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PODCAST: Regulatory initiatives, deadlines inescapable


Although the timeline for implementation of the ICD-10 coding system has been pushed back to October 2015, all dermatologists will have to deal with this eventually. Meaningful Use regulations are also here to stay and will impact every practitioner sooner or later. Mark Kaufman, M.D., associate clinical professor in the department of dermatology at Mount Sinai Medical School in New York, explains the many vagaries of these initiatives for those of us who insist on pretending that they will never happen.


Although the timeline for implementation of the ICD-10 coding system has been pushed back to October 2015, all dermatologists will have to deal with this eventually. Meaningful Use regulations are also here to stay and will impact every practitioner sooner or later. Mark Kaufmann, M.D., associate clinical professor in the department of dermatology at Mount Sinai Medical School in New York, explains the many vagaries of these initiatives for those of us who insist on pretending that they will never happen. Dr. Kaufmann is a dermatologist in private practice in New York and also serves as the chairman of the EHR Implementation Taskforce for the American Academy of Dermatology, as well as co-chair of the ICD-10 workgroup.

Dr. Levine: What’s the timeline for the implementation of ICD-10 and how does one go about implementing it in their office?

Dr. KaufmannDr. Kaufmann: With the passage of the last SGR patch, the implementation of ICD-10 has now been delayed until Oct. 1, 2015. On Sept. 30, 2015, we will have to use ICD-9 codes to submit claims to Medicare, and on Oct. 1 you will have to use ICD-10 codes or you will be denied payment. It’s a pretty sharp demarcation line that we have to follow. Implementation is probably much more than any of us are prepared for. Based on a nonscientific, anecdotal poll that I have been taking, most dermatologists’ plan for implementing ICD-10 is to put their heads in the sand and hope that it just goes away. It’s not going to; it’s going to happen.

Dr. Levine: Are these codes going to be mandatory for private insurance companies as well?

Dr. Kaufmann: It’s unclear. It’s up to the private insurers when they want to implement ICD-10. Some of them may not be ready on Oct. 1, 2015. So we may be stuck in a situation where we are coding differently for Medicare patients than we are for our private patients. We are still waiting for better clarification from the commercial insurers. But I think when they see that ICD-10 actually is having some effect on delayed payment; a lot of commercial insurers will probably want to join that effort.

Next: What's the cost of implementation?


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Dr. Levine: What specific cost can one expect in trying to implement this for his or her office?

Dr. Kaufmann: There is the fixed cost, which is just buying the books or downloading the codes. There are several smartphone apps that can actually help you with ICD-10. One available for the iPhone is called “ICD-10 On the Go.” The problem for most of us is having been in practice for many years or even just a few years, most of us have become used to and have probably memorized most of the ICD-9 codes that we use on a daily basis.

The coding system is going from 13,000 total codes to 68,000 codes, and then on top of that, laterality is going to come into play for the first time. Meaning, it’s not going to be enough to say the patient has a basal cell carcinoma on their arm. It’s going to be basal cell on the right or the left arm or the “right eyelid” instead of “face.” So you can already tell that this is going to generate a lot more codes that are going to be impossible to memorize.

The difficulty we are going to have is that all of us who are used to using a superbill that has just one page of ICD-9 codes on it, will not be able to have a similar sheet for ICD-10. The academy (American Academy of Dermatology) has actually come out with a laminated four-page crosswalk, which does convert many of the common codes that we use. It’s helpful, but still not comprehensive.

For instance, there is one ICD-9 code that you use for an arthropod bite. There actually are 180 codes in ICD-10 for an insect bite. So there is no way you are going to be able to have a superbill that’s going to be able to contain all of the codes that you are going to need.

We do need more help and that’s where the costs actually are going to come in. Part of the reasoning behind the AMA’s (American Medical Association) plea to delay ICD-10 was that the cost of implementing ICD-10 was actually underestimated by AMA polls in the past. They estimated in 2008 that a small practice would have to pay about $83,000 to implement ICD-10. And now they are saying that it could be up to $225,000 for a small practice.  Remember, it’s not just the cost of implementing ICD-10, but also the cost of delayed payment that will be a big problem for many people in private practice.

Dr. Levine: What are the logistics of converting from ICD-9 to ICD-10?

Dr. Kaufmann: Ironically, and I straddle both work groups here, there may be more impetus to switch to electronic health records because of ICD-10 than there was for Meaningful Use. That’s because ICD-10 may be easier to implement within an electronic health record (EHR). Certainly one that’s able to generate a code for you de novo on every patient you see. There are EHRs available that do that. And, it’s important for people who do have EHRs to speak to their vendors and ask them:

  • What are you doing for ICD-10?

  • What’s going to happen to me on Oct. 1, 2015?

  • Am I going to have to look through 100 pages of codes or is your system going to choose the code for me?

I think that may be a much more important thing to look for than Meaningful Use bullet points, because that’s something that really could actually add value to your practice.


