Physician's Office


AHIMA partnered with the American Medical Association to develop the physician model for implementing ICD-10.

 

Instead of organizing the physician practice ICD-10 models by roles as in the other models offered by AHIMA, the ICD-10 models developed for physician practices are based on processes performed in the physician practice. This matrix contains rows for each process identified as impacted by ICD-10-CM implementation. Identify the row that best describes the processes that you are responsible for, and click on the model identified in that row.

This matrix illustrates that physician practice employees might need to review more than one process-based model, depending on how many processes they have responsibility for. For example, physicians document in the medical record so the model for group 2 process is applicable. If a physician will also be assigning ICD-10-CM codes on orders then the model for group 1 process is also applicable. The physician champion model is developed for the physicians who need to be thoroughly familiar with ICD-10-CM.

Matrix

 

 

Example of Roles at a Physician Practice

Physician Champion

Physicians & Providers (physician assistants, nurse practitioners, clinical nurse specialists, certified nurse midwives)

Clinical Staff (registered nurses, licensed practical nurses, medical assistants)

Administrative roles (office manager, coding, billing, scheduling, quality management, compliance officer, etc. (see pages 4 and 5 for additional details)

Ancillary (imaging, laboratory, perfusion, respiratory therapy, cardiology, and other ancillary departments)

Physician Champion

This is the go-to physician that many practices have who will be expected to have knowledge on all aspects of ICD-10-CM

 Model for Physician Champion

 

 

 

 

Group 1 Processes

Coding Process

 

 

 

Model for Group 1 Processes

 

Process of Fulfilling Requests for ICD-10-CM Codes on Orders, Etc.

 

 Model for Group 1 Processes

Model for Group 1 Processes

 

Model for Group 1 Processes

Regulatory Compliance Process

 

 

 

Model for Group 1 Processes

 

Group 2 Process

Process of Medical Record Documentation by Physicians and other Healthcare Providers

 

Model for Group 2 Process

Model for Group 2 Process

 

Model for Group 2 Process

Group 3 Processes

Billing Process

 

 

 

Model for Group 3 Processes

 

Process of Precertification and Scheduling

 

 

Model for Group 3 Processes

Model for Group 3 Processes

 

Internal and External Reporting Processes

 

 

 

Model for Group 3 Processes

 

Physician Champion

In every office setting, whether the small, independent physician office setting, or in a large multi-specialty group, a successful transition will require the leadership and vision of a Physician Champion. This individual is the resource physician that many offices have, either formally or informally, who provide advice and guidance to their staff on coding and billing issues. This physician will need to be familiar with all aspects of the ICD-10-CM code set.

Early in the implementation process the focus should be on understanding how ICD-10-CM is different from ICD-9-CM (including familiarity with the maps between them). Next focus should shift to a more in depth understanding of the fundamentals of ICD-10-CM and preparing to code with this new code set. During the final year leading up to implementation the focus is on becoming an expert in applying ICD-10-CM codes to encounters.

To Do Phase 1:

  1. Develop a general understanding of the ICD-10-CM final rule and its implications to the documentation process.
  2. Learn the fundamentals of the ICD-10-CM system and identify the differences between ICD-9-CM and ICD-10-CM.
  3. Review code structure and coding conventions for ICD-10-CM.
  4. Review the ICD-10-CM coding guidelines and identify the differences with the ICD-9-CM coding guidelines.
  5. Become aware of the general equivalence mappings (GEMs) between ICD-9-CM and ICD-10-CM.
  6. Assess level of preparedness of vendors (e.g., outsourcing contracts, new technology such as computer-assisted coding and EHR) for ICD-10-CM. The vendors of the new technology must provide assurance that the new technology is compatible with ICD-10-CM.
  7. Network with peers and professional organizations to identify issues and evaluate best practices.
  8. Network on ICD-10-CM preparation and with area hospitals and hospitals in which physicians have medical staff privileges.
  9. Evaluate any plans for introducing new technology (EHR or computer-assisted coding (CAC)) prior to or around ICD-10-CM implementation to determine the impact on ICD-10-CM educational needs of those performing coding and regulatory compliance.
  10. Assess the impact to EHR due to the change to ICD-10-CM.
  11. Evaluate current documentation practices and identify opportunities for documentation improvement based on results of documentation analysis.
  12. Identify common patient comorbidities pertinent to managed care reimbursement models and how ICD-10-CM identifies specificity with the diagnoses considered comorbidities.

