Survival Strategies for ICD-10

By Kim Snyder, CPC, PCS

Kim Snyder, CPC, PCS

In the United States, official use of the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) begins with dates of service after October 1, 2013. A coding system created by the World Health Organization, ICD-10 notes various medical records including diseases, symptoms, abnormal findings, and external causes of injury. Under ICD-10, the number of diagnoses will grow nearly 400%, and every imaging procedure will have a new diagnosis code. The new codes will be three to seven characters in length and all alphanumeric, while the current ICD system is only three to five digits in length with some alpha characters.

Impact of ICD-10

This dramatic increase in the number of new codes means there are not only more digits in each code, but also many alpha characters—creating a situation akin to the Y2K debacle in which older systems that are limited to five-digit codes will be unable to adjust to the new code set. Although ICD-10 is a necessary move toward high-quality health care, it is expected to impact all physicians and comes with some challenges and worries for radiologists and practice administrators.

Radiology groups that currently have an in-house billing operation share concern regarding the readiness of their software for the ICD-10 transition, the testing with the carriers, and the associated costs. Some fear ICD-10 will give insurance companies new tools to postpone and deny reimbursements.

It is currently estimated that nearly 20% of all health care claims are either inappropriately paid or denied. As a result, the amount of revenue lost to manual and inconsistent auditing is astonishing; I approximate between 5% and 10%. And, during the ICD-10 transition, an estimated additional 10% of claims will be returned due to erroneous billing diagnoses.

Strategies for Survival

Outsourcing billing can alleviate these concerns because they become the billing providers’ responsibility. During this monumental transition, billing experts who are current on the latest codes can reduce the expenses associated with billing, collect payments that may have been overlooked, and make practice management more efficient. In addition, a billing company that controls the development of its own technology allows for better and faster response to ICD-10, as well as the plethora of upcoming government mandates.

As the ICD-10 codes become common throughout the insurance industry, practices could benefit from a partner that can handle appeals on rejected claims and keep the pressure on payors to capture dollars in a timely manner. ICD-10 codes will require radiologists to include a greater level of specificity that is often lacking with radiology reports. Ensuring that a code will pass an insurer’s scrutiny is going to be more demanding than ever. While the increase in the number of new codes may require greater specificity on claims, robust billing technology that is ready for the transition will actually make it easier to assign codes correctly, which means fewer errors, fewer unpaid claims, and fewer requests to resubmit claims with supporting documentation. Because not all insurance carriers (workers’ compensation and some auto carriers) are required to report ICD-10, having a billing system that is able to handle dual ICD diagnosis coding is critical. The practice’s bottom line will go up, while they will feel free of the stress of ICD-10.

Save Time, Improve Your Bottom Line

Automated coding assisted technology that is integrated with a billing provider’s software can minimize denials before a bill is even sent, resulting in increased accuracy and optimized payments in the new ICD-10 coding environment. This makes billing more efficient, with a 45- to 60-day window as the average.

A company that works hand-in-hand with radiologists to provide ongoing training to educate and improve dictation will provide more accurate and compliant reimbursement opportunities. In many practices, there is evidence of unclaimed revenue attributed to missed coding opportunities, lack of knowledge about coding improvements, and missed documentation and dictation opportunities. These areas also provide risk of improper coding and payments.

In-House Billing Tips

Some groups prefer to maintain billing on their own and opt to keep these operations in-house. In this case, it is important for practice managers to provide ICD-10 training to coders, billers and other staff members. In addition, a plan should be designed to avoid backlogs and delays during the initial stages of the transition.

Practices with in-house billers must evaluate their vendor partners’ preparedness. Important questions to ask include:

  • What changes will the vendor be making to their product to accommodate the change from ICD-9 to ICD-10?
  • Are these changes included in their current contract, or will there be additional fees?
  • When will a compliant version of your software be available?
  • How will your software accommodate both ICD-9 and ICD-10 during the transition period?
  • When will your clearinghouse be ready to accept claims with ICD-10 codes?

In-house billing companies will have to deal with the additional pressures of outside software upgrades, revising support service contracts, and providing their own training to staff, which can all be very costly. Even though there is an anticipated delay in reimbursement expected from payors, any additional delay can be avoided with a tailored service.

