Health Care

If Obamacare Doesn't Kill Small Medical Practices, Bureaucratic ICD-10 Coding Requirements Might


U.S. Government

News headlines have focused on the bureaucratic mandates, financial looniness, and unlikely assumptions that seem designed to drive medical providers away from the Affordable Care Act or out of business entirely. But this year, a non-Obamacare bureaucratic car bomb is set to explode in the medical world in the form of ICD-10—a new coding system for patient diagnoses and inpatient procedures. Mandated by the Centers for Medicare & Medicaid Services, the coding system standardizes communications among providers and insurers. Well, it standardizes them more, since ICD-9 has been in place for 30 years. Uncertainty over hitches in replacing the old coding system with a brand new one has industry experts advising practices to keep several months worth of cash on hand to cover lags in reimbursement. Practices lacking that much liquidity under the mattress may be truly screwed.

Theoretically, the new coding system covers inpatient care involving Medicare, Medicaid, and "everyone covered by the Health Insurance Portability Accountability Act." The government says up and down that the new codes aren't really necessary for private practices providing outpatient care. A handy FAQ insists:

Will ICD-10 replace Current Procedural Terminology (CPT) procedure coding?

No. The switch to ICD-10 does not affect CPT coding for outpatient procedures. Like ICD-9 procedure codes, ICD-10-PCS codes are for hospital inpatient procedures only.

But as EHRIntelligence points out, "While it's true that CPT/HCPCS codes will continue to be the gold standard for outpatient procedures, providers will be required to include ICD-10 diagnostic codes with their claims in order to receive reimbursements from payers."

So, if doctors want to be compensated by anybody other than cash-only patients, they need to adopt the new codes, too.

The problem is that glitches are anticipated in switchover to the new coding system, since nobody is allowed to use it before October 1, 2014, and everybody is required to use it after that day. That's right, another government-mandated healthcare industry hard launch, exactly one year after debuted.

Actually, ICD-10 and were originally scheduled to launch on the same day in 2013. That would have been fun.

The Healthcare Billing & Management Association warns that "it is possible that not all payors will be ready for ICD-10 on October 1, 2014," so "it will be important that you are able to submit in both ICD-9 and ICD-10 formats." The group further recommends that practices "establish a line of credit to tide the office over during the first months following the implementation of ICD-10" to acommodate reimbursement delays.

The CMS itself notes in its Implementation Guide for Small and Medium Practices:

The transition to ICD-10 will result in changes to physician reimbursements. … [C]hallenges with billing productivity combined with potential payer claim processing challenges may result in signicant impact to cash flow. This may require the need for reserve funds or lines of credit to offset cash flow challenges.

According to HealthcareITNews:

Healthcare providers may face disruptions in their payments even if they are on target to operate using ICD-10 codes on Oct. 1, 2014. 

Since providers will, and indeed need, to be able to pay rent and staff salaries if the transition does not flow as smoothly as testing has indicated, experts advise having up to several months' cash reserves or access to cash through a loan or line of credit to avoid potential headaches.

"Just figure that with the transition to ICD-10 there will be delays in reimbursement," said April Arzate, vice president of client services at MediGain, a Dallas-based revenue cycle and healthcare analytics company.

Arzate recommends keeping enough cash on hand to cover medical supplies, payroll, rent, and the rest of a medical practice's overhead for three to six months.

A separate document on risk-mitigation strategies for implementing ICD-10, prepared by the Healthcare Information and Management Systems Society, specifies a "minimum of six months of cash reserves to mitigate revenue impacts over the ICD-10 transformation period."

Lines of credit might step in where available cash is short, but banks issue lines of credit to good risks—not medical practices already struggling in an uncertain regulatory environment.

If you're a doctor, now is a good time to look at your cash flow, or your retirement options. If you're a patient, you might just consider buying your favorite doc a good-bye drink.

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  1. Great, more incentives to perform procedures regardless of the medical benefits.

    1. It’s just the opposite. These codes map to diagnosis related groupers which have a value associated with them. You are reimbursed a flat amount based on the code regardless of your expense as a physician.

  2. Mandated by the Centers for Medicare & Medicaid Servives

    It’s spelled “Survive”. “Centers for Medicare & Medicaid Survive”. As bureaucracies always do.

  3. What’s the IDC-10 code for a turtle bite?

    1. It’s in there somewhere.

    2. You mean the euphemism? Or a real turtle bite?

      1. Turtles aren’t euphemisms, they’re reptiles. They lay eggs on land.

    3. Is it a wild turtle or a pet turtle? Did the incident happen in the water or on dry land? Is it a snapper? A slider? A box turtle? Are you sure it’s a turtle? Because if it’s a tortoise we’ve got to start all over.

      1. …”Because if it’s a tortoise we’ve got to start all over.”

