By Lisa A. Eramo
Ask any coder about the ICD-10 transition, and he or she will likely tell you that it hasn’t been easy. Coders working in physician practices have had a tough time. Many of these coders have more responsibilities than their inpatient coder counterparts. Physician practice coders may even be shouldering the entire burden of ICD-10 implementation without direct physician support.
Training Continues to Lag
“The budget is the paramount issue,” says Anita C. Archer, CPC, director of regulatory and compliance at Hayes Management Consulting. “Providing funding for [physician practice] coders to attend training is a problem. There is a much better infrastructure on the HIM side.”
MeShawn Foster, MJ, RHIT, ICD-10-CM/PCS trainer and senior consultant with a large consulting firm, agrees that many coders don’t have access to sufficient training resources. “Based on what I’ve heard, some coders have had to use their own money for training and even their own paid time off to attend the training,” she says. “With hospital coders, the training is available, and they don’t need to pay out of pocket. Justifying the cost of some of these conferences is hard for the physician coder.”
Liz Redman, RMC, clinic coding manager at Citizens Memorial Hospital, says physician practice coders face an incredible amount of stress as the ICD-10 deadline approaches. “It’s a very frightening situation to be in,” she says. “Coders need to get educated for themselves. If their doctors can’t afford it, they need to go online and find some type of free training.”
Archer says many physicians didn’t even begin to take an interest in coder training until Congress passed H.R. 2, the Medicare Access and CHIP Reauthorization Act in April. “Now they’re saying, ‘Oh, I think we need to get serious about this.’”
While many hospital coders received ICD-10 training months ago—and now have the luxury of being able to dual code—those working in the practice setting are often still trying to convince physicians that ICD-10 education is necessary, says Archer.
“Physicians expect coders to just navigate through this transition,” she says. “There are also a number of smaller practices expecting their billing services or EHR vendor to take care of ICD-10 for them.”
Although hospital-owned and affiliated practices may be better off in terms of ICD-10 progress, many smaller and independently-owned practices have yet to draft a formal implementation plan or start taking a look at documentation, says Archer. This creates a lot of unnecessary anxiety for coders working in these settings, she adds.
Citizens Memorial Hospital, which includes 12 rural health clinics and 15 specialty clinics, began its ICD-10 preparations several years ago. Luckily for its physician practice coders, the hospital took a proactive implementation approach that included physician practices. “We’ve been very fortunate. Our CFO and CEO have been very generous supplying us with the funds we need for training,” says Redman.
Other Challenges for Physician Practice Coders
A lack of formal ICD-10 training is only one of the many challenges that physician practice coders face.
A bigger challenge is that physician practice coders perform much more than just coding, says Archer. “Most physician practice coders may be answering phones, helping with referrals, or doing some task related to billing. They need to figure out how they’re going to train on a lunch hour or other break,” she adds.
Another challenge relates to physician education. In the hospital setting, CDI specialists are often charged with physician education, and a physician advisor may even be on board to assist with buy-in. However, in the practice setting, coders themselves must provide education and documentation feedback directly to physicians, many of whom feel that ICD-10 requires nothing more than updating a cheat sheet of diagnoses, says Archer.
Physician practice coders are also faced with the daunting task of updating the practice’s superbill, says Foster. This requires an analysis of the practice’s patient demographics to ensure that the superbill reflects the most commonly used diagnosis codes. Many superbills must be abbreviated because of the added specificity inherent in ICD-10. Without this abbreviation, superbills that were once one or two pages could easily expand to a dozen or more pages, becoming a clunky and unusable resource, she adds.
Updating EHR templates is another challenge, says Mike Stearns, MD, CHTS-CP, CHTS-PW, CPC, CFPC, principal and founder of Apollo HIT. Stearns says many practices customize their templates based on payer requirements and information gleaned from denials. Although this adds efficiency, it can also be detrimental because all of this data must be updated manually.
“Practices create their own versions of templates, and vendors really can’t change those templates for you,” he adds.
Empowerment Equals Success
Experts offer several tips to help physician practice coders make the most of the ICD-10 preparation time that’s remaining.
- Become an ICD-10 super-user. If physicians haven’t taken the lead on ICD-10, coders can—and should—take the reins, says Foster. Tap into free resources provided by AHIMA, AAPC, CMS, and HIMSS. Review the ICD-10-CM Official Guidelines for Coding and Reporting to make note of guideline changes that affect your specialty. Disseminate important information to coders and other staff members in the practice. Purchase a draft ICD-10 code set to familiarize yourself with relevant code changes.
- Start small to avoid becoming overwhelmed. After reviewing specialty-specific code and guideline changes, Foster says coders should convert their top 20 diagnoses from ICD-9 to ICD-10. “The diagnoses, though more granular, will be the same,” she says. How do the codes change? What additional documentation is necessary? How must templates be updated accordingly?
- Advocate for 1-2 hours of practice time per week. “Dual coding is everyone’s albatross. Nobody has the time to do it, and nobody wants to do it,” says Archer. “You need to take it on and make it your priority. Even if you can only dual code five charts a day, it’s better than nothing.”
- Network with other coders. If the cost of an ICD-10 boot camp or webinar is too expensive, consider asking other local coders to split the cost, says Archer. Coders may be able to get discounts if they can gather groups of 8-10 (or more) individuals. “It’s so much cheaper for coders to get what they need this way,” she adds.
- Identify a physician champion in mid- to large-size practices. As is the case in the hospital setting, this physician can advocate for ICD-10 on coders’ behalf.
- Provide input into template design. In the hospital setting, coders often have representation on an ICD-10 implementation team, one task of which is to ensure template updates. This just isn’t the case in practices. Stearns says coders should work with the practice’s EHR vendor to ensure that all templates are updated correctly. Not doing so can jeopardize coding accuracy and create more work for coders in the end, he adds.
- Open lines of communication. Stearns says it’s helpful to schedule hour-long weekly meetings between physicians and coders to review denials, update templates, and discuss ICD-10 opportunities. Although this may be an hour of lost revenue each week, it will certainly result in long-term payoffs, he adds.
Other Tips to Consider
Redman provides these additional tips based on her experience:
- Consider coder specialization within the practice (i.e., certain coders focus on certain diagnoses).
- Reach out to coding managers at the hospital level (if the practice is affiliated with a hospital) to see whether any ICD-10 resources can be shared or whether the hospital can assist with template and superbill updates.
- Advocate for additional coverage. Citizens Memorial will likely add at least one FTE to account for anticipated productivity decreases.
Lisa A. Eramo (firstname.lastname@example.org) is a freelance writer and editor in Cranston, RI who specializes in healthcare regulatory topics, health information management, and medical coding.
Eramo, Lisa A.
"Solving Unique ICD-10 Concerns for Physician Practice and Outpatient Coders: 7 Transition Tips"
(Journal of AHIMA),