ICD-10 Codes Are a Brave New World for Oncology Practices

Kathy Oubre

Getting ready for the International Classification of Diseases, Tenth Revision (ICD-10), the mammoth set of code changes required by the Centers for Medicare & Medicaid Services (CMS), has involved a huge commitment to staff training and also much attention to the finer details, says Kathy Oubre, chief operating officer of Pontchartrain Hematology Oncology in Covington, Louisiana.

After several false starts, the new ICD-10 coding system, which includes thousands of new medical codes for billing and reporting, will go live on October 1, and Oubre’s practice, like many across the country, has been working hard to get employees used to the new system, so that problems with implementation can be minimized come October.

Pontchartrain—a practice of 2 clinics, 2 MDs, a nurse practitioner, and 17 support staff—has built in certain safeguards to lessen the chance that something will go wrong. The practice is going to increase the time allotted for patient visits from 15 minutes to 20 minutes and is suspending any double booking, so that doctors and other staff will have enough time to complete the new coding requirements.

The practice has also taken out a line of credit to guard against an interruption in revenue flow—caused by code-related denials or confusion—that some have estimated may be 90 days, Oubre says.

“For oncologists, and I’m sure every other type of provider, you don’t want to do it wrong. All of this matters—patients are relying on us. It’s not just some minor business issue like a new phone system, so we feel a responsibility. We know this is going to slow us down, and we’ve advised our patients that there may be some inconveniences,” Oubre says.

Prior training at the clinic has involved roughly 62 hours of work by each staff member and as many as 250 practice runs involving patient case dual coding between the existing ICD-9 and the new ICD-10 set of codes. One of Pontchartrain’s clinics actually began coding everything in ICD-10 in late August 2015 in an attempt to fully ready the staff and debug their operations.

Even so, there are variables to consider, such as how the transition will be handled by providers and other entities with whom Pontchartrain regularly interacts. And there are somewhat hidden issues as well, problem areas that Oubre believes will add layers of complexity to implementation.

“We have our line of credit. We are going to be using it as our backup, but it can only last for so long, and we’re concerned that not only will we have problems from Medicare, but also from the Blues, Aetna, and all of those private payers. Everyone has done their end-to-end testing, but no one really knows what is going to happen until it actually goes live,” she says.

One example of a potential problem area is the pre-authorizations that must be arranged for future care. If the appointments happen after October 1, they’ll need to be coded according to ICD-10, Oubre notes. Incidental, non-oncological care (eg, hypertension) will need to be coded too, a change from ICD-9; and also, requests on behalf of patients for financial assistance will have to be coded in ICD-10. “A lot of those companies are not going to roll over from ICD-9 to 10; some of them are going to require us to resubmit. I’m not sure most practices have thought about that,” Oubre says.

Stephen Grubbs, MD

Stephen Grubbs, MD, senior director of the Clinical Affairs Department at ASCO, says he believes that oncology practices are fairly well prepared for ICD-10 and that this is partly due to the fact that the delays in implementation have given them extra time to get their practices in alignment. He says that at this point, it’s essential for practices to test their training and their systems in advance of implementation.

“If you have a payer who is willing to let you do a test transaction, it’s probably worth your while to see if there are any bugs there before you go live on October 1.”

Grubbs, formerly of Medical Oncology Hematology Consultants, PA, in Newark, Delaware, also notes that now is the time to ask any questions of the available authorities. “What we anticipate is after October 1 problems will start popping up. There may be so many questions being asked of CMS or vendors that their ability to get back to you might be slower than you would like.”

Like Oubre, Grubbs notes that there is significantly more refinement associated with ICD-10 reporting. He thinks that entering detail into the electronic health record (EHR) will be simple enough, but it will require vigilance and care to get it right. “You’ve just got to be very careful on the details in your EHR to make it easier for your billing folks to pick the right codes.”

In some cases, ICD-10 will make it easier to bill more accurately than before, he says. “Clearly the ICD-10 coding is much more accurate in hematological malignancies, such as leukemia and lymphoma and myelodysplastic syndrome, where we used to have this overarching diagnosis, and now they’ve actually split them out into really what the diseases are,” Grubbs says.

“On the other hand, there are areas where you just scratch your head.” He notes that in cases of breast cancer, it’s now necessary to choose a billing code according to the exact part of the breast that has the primary tumor. “This detail doesn’t really add anything to my assessment of the disease and its outcome, whereas in other cases, the coding is actually more accurate than it used to be, so it’s really a mixed bag.”

In the same bag, you will likely find more than one case of pre-implementation butterflies, for which there may even be a code.

“The one plus,” says Oubre, “is that we’re small. I can interact with every single person on my staff daily and very easily; whereas if we had a larger staff, I would worry that some things might slip through the cracks. Having our staff aware that they can call my cell phone or text me is part of that interaction that, I think, at the end of the day, helps to ease the anxiety.”