        And you won’t find out until you’ve filled out the first 20 pages of forms.

        1. You don’t have to fill out forms here. That’s the beauty of having a code for everything. It just requires one code. And a couple hours of searching to find it.

          1. (unless it’s part of the O-care site):
            404 not found nginx google

    4. Under the subsection W59.2 for “Contact with turtles”, the parent code for “Bitten by turtle” is W59.21. It has further three child codes, W59.21XA “Initial encounter”, W59.21XD “subsequent encounter” and W59.21XS “sequela”. So you could three codes for the turtle bite depending on both your and the turtles behaviour.

      1. I forgot about that. Good call.

      2. Those are the actual codes. My organization is working on ICD-10 conversion now. Imagine billions of records that now have many-to-one relations attached to each one, thousands of data feeds and lab systems that now have to handle ICD-9 and ICD-10.

        This is going to be a great year!

        1. Between ICD-10, Meaningful Use 2, SNOMED and PQRS, I’m looking a perfect storm of software platform upgrades this year in the clinic where I work. New, required patient education licenses alone are almost 10 grand. Mandatory HIE. Training. Loss of productivity as the providers and staff ramp up on all of the changes and additional requirements. Yeah, this is gonna be an awesome year to be in medical IT.

          1. We just got our certification from CCHIT for MU2 and just finished our HIE implementation. That was last year’s massive project and it required over $1M in hardware upgrades alone (P770 LPAR are not cheap). This has been planned for a while and we built an entirely new data center to handle it at around $300M. Now we have to upgrade or “old” data center since everything is built to be redundant. This is going to completely crush small shops and probably a lot of big ones too.

            1. Yep. I run an IT shop for a clinic with 38 providers and the mountain just keeps growing. I’ve been telling peers in the field who work at other facilities that the cash outflow required to meet the new rules and regulations is going to be unsustainable for a whole lot of clinics and I include ours in that list. We were bought out by a big hospital corporation back in 2010 and the providers at our place insisted on maintaining their existing EPM/EMR. Fine and dandy for them because they no longer have to worry about the capital needed to sustain the infrastructure. Sadly, the larger corporation is uninterested in sustaining as well so it’s tooth and nail to get monies for hardware and software upgrades.

    5. You are probably joking, but there’s going to be one. Right now under ICD-9 there is a code for bite from nonvenomous snakes and lizards, which might be used, or possibly also bite from other animal except arthropod. ICD-9 has about 14,000 codes in it. ICD-10 has ten times that, so yes, there probably will be several codes for turtle bites.

      My personal favorite codes are the ones involving exploding spacecraft, incidentally. And no, I’m not making that up.

      1. You joke, but those Challenger astronauts would still be alive.

    6. It’s turtle bites all the way down.

    7. It depends. If the turtle gets you in the nads, the code would be S31.35 – Open bite of scrotum and testes. You’re welcome!

  4. Uh oh, I still have a doctor that likes to call me up on the software package he still runs that was written by old company I used to work for back in the 80s and 90s. I keep warning him, “I’m happy to help you out, but you’re way past your expiration date, and at some point, the music’s gonna stop and you’re not going to have a chair”. He keeps nodding furiously and saying that he plans to retire anyway.

    This just might do it.

  5. Then I wonder why the feds are bribing private practitioners with up to $63,750 in free money to uupgrade their systems?…..ePrograms/

    1. Free money? Not so much. If you’re not in the field, you have no idea how much it actually costs to meet all of the requirements, much less how much you bend over and spread for the government.

  6. Timing is perfect- this will blow up just before the elections.

    1. Not as long as the guy with the phone and the penis in charge.

      1. good thing Michelle’s not POTUS

      2. Obama is a dick but that doesn’t mean he has one.

      3. The penis mightier?

    2. Old Man With Candy|1.29.14 @ 8:00PM|#
      “Timing is perfect- this will blow up just before the elections.”

      Well, given the number of people who prolly won’t have insurance by then, the need for docs will be ‘way down.

    3. I don’t see that this is going to be as big a deal as the Obamacare snafu. While it’ll inconvenience the hell out of a lot of people, it’s too much inside-baseball for most people.

      Now, the employee mandates that are supposed to go into affect just before the election (if Obama doesn’t illegally delay them again, anyway)? Yeah, those are going to be a problem.

      1. (if Obama doesn’t illegally delay them again, anyway)

        Ding ding ding!

      2. it’s too much inside-baseball for most people.

        This is correct. The picayune changes to the ICD list of codes has been done before. People will muddle through it, the cost of healthcare will rise, but imperceptibly and life will inexorably chug on towards… gomorrah, or whatever brand of socialism seems to be so popular with the jet set these days.

  7. Just to make everybody angry:…..ondo-beach

    1. From the updated story:

      The AR-15’s owner apparently did not give an explanation for the ticking device when police interviewed him, Freeman said.