Complicating Collections

Aside from the difficulties surrounding ICD-10, the challenge for every radiology practice is to have a tight focus on getting every collectible dollar at a lower cost of billing. This is no easy feat as payment responsibility shifts from institutional payors to patients whose dollars are more difficult to collect. More and more consumer-driven, high-deductible health insurance plans, such as Health Savings Accounts, mean mounting reimbursement pressures. In this forbidding environment, radiologists across the country are outsourcing their billing and as a result are experiencing consistent and cost-effective improvements in reimbursement.

Kim Snyder is a Certified Professional Coder and Physician Coding Specialist and Partner of Coding for Zotec Partners. Founded in 1998, Zotec Partners is a leader in medical billing, practice management, and Radiology Information Systems software and services. To learn more, visit

Top-Down Approach Reduces Unneeded Exams

By Renee Diiulio

It’s never easy to effect change, and a team at the University of Rochester Medical Center (URMC) in Rochester, NY, has proven it. In an effort to reduce unnecessary dose through elimination of an unwarranted exam, the radiology department’s effort at education and policy change proved ineffectual.1 Modifying the strategy to implement change via a top-down approach, however, fared with much better success: between January 2008 and January 2009, the number of targeted unnecessary x-ray exams performed was reduced by 83%.1

Bottoms Up

Faced with growing concern regarding overutilization and overexposure to radiation, the URMC team decided to attack inappropriate studies. With multiple studies showing radiographs to detect cervical spine fractures demonstrate poor sensitivity, the team thought these examinations would be an easy first target.1

“Not only are these x-ray exams unwarranted, they consume valuable resources, add an additional burden to emergency department and radiology staff, and subject patients to unnecessary radiation,” said Mark J. Adams, MD, MBA, FACR, lead author of the study, in a release announcing the research.

Using this logic, the radiology department attempted to educate ordering physicians on both a departmental and individual level on the appropriate use of radiographic cervical exams to look for fractures in a patient who has already undergone a negative CT scan. They targeted the emergency department, orthopedic and spine team physicians, and mid-level providers. Unfortunately, logic alone was not enough to inspire great change, and in February 2007, the effort was broadened.

In Between

Working with the center’s trauma council (comprised of emergency physicians, trauma surgeons, orthopedic surgeons, the spine team, and mid-level providers), an algorithm was developed to provide a clear indication for the appropriateness of x-ray evaluation of post-CT cervical spines.

These studies were deemed to be appropriately ordered when completed before a CT scan, when performed after an abnormal CT scan, or following a normal CT to investigate for stability using lateral radiography in flexion or extension.1 The study was not deemed appropriate following a CT scan of the cervical spine with no acute findings.1 If a radiographic cervical examination had been initiated but not completed prior to a CT scan, it was not necessary to finish the study.1

But again there was little change. In January 2007, the URMC team recorded 9 inappropriate examinations out of 35 (26%); in January 2008, they found 6 inappropriate out of 34 (18%).1

Top Down

Not happy with the lack of change, the team presented the data to the trauma council and the emergency department oversight steering committee. The attendance of the medical director instantly raised the profile of the problem. A new policy, presenting the algorithm clearly, was put together and distributed from the top down through department heads to care providers.1 Radiologists and technologists were encouraged to question relevant exams.

The new approach worked. In January 2009, only 1 inappropriate examination was reported out of 34 (5%), and in February, the number had fallen to zero.1 However, once again proving change is difficult, a slight increase was seen in August 2009 (2 out of 34, 10%).1 This was attributed to staff turnover.

Therefore, the team decided that continuous monitoring and periodic retraining should be the final steps in a formalized process to effect change that starts with presentations to high-level committees; includes the development of simple, easy-to-follow, clearly structured algorithms; employs top-down vertical delivery of new policy information; and provides reinforcement from radiology. Using this approach, change may still not come easy, but it will come.

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  1. Elimination of unnecessary cervical spine radiographs in the emergency department. J Am Coll Radiol. 2010;7(7):530-531.