Speaking at the Medical Group Management Association’s (MGMA’s) annual conference in San Diego, US, last October, Robert Tennant, senior policy adviser for the association’s government affairs department, was seemingly not in the mood to mince words when the theme of his address shifted onto the new ICD-10 coding system.
"ICD-10 is here, so we have to deal with it," he said, before adding, "this is probably the biggest challenge we in healthcare have faced since [President Lyndon] Johnson signed into law Medicare."
It’s not been ascertained what kind of emotions Tennant’s claim stirred among delegates, but it’s fair to assume that, at the mere mention of ICD-10 – or, to give it its full name, International Classification of Diseases, version ten – there would have been a few raised hackles.
Currently, medical insurers are billed using the ICD-9 coding system, which comprises 14,000 codes. Under ICD-10, to which healthcare practices are obliged to switch in October 2014, this figure will expand to 69,000.
Henceforth, providers will be required to be much more specific when it comes to their diagnoses and documentation, with the hope that this will lead to better and more targeted treatment of illnesses.
However, there has been much bellyaching from hospitals, doctors and other providers over associated issues such as software expenses, administrative burdens and payment reductions. According to studies conducted by the MGMA, it would cost a ten-doctor practice in the region of $285,000 to upgrade to ICD-10.
Radiology departments aren’t exempt from such concerns, although, admittedly, their expenditure is likely to be considerably less.
According to Geraldine McGinty, chair of the American College of Radiology’s (ACR’s) Commission on Economics, the diagnostic imaging community is still very much in the process of getting to grips with the transition to ICD-10.
"It’s a very significant operational challenge," she says. "We’ve already spent a lot of time trying to help our members understand what is coming and get acclimatised and adjusted. This means providing them with the resources and expertise that they really need."
Changes in documentation
At first sight, it’s easy to misconstrue the new coding changes as belonging to the fiercely debated Affordable Care Act. This would be erroneous: ICD-10 was drawn up under the previous Bush administration.
However, it would seem that the roll-out of ‘Obamacare’, which continues to see President Obama at loggerheads with his Republican opponents, has affected radiologists’ reception of the coding changes.
"With the impact of the Affordable Care Act, unstable Medicare payments and reimbursement cuts, radiology departments have had to deal with a lot recently," says McGinty. "ICD-10 is another thing on top of that, which is why some of our members are still trying to block it out for as long as they can!"
If practices are hoping for deadline deferment, it seems unlikely; the US Department of Health & Human Services has already pushed back the compliance date (previously scheduled for 1 October 2013) in order to give providers more time to adjust.
Therefore, radiologists will need to work quickly to meet a number of administrative challenges that come with ICD-10.
For instance, the current ICD-9 codes, which range from three to five digits, will now be up to seven digits long. This has caused consternation within the ACR; it claims current systems weren’t created to accept longer codes.
As a result, practices and facilities will need to upgrade their existing systems accordingly.
"From the radiologists’ point of view, it is about understanding the changes in documentation that are needed," says McGinty. "This is so important, given the degree of specificity that is going to be needed when billing. Alterations will also need to be made to information systems and how they connect to the billing system."
Another concern is that ICD-10 will make radiologists increasingly reliant on the clinical data they receive from referring clinicians – in most cases, reimbursement for imaging services is contingent on proof of medical necessity, provided by a physician.
Speaking at the American Healthcare Radiology Administrators’ conference in Baltimore in October, Melody Mulaik, a respected coding and billing specialist, argued that "because radiologists are so reliant on the hospital or other systems for information, problems can easily arise if a radiologist doesn’t receive enough documentation from the referring physician."
It’s a sentiment shared by McGinty.
"Sometimes, we don’t get the full clinical history that we need from some of our busy colleagues," she says, somewhat diplomatically. "With ICD-10, we are definitely going to have to work harder in convincing referring physicians to give us the most expansive clinical data possible."
The nub of the debate around ICD-10 coding changes relates to reduced reimbursement, with cuts predicted for a number of treatments. Breast biopsy codes are set to see a drop of 29-50%, according to ACR analysis.
Radiology departments can also expect to see a reduction in CT and MRI procedures of 30-40%. As mandated by the Centers for Medicare & Medicaid Services (CMS), CT and MRI services under ICD-10 will be provided through separate cost centres in order to provide greater clarity on how to allocate billing.
"With changes to these codes – especially breast biopsies – we are expecting significant reimbursement decreases," says McGinty. "This is something that we do find worrying, as access to these services, which is so important, could be diminished for Medicare beneficiaries. Practices are struggling already, and, with these reductions, they might not be able to provide such services as readily."
As cuts connected to coding alterations only apply to Medicare billing, some radiology practices are also being advised to negotiate new fees with private payers in a bid to offset predicted reimbursement cuts.
"Members should make sure they negotiate with private payers that aren’t tied to the fee schedule each year," argued Kathryn Keysor, ACR’s director of economics and health policy, when speaking on the matter last year. "They can have contracts based on the 2008 fee schedule – or one from another year – rather than the current year. There is wiggle room to negotiate with many private members."
Guidance and preparations
Whether practices choose to haggle remains to be seen. In the meantime, the best way in which radiology departments can ready themselves for the switch to ICD-10 is through investing suitably in staff training and ramping up awareness.
According to Diane Hayek, manager of the ACR’s department of economics and health policy, there are ample resources to act as a lodestar, including the ICD-10 Tool Kit, offered by the Radiology Business Management Association.
"There have been quite a few tools, like the ICD-10 Tool Kit, out there for some time," she explains. "We have been publishing guidelines on how to prepare for the transition since 2011, which provides information on planning, training, systems upgrades and testing. We’ve also established an ICD-10 resources page with links to CMS and AMA [American Medical Association] web pages.
"You also need to make sure that you are communicating with your vendors to get all of those. In addition, you have to train your staff – right now, the ACR is preparing to offer documentation improvement training podcasts, specifically designed for radiologists."
Running from 3-7 March, the CMS will conduct its first front-end testing of ICD-10, which will trial the efficiency of the system on the providers’ side, and offer real-time desk support. Radiology departments are urged to take part, says Hayek.
"Given that we have such a huge amount of work to review, practices need to take advantage of the upcoming front-end testing," she says. "We are encouraging all ACR members to do so."
For McGinty, in spite of her aforementioned concerns over the high levels of pressure currently being exerted on radiology departments, there is still reason to believe that the transition to ICD-10 can take place in a relatively painless fashion.
"The radiology community has gone through an enormous amount of change in recent years, but it is actually very positive about the future," she says. "It wants to be part of a system delivering high-value healthcare, and reimbursed appropriately. If this is one more challenge, we’ll have to get through it."
There are several months left before changes comes into play, and one gets the sense that a behavioural shift might need to occur if providers are to hit the ground running come 1 October. As McGinty implies, there appears to be little point in delaying the inevitable.