      He added that it was fortunate the gun was found when it was, and that the finder contacted authorities.

      “Luckily, no one was hurt,” Freeman said.

      The AR-15 has been returned to its owner, ending Redondo Beach police involvement in the incident. Freeman did not know if there would be any consequences for the gun’s owner.

      Huh, the gun must have been sleeping. The South Bay is truly lucky it didn’t go off on its volition on some terrorizing rampage.

      And if the owner is a Fed or LEO he sure as shit isn’t going to face any consequences.

      1. My question is how an LEO is considered the owner of a “government issued” gun. My understanding was that such guns are only for use in the line of duty, and can be taken away from the officer at any time.

        1. What you can take away from the article:
          Select fire SBRs are toys.

    2. Why do they keep referring to the guy who left it behind as the generically bland “owner”?

    3. The AR-15 has been returned to its owner, ending Redondo Beach police involvement in the incident. Freeman did not know if there would be any consequences for the gun’s owner.

      Oooh! Oooh! Pick me! Pick me!

  8. US POlitics, best politics money can buy!

  9. So does Welch give himself a deadline for the Independents thread?

  10. Something tells me a certain pediatric wifey bird said something in a certain author’s ear.

  11. I run a medical billing service and I’ve got the feeling this is going to suck hard. We mainly work for HME/DME providers and I’ll tell you, they don’t have a few months worth of cash on hand. Most don’t have a few weeks. That means I am probably in big trouble.

    1. You could start a loan-shark bizz. Take some good ‘scrips in payment and move ’em right out the door.

    2. Good luck, I used to write medical software and we had a medical billing service on the side. Not an easy business.

  12. That’s right, another government-mandated healthcare industry hard launch, exactly one year after debuted.

    And I think we can safely assume it’s also going to be a massive clusterfuck, because this is not how you roll out standards changes.

  13. ICD 10 could easily have been called the computer programmer full employment act.

    Hey for all those docs out there, just buy an EHR system with Dragon naturally speaking implementation, we’ll do all your ICD10 coding automatically on the fly as you speak.

  14. I’m in the process of completing a bullshit medical assistant course (to get patient experience to apply to PA school in the future.) I keep asking why they will only teach us the icd-9 when basically everyone is being forced to use icd-10 in just a few months. They just keep tell me it’s the responsibility of my future employer. Than I was told when I went out in the field there are certain %’s a doctors office submits in order to get kick backs. I asked where this data was submitted to and my teacher told me who cares it’s free money. I should also mention she was fired and my class is now extended for another two months. Not even sure why I have to pay to take a test I can teach myself. I am beginning to question my career path, unless I can work at an office that doesn’t take medicaid, medicare, and insurances offered on the market place.

    1. Dude, this is America. Just nod, smile and take the free money.

  15. Taken another way this is a boon for 3rd party solution providers and consultants taking practices through the conversion.

    Taken from the administration’s perspective that’s equivalent to a jobs program and what could be more socially fair than sticking it to all those rich greedy doctors…

    Add people wonder why the cost of healthcare has gotten where it is.

  16. “it will be important that you are able to submit in both ICD-9 and ICD-10 formats.” The group further recommends that practices “establish a line of credit to tide the office over during the first months following the implementation of ICD-10” to acommodate reimbursement delays.

    Giving the insurance industry another reason to resist, obstruct and delay. It’s already hard enough to get them to pay up and pay fairly.

  17. my best friend’s ex-wife makes $70/hour on the laptop. She has been without work for 9 months but last month her pay was $15111 just working on the laptop for a few hours. see here W? o? r? k? s? 7? 7? .? ?? ?? ??

  18. I just got the letter from my family doctor that he is now cash only. I’m thrilled he hasn’t decided to retire; but even using FSA dollars this is going to be expensive.

  19. my best friend’s ex-wife makes $70/hour on the laptop. She has been without work for 9 months but last month her pay was $15111 just working on the laptop for a few hours. see here W? o? r? k? s? 7? 7? .? ?? ?? ??

  20. Peyton. I can see what your saying… Antonio`s c0mment is inconceivable… last monday I bought a gorgeous Ford Focus when I got my check for $4326 this-past/4 weeks and-in excess of, $10 thousand this past-munth. without a doubt its the best work Ive ever had. I started this 5 months ago and right away began to bring in at least $81.. p/h. you can find out more ?????? http://www.works77.???m

  21. my best friend’s sister-in-law makes $70 /hour on the computer . She has been without work for 7 months but last month her check was $12532 just working on the computer for a few hours. you can look here


  22. As with the passage of time the the small medical jobs are constant on rise. A medical subordinates with the average annual salary of $29,990 is one off the most growing field in ever state of the America. Obama care will not effect such jobs.

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