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Coding system coming in '14 will change parts of health system

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Imagine that starting Oct. 1, 2014, every publishing company in the United States had to use Swahili for all official business.

Swap in health care for publishing, International Classification of Diseases Tenth Revision for Swahili, and medical billing and coding for official business — and it's true.

"It will be huge," said Lisa Hershey, program director of the medical billing and coding programs at YTI Career Institute's Lancaster campus. "The change from ICD-9 to ICD-10 is the largest change in the billing and coding industry in the last 30 years."

The transition will touch everything from physician documentation to accounting to billing to IT. People preparing for ICD-10 say that, in some ways, it will be as big a transition for the health care community as the switch to electronic health records has been.

ICD-10 isn't part of the Patient Protection and Affordable Care Act, but the transition will happen concurrently with many major provisions of PPACA.

Dr. James Madara, CEO of the American Medical Association, repeatedly stressed that in a May letter asking the Centers for Medicare and Medicaid Services to push back the deadline and reconsider the decision. CMS announced in August that the 2014 deadline was final.

"This is a massive administrative and financial undertaking for physicians, requiring education, software, coder training and testing with payers," Madara wrote. He cited "considerable concern" about implementing ICD-10 at the same time as electronic health record systems and said physicians are already overwhelmed with simultaneous implementation of multiple health IT programs.

Furthermore, he wrote, "Depending on the size of a medical practice, the total cost of implementing ICD-10 ranges from $83,290 to more than $2.7 million."


However, according to Karen Tinney, how much training and preparation will be needed for the transition can vary widely depending on role. Tinney is director of health information services at Ephrata Community Hospital, where a committee has been preparing for ICD-10 for more than a year.

On the inpatient side, Tinney said, physicians fill in charts, which doesn't require knowledge of specific codes — that falls to the coding department, which gets the charts after patients are discharged. However, ICD-10 requires a lot more specificity: Where ICD-9 had only one applicable code, ICD-10 might have 10 options. Consequently, doctors will have to document in much more detail than they do now.

Outside hospitals, Tinney said, "It's a little scarier," because physicians have to select diagnosis codes to order tests. However, the cases family doctors and specialists see tend to fall within certain parts of the code book, so they shouldn't need to become intimately familiar with the whole thing — just the sections they use regularly.

"The coders themselves will need intense training," Tinney said.

They're going through refresher anatomy and physiology classes now, so they're up to speed for all that specificity. Then, early in 2014, Tinney envisions weekly classes in ICD-10, complete with homework. The hospital already sent someone to be certified as an ICD-10 trainer.

Other people who aren't coders must learn the system, Tinney said, such as those who work in medical records, patient billing and care, and contract management.

The nature of the transition means it can't be gradual; although practice programs are available, no real coding can be done in ICD-10 until Oct. 1. From then on, nothing can be done in ICD-9, Tinney said — except that auto and workers' compensation systems aren't switching to ICD-10, so coders can't just forget the ICD-9 codes.

America is coming late to ICD-10: It was developed in the 1970s, and most countries adopted it years ago. America is also different from many other countries in that codes drive reimbursement, Tinney said, which means that the hospital's contracts with various payers have to be updated, and the hospital is trying to figure out how that will affect its reimbursement.


Another major facet of the transition is making sure all programs that providers and payers use can handle the new codes.

Stacie Watson, who heads Aetna's ICD-10 program, said the Connecticut-based insurer is preparing for the transition, "including remediation of our impacted systems and vendor tools," and has committed "to begin testing in 2013 with those entities that are also ready."

"We strongly encourage providers and vendors to continue working toward compliance," Watson said, referencing Aetna's webpage for providers that notes the importance of contacting billing and software vendors to understand their plans for conversion and testing.

The Pennsylvania Medical Society's communication with members about ICD-10 has included both technology and training issues, according to Lara Brooks, associate director of practice economics and payer relations.

Brooks said she believes getting started on the transition process early will be key to navigating ICD-10 successfully. But, she said, because there are so many other changes coming at physicians right now, ICD-10 hasn't really been first and foremost on their minds.

Growing field

The medical billing and coding program at YTI's Lancaster campus lasts 12 months, Hershey said, and this fall it also began offering a 21-month health information technology program. Large groups of students started ICD-10-related programs this year, and there are about 75 students in all.

Because ICD-9 will still be used until Oct. 1, 2014, Hershey said, YTI is still teaching it to students. However, she said, students are also being introduced to ICD-10, with emphasis on guidelines that are similar even though the codes are different. Eventually the focus will shift to ICD-10.

As for offering classes for coders already proficient in ICD-9 who need to learn ICD-10, Hershey said, "It is something we're looking to offer in the future."

The U.S. Bureau of Labor Statistics predicts a 21 percent growth in the number of medical record and health information technician jobs from 2010 to 2020. Factors in that growth include the aging population and increased use of electronic records, the bureau said.

Plus, Hershey said, with the transition, "There's a definite expected decrease in productivity for coders."

Tinney said staffing is a concern, because it's not yet clear how much or how long productivity will decrease. She expects the hospital will need additional coders at least for a while, she said, and might get temporary help from one of the specialty transition firms that have sprung up.

But, Tinney said, those firms aren't all good news for hospitals, because they're in the market for experienced coders and may be able to hire them away from hospitals.

"One of the other issues is that a lot of coders who are older don't want to go through ICD-10 training," Hershey said. "They're going to retire early. There's going to be a shortage of coders."

About ICD-10

Stands for: International Classification of Diseases, Tenth Revision

Codes available: Roughly 68,000. ICD-9 has just 13,000.

Deadline for all services and discharges to use ICD-10: Oct. 1, 2014

Penalty for not complying by deadline: Transactions will be rejected as noncompliant and will not be processed

Quick fact: Hospitals have used ICD-10 to report inpatient cause of death since 1999.

What’s used where

Diagnosis and symptoms: Will switch to ICD-10-CM (Clinical Modification)

Hospital inpatient procedures: Will switch to ICD-10-PCS (Procedure Coding System)

Outpatient and office services and procedures: Will keep CPT (Current Procedural Terminology) and HCPCS (Healthcare Common Procedure Coding System)

Source: American Medical Association

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