Next: Can a physician still maintain paper charts?


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Dr. Levine: Is there any way that a person can maintain a paper chart and do ICD-10?

Dr. Kaufmann: Yes, I think it will happen. I think your coding staff, after they’ve passed out because of all the codes they have to look through, will eventually get the hang of it. I am hopeful that there may even be some apps that come out that can help you generate an ICD-10 code on an iPad or on a tablet; where you will be able to chose a diagnosis from a list, touch on where on the body it is, and that would hopefully be able to generate a code quicker. We are used to taking less than 30 seconds to generate an ICD-9 code, and it’s going to take minutes if not 10s of minutes to generate the correct ICD-10 code. So the answer to the question is: Yes you will be able to exist on paper with ICD-10, but it will take a lot more effort from your billing staff or from the provider if they are the one who is doing the coding.

Dr. Levine: Is the Academy involved in helping dermatologists make this transition?

Dr. Kaufmann: Yes, we are trying. We have been sounding the alarm for the last year. The academy - as I said - has come out with a crosswalk, and they have also had webinars, both live and archived that can be viewed on-demand.

Dr. Levine: Let’s switch gears to another regulatory issue, and that is the whole subject of Meaningful Use and what does it mean to us as dermatologists?

Dr. Kaufmann: There are many who will tell you that Meaningful Use is neither meaningful nor useful, and in many ways, I would agree with that, because many of us find ourselves jumping through regulatory hoops with EHRs that don’t really affect our practice of dermatology. Meaningful Use has very little relevance to dermatology. I think EHRs can be very helpful and useful in a practice, certainly the fact that you don’t have to look for charts any more is, in and of itself, a great thing. But Meaningful Use I think has been - and Congress has felt the same way - somewhat of a failure in trying to generate what the holy grail is, which is to have interoperable systems that talk to one another and are useful and relevant to the practice of medicine. The relevance and the utility - the usability - is what a lot of people find missing still in EHRs.


Next: What if you don't comply?


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Dr. Levine: What happens if one decides that she either cannot or will not to comply with these Meaningful Use guidelines? What are the consequences of that?

Dr. Kaufmann: The consequences start this year. If you haven’t attested for Meaningful Use by Oct. 1, 2014, in 2015 you will have a penalty on your Medicare reimbursement. For 2015, it is 1 percent, and that penalty over several years can go up to 5 percent. There is also a desire on the part of CMS (Centers for Medicare and Medicaid Services) to consolidate all of the penalties into one large penalty. This would include Meaningful Use, PQRS (Physician Quality Reporting System), and value-based modifiers. CMS has always had an all-or-nothing policy with their penalty programs; meaning you are either compliant with everything or you are not complaint. So, the problem is that people who may not have been able to be Meaningful Users, but did participate in PQRS, will no longer have that option, so you will not be able to mitigate your penalty with another program if the consolidation of the programs occurs.

Dr. Levine: What are the logistics of complying in terms of documentation and reporting?

Dr. Kaufmann: Meaningful Use is a somewhat complicated program that basically forces you to do 20 measures. Among these measures are things like e-prescribing, computerized physician order entry and being able to input a diagnosis and generate a patient list; and these are things that can be done by most dermatologists. There are some more difficult measures, such as the clinical quality measurements as well as vital signs, which for many dermatologist is a difficult measure, but CMS has actually been responsive to the vital sign measure and now most dermatologists should be able to meet the vital sign measure. You actually then have to attest that you did these things. If you successfully attest for 2013, you will not be penalized in 2015, and if you attest within 2014 up until Oct. 1, you will also be able to escape the penalty for Meaningful Use in 2015.

Dr. Levine: As dermatologists, clearly we practice a lot differently than other specialties. Are we being given any kind of special dispensation for the way we practice with regard to Meaningful Use?

Dr. Kaufmann: I think the small specialties in general have been given a lot of leeway. There are exclusions for many of the measures. As I mentioned, the vital sign measure has been tweaked by CMS and we are given a lot more room for different types of practice styles with vital signs. The other specialties such as ophthalmology and ENT also are benefiting from these exclusions. There are immunization measures; clearly most of us don’t do immunizations, and so those things aren’t relevant.

When it comes to the exclusions, if you attest that this truly is not relevant to your practice, they actually will allow you on many of the measures to pass anyway, because CMS has an all or none attitude when it comes to these programs. For the most part, if you can’t meet one of the 20 measures for Meaningful Use, you are actually are not a Meaningful User; and if that happens, it doesn’t matter how many measures you did meet, it’s only the measure that you didn’t meet that matters.

More on Meaningful Use

Meaningful Use criteria frustrating but inescapable

CMS to give physicians flexibility in meeting Meaningful Use 2, scale back Meaningful Use 3

7 strategies to protect your practice from Meaningful Use audits

More on ICD-10

How to insure against RAC audits, ICD-10, Affordable Care Act

Healthcare is not ready for ICD-10, WEDI report says


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