis Screening for CHOA, listed a few of the concerns she has heard from fellow practitioners.
“I think there is anticipation of things that feel uncertain,” she said. “For example, do we have confidence that beginning Oct. 1, prescriptions will come to us with the ICD-10 [code] on them? Will we have the proper ICD-10 codes when we submit for authorization from the insurance companies and all of our payers? I think there are also questions about documentation,” she said.
Sisson noted that patients evaluated by a physician before Sept. 30, 2015 may come to their O&P practitioner with an ICD-9 code but the O&P claim for dates of service after on or after Oct. 30, 2015, will need to include an ICD-10 code. This will require outreach to the physician’s office, which could lead to a delay in care for the patient.
Cameron added, “Even from a nonclinical perspective, some of the unknowns for us are, are the payers ready? What sort of things will be getting denied? Those types of things we just do not have any control over.”
Lombardo said the increased specificity of codes could also lead to trouble with insurance companies who only want to cover certain types of injuries.
“For example, for diagnoses that clearly indicate that an injury occurred during a sport,” she said. “We wonder, might that have an impact on orthotic devices that are prescribed for those types of injuries? Sometimes insurance companies are not as supportive of activity-related injuries as we would like to see.”
Another issue O&P practitioners may deal with is receiving patients with codes for different conditions than the ones that are bringing them to the O&P facility. Due to the increased specificity of codes, patient situations are more likely to require multiple codes to cover all the bases.
“If there need to be additional codes … for example, sometimes a physician might apply an ICD-10 code that is a diagnosis that the patient presents with [during the physician visit], however, that might not be the reason they are coming to orthotics and prosthetics,” Lombardo said. “In that case, we would want to circle back to the physician to validate that the diagnosis for which we need to treat the child is in fact part of the physician’s documentation as well; that it is agreed upon.”
Working with physicians
Chief among the concerns expressed about the transition in O&P was the relationship with physicians. Sources agreed O&P practitioners need to work with physicians to ensure a correct diagnosis for patients.
“Our profession would endorse that orthotists and prosthetists need to circle back to the physician and have a dialogue about the ICD-10 code that reflects the diagnosis,” Lombardo said, referring to the American Orthotic & Prosthetic Association (AOPA). “If [the code] is blank altogether, we cannot just fill it in … It is outside of the scope of an orthotist or prosthetist to diagnose.”
Similarly, “the approach we take at Hanger is that we really want to rely on referring physician offices for the correct documentation. … We want to be able to expect to get the information that is patient specific and that corroborates with the physician’s record,” Hast said. “This is a great opportunity to begin to help educate referring physicians, because it is the patient who gets caught in the middle of this. To be able to get the right information at the outset will help the patient get the benefit they need or the device they need [more quickly] than if there is a lot of back and forth.”
While many O&P practitioners know they should work with physicians on these issues, they may worry that questions about diagnoses will clog up the paperwork on both ends and cause additional frustration for physicians trying to learn the new system.
“In almost every practice I work with, practitioners express a concern that building relationships with physicians is difficult,” Sisson acknowledged.
“I think everyone is worried about encumbering physicians and their office staff more than they already are,” Hast agreed. “But the alternative is that the patient ends up not having a covered benefit, and the O&P practitioner ends up unable to adequately defend an appropriate device if an appeal is required. This makes the perfect time to … open that dialogue.”
Focusing on key relationships and keeping it simple were two goals recommended by sources.
“I would suggest you take a look at who your top referrers are and develop a simple communication piece,” Hast said. “These [physicians] are immersed in ICD-10 transitions issues of their own, but if you can develop something that is simple to understand and just hits the high points of what would be helpful to patients who they are requesting O&P services for and just get that in front of them. That could be in the form of visiting the office staff if that is something they do regularly or sending a communication, emailing, any of those things.”
Additionally, Lombardo recommended creating a simple form that can be sent to a physician’s office any time the O&P office needs an updated or modified ICD-10 code.
“It can be a template that is easy for the clinician to fill out, and then can be faxed over to the [physician’s] practice indicating that additional diagnoses be considered. [This is] not so dissimilar to what happens now with some of the Medicare[-related] types of communication.”
The document should make it clear where the fax is coming from and what is expected from the physician.
Lombardo uses a similar template to request a physician’s review and co-signature on a letter of medical necessity, a requirement in Georgia for Medicaid cases in the pediatric setting.
“We have a cover sheet template that is easy for the clinician to use — all of the wording is already done. The physician practice [who] receives that fax knows exactly what we are requesting and knows how to move that document forward.”
Hast noted, “In O&P, you have to be careful that you are not suggesting diagnosis codes because that is not permitted. But what you can do is educate, and that is what we are trying to do now.”
One benefit to the delayed implementation of ICD-10 is the development of multiple resources and tools to help physicians, practitioners and others using the codes. Most sources recommended the use of the AOPA Bridge tool, available to AOPA members on the organization’s website. Users can input existing ICD-9 codes into the tool, which then provides all corresponding ICD-10 codes.
“There is also an ICD-10 mapping manual and that does the same thing,” Lombardo said. “It is just a paper book.”
Sisson also recommended the resources available through CMS at www.roadto10.org.
CHOA also created a toolkit for orthotists and prosthetists to navigate common codes, available at http://www.choa.org/Health-Professionals/Physician-Resources/ICD-10.
“To provide specialty specific assistance, we created toolkits that took the most common ICD-9 codes (for that specialty), mapped them to ICD-10 codes and provided possible documentation tips and best practices,” Cameron said. “The toolkits should be used as a guide to documentation best practices, and are not a substitute for a coding manual.”
Doss emphasized the idea that while tools like crosswalks and maps can help practitioners with their most commonly used codes, they should make sure the code itself takes a backseat to the documentation. She tells those who attend her trainings on ICD-10 that “you can use these tools and references as a guide, but they are not meant to replace good documentation … and good clinical judgment,” she said. — by Amanda Alexander
Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities. CMS. Available at https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf. Accessed Sept. 22, 2015.
CMS and AMA Announce Efforts to Help Providers Get Ready for ICD-10 [press release]. Available at https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf. Accessed Sept. 22, 2015.
CMS completes first week of ICD-10 end-to-end testing. Cardiology Today. Available at http://www.healio.com/cardiology/practice-management/news/online/%7B50c77661-15c0-4481-a5ca-aa650b5dbedc%7D/cms-completes-first-week-of-icd-10-end-to-end-testing. Accessed Sept. 22, 2015.
ICD-10 Bridge. American Orthotic and Prosthetic Association. Available at http://www.aopanet.org/coding-reimbursement/icd-10-bridge/. Accessed Sept. 22, 2015.
Disclosures: Cameron, Collins, Doss, Hardin, Hast, Lombardo and Sisson report no relevant financial disclosures.