Corresponding Resources:

To Do Phase 2:

  1. Become an expert in applying the ICD-10-CM codes in the six to nine months prior to implementation.
  2. Identify best available specialty specific pertinent subsets of GEM equivalency.
  3. Practice using ICD-10-CM codes and any computer-assisted coding tool each week leading into “go live” on implementation day.
  4. Participate with state and local medical associations, and payers on ICD-10-CM opportunities.
  5. Implement newly identified clinical documentation practices to ensure compatibility with requirements for ICD-10-CM code assignment.
  6. Ensure that other providers within the practice understand the need for enhanced documentation related to ICD-10-CM
  7. Develop or adapt resources to guide ICD-10-CM code selection with the processes of documentation and related activities (fee tickets/billings, lab or imaging orders, prescription orders) identifying patient comorbidities.
  8. Network with peers to discuss additional documentation improvement ideas. Take advantage of other state associations or specialty associations opportunities.
  9. Obtain and review pertinent Medicare payer amended National and Local Coverage Determination (NCD/LCD) policies for the services most frequently performed in the practice.
  10. Verify the narrative descriptor in the EHR is identifying the correct ICD-10-CM code to the maximum level of specificity.
  11. Test vendor products utilized in the practice to validate compatibility with ICD-10-CM.

Corresponding Resources:

To Do Immediately Following Implementation:

  1. Identify documentation and charge capture issues with implementation of ICD-10-CM and develop a plan of action to resolve issues.
  2. Closely monitor the use of ‘other specified’ and ‘unspecified’ diagnosis codes in ICD-10-CM and potential documentation opportunities related to the use of those codes.
  3. Closely monitor productivity and quality measures such as coding accuracy rate, and claim denial rates for issues that might be related to the implementation of ICD-10-CM.
  4. Determine areas where additional education is needed in regards to coding and documentation now that ICD-10-CM has been implemented.
  5. If claims denied or held up for diagnosis, review processes used for code selection, payor policies pertinent and make midcourse corrections, not simply resubmitting claims
  6. Evaluate additional resources or support, if any, that external sources and vendors will provide during the adjustment period following ICD-10-CM implementation.
  7. Network with peers to evaluate issues that have been identified elsewhere both locally and nationally.
Return to matrix

Group 1:

Group 1 Processes related to assigning and/or auditing ICD-10-CM codes include the coding process, processes such as requests for ICD-10-CM codes included with orders for lab and imaging, pharmacy benefits, etc., and regulatory compliance process. AHIMA estimates that approximately 16 hours of coding training are likely needed for each outpatient coder to learn ICD-10-CM. However, coders may need additional training to refresh or expand knowledge in the biomedical sciences.
For a successful transition to ICD-10, the challenges for those involved in group 1 processes at physician practices are to:        

  • Ensure they have sufficient foundational knowledge of the biomedical sciences
  • Learn how to apply ICD-10-CM codes correctly on encounters
  • Understand how to utilize all resources available to ensure continued accuracy in the ICD-9-CM and ICD-10-CM transition.

Earlier in the implementation process the focus should be on obtaining and/or refreshing the foundational knowledge of the biomedical sciences and understanding how ICD-10-CM is different from ICD-9-CM (including familiarity with the maps between them). Beginning two years prior to implementation, the focus is more in depth understanding of the fundamentals of ICD-10-CM and preparing to code with this new code set. Beginning one year prior to implementation, the focus is on becoming an expert in applying ICD-10-CM codes to encounters.

To Do Phase 1:

  1. Review code structure and coding conventions for ICD-10-CM.
  2. Learn the fundamentals of the ICD-10-CM system and identify the differences between ICD-9-CM and ICD-10-CM.
  3. Review the ICD-10-CM coding guidelines and identify the differences with the ICD-9-CM coding guidelines.
  4. Identify a physician champion within the physician practice as the ICD-10-CM resource for the physician practice. This physician will need to know the fundamentals of ICD-10-CM in order to be prepared for the questions that the office employees will ask related to ICD-10-CM particularly in the areas of anatomy and physiology.  This physician can assess areas where education in anatomy and physiology might be needed for the office staff who work with ICD-10-CM.
  5. Become aware of the general equivalence mappings (GEMs) between ICD-9-CM and ICD-10-CM.
  6. Assess level of preparedness of vendors (e.g., outsourcing contracts, new technology such as computer-assisted coding and EHR) for ICD-10-CM. The vendors of the new technology must provide assurance that the new technology is compatible with ICD-10-CM.
  7. Network with peers and professional organizations to identify issues and evaluate best practices.
  8. Network on ICD-10-CM preparation and training with area hospitals and hospitals in which physicians have medical staff privileges.
  9. Evaluate any plans for introducing new technology (EHR or computer-assisted coding (CAC)) prior to or around ICD-10-CM implementation to determine the impact on ICD-10-CM educational needs of those performing coding and regulatory compliance.
  10. Identify opportunities for documentation improvement based on results of documentation analysis.
  11. Identify common patient comorbidities pertinent to managed care reimbursement models and how ICD-10-CM identifies specificity with the diagnoses considered comorbidities.

Corresponding Resources:

To Do Phase 2:

  1. Become an expert in applying ICD-10-CM codes to cases in the six to nine months prior to implementation.
  2. Practice using ICD-10-CM codes and any computer-assisted coding tool each week leading into “go live” on implementation day.
  3. Network with peers to seek answers to cases and confirm application of ICD-10-CM codes.
  4. Participate with state and local medical associations, professional coder associations, and payers on ICD-10-CM training opportunities.
  5. Implement newly identified clinical documentation practices to ensure compatibility with requirements for ICD-10-CM code assignment.
  6. Explore general equivalence mappings to determine availability of specialty specific resources for using the GEMs.
  7. Plan for impact of ICD-10-CM code set on charge capture process.
  8. Obtain and review pertinent Medicare payer amended National and Local Coverage Determination (NCD/LCD) policies for the services most frequently performed in the practice.
  9. Test vendor products utilized in the practice to validate compatibility with ICD-10-CM.

Corresponding Resources:

To Do Immediately Following Implementation:

  1. Identify documentation andcharge capture issues with implementation of ICD-10-CM and develop a plan of action to resolve issues.
  2. Closely monitor productivity and quality measures such as coding accuracy rate, and claim denial rates for issues that might be related to the implementation of ICD-10-CM.
  3. Determine areas where additional education is needed in regards to coding and documentation now that ICD-10-CM has been implemented.
  4. Evaluate additional resources or support, if any, that external sources and vendors will provide during the adjustment period following ICD-10-CM implementation.
  5. Network with peers to evaluate issues that have been identified elsewhere both locally and nationally.
Return to matrix

Group 2:

For a successful transition to ICD-10, the challenges for those involved in group 2 processes at physician practices are to:

  • Ensure they have enough knowledge of ICD-10-CM to understand the potential documentation issues
  • Review correct ICD-10-CM code assignment on patient encounters       
  • Review and understand how to utilize all resources available to ensure continued accuracy in the ICD-9-CM and ICD-10-CM transition.
Early in the implementation process the focus should be on obtaining foundational knowledge of ICD-10-CM and understanding how ICD-10-CM is different from ICD-9-CM (including familiarity with the maps between them). Also during this time an understanding in the differences between the 4010 and the 5010 should be established. In late 2011 through 2012, the focus is more in depth understanding of the current documentation practices for the most common diagnoses in a practice and how this will be affected by ICD-10-CM. In late 2012 through 2013, the focus is on applying newly identified documentation practices.

To Do Phase 1:

  1. Develop a general understanding of the ICD-10-CM final rule and its implications to the documentation process.
  2. Develop a general understanding of the transition to 5010 electronic transactions.
  3. Review the fundamental differences between ICD-9-CM and ICD-10-CM.
  4. Overview of the code structure and coding conventions for ICD-10-CM.
  5. Overview of the ICD-10-CM coding guidelines.
  6. Begin learning about the general equivalence mappings (GEMs) between ICD-9-CM and ICD-10-CM.
  7. Identify specialty-specific mapping resources that may be available.
  8. Evaluate any plans for introducing new technology (EHR or computer-assisted coding (CAC)) prior to or around ICD-10-CM implementation to determine the impact on ICD-10-CM educational needs of those performing [insert name of process] process.
  9. Review impact of EHR on diagnosis code assignment.
  10. Evaluate current documentation practices for most common diagnoses in the practice.
  11. Evaluate how and where ICD-9-CM codes are utilized in documentation now and in process of submitting bills.
  12. Identify opportunities for documentation improvement based on results of documentation analysis.
  13. Network with peers to identify issues and evaluate best practices.
  14. Identify other activities closely related to documentation where ICD-9-CM codes are utilized now (lab or imaging orders, authorizations, etc.) identifying patient comorbidities in medical groups where pertinent to managed care capitation.

Corresponding Resources:

To Do Phase 2:

  1. Become familiar with ICD-10-CM codes in the six to nine months prior to Implementation.
  2. Identify best available specialty specific pertinent subsets of GEM equivalency.
  3. Implement newly identified documentation practices in daily work prior to “go live” on implementation day.
  4. Network with peers to additional documentation improvement ideas. Take advantage of state associations or specialty associations training opportunities.
  5. Develop or adapt resources to guide ICD-10-CM code selection with the processes of documentation and related activities (fee tickets/billings, lab or imaging orders, prescription orders) identifying patient comorbidities.
  6. Practice and become proficient at identifying ICD-10-CM codes during patient encounters
  7. Obtain and review pertinent Medicare payer amended Local Coverage Determination (LCD) policies for the services affected most in the practice; adapt coding resources to incorporate specific service/diagnosis links.
  8. Verify the EMR correctly identifying ICD-10-CM codes intended for selected set of patient encounters (e.g. one day of encounters, several encounters per day).

To Do Immediately Following Implementation:

  1. Identify potential documentation issues with implementation of ICD-10-CM and develop a plan of action to resolve issues and/or provide additional education.
  2. Closely monitor the use of ‘other specified’ and ‘unspecified’ diagnosis codes in ICD-10-CM and potential documentation opportunities related to the use of those codes.
  3. If claims denied or held up for diagnosis, review processes used for code selection, payor policies pertinent and make midcourse corrections, not simply resubmitting claims
  4. Determine areas where additional education is needed in regards to coding and documentation now that ICD-10-CM has been implemented.
  5. Evaluate additional resources or support, if any, that external sources and vendors will provide during the adjustment period following ICD-10-CM implementation.
  6. Network with peers to evaluate issues that have been identified elsewhere both locally and nationally.
Return to matrix

Group 3:

Group 3 Processes: Processes which require knowledge of ICD-10-CM codes and are not Group 1 or Group 2 processes and functions

  • Revenue cycle management, including:
    • Precertification, pre-authorization, scheduling, referrals, etc.
    • Billing functions
    • Payer contracting
  • External reporting such as quality measures (PQRS, MU, P4P) and public health
  • Internal reporting such as registries (tracking patient populations) and Provider Profiling
  • Information Technology/Systems
  • Leadership and management

For a successful transition to ICD-10, the challenges for those involved in group 3 processes at physician practices are to:

  • Ensure they have enough knowledge of ICD-10-CM to understand the potential issues
  • Review and understand how to utilize all resources available to ensure continued accuracy in the ICD-9-CM and ICD-10-CM transition.

To Do Phase 1:

  1. Introduce fundamentals of ICD-10, including basic understanding of code structures and how different from ICD-9
  2. Develop an understanding of how ICD-10 will impact each job and or process
  3. Provide early training to understand key points and timeframes for ICD-10 classification system implementation
  4. Review what GEMs are and how they are used
  5. Web based overview and review (high level) of anatomy & physiology and medical terminology as appropriate to group (i.e., registration, authorization)

Corresponding Resources:

To Do Phase 2:

  1. Learn how to use GEMS to understand specialty coding for particular area
  2. Learn specialty codes for the particular practice or specialty for the top XX codes
  3. Familiarize users with changes on charge slips and charge master
  4. Review fundamentals of ICD- 10-CM , including basic understanding of code structures; how different from ICD-9-CM;
  5. Provide local learning resources and access to expert coders for group 3 users
  6. Web based overview and review (high level) of anatomy & physiology and medical terminology as appropriate to group (i.e., registration, authorization)

Corresponding Resources:

To Do Immediately Following Implementation:

  1. Closely monitor productivity and process quality for any additional educational needs; e.g. preauthorization eligibility claims, etc.
  2. Identify issues with implementation of ICD-10-CM and develop a plan of action to resolve issues.
  3. Identify financial impact of using new codes in order to identify training needs
Return to matrix