Anesthesia Coding Alert

It’s never too early – or late – to start preparing.

With ICD-10 implementation just under a year away, now is the perfect time to ensure your practice is preparing for the two-fold challenge: educating your staff and upgrading your computer systems. Read on for advice from anesthesia experts that will help you hone in on the basics you should be addressing now. 

Switch From Paper-Based to Electronic Billing

“ICD-10 is an excellent reason to upgrade existing computer systems,” says David A. Lubarsky, MD, Assistant Vice President for Medical Administration with the University of Miami Miller School of Medicine. For example, software templates including coding customized to each physician’s specialty would bring higher clinical efficiency and increase patient output. 

Make your list: Your checklist for the upgrade would include: 

• Will the software be able to accommodate both ICD-9 and ICD-10 in all electronic transactions? 
• If not, which ones won’t support ICD-10? 
• What types of training are included in the maintenance plan? 
• Which will carry an additional cost? 
• Are there any additional costs associated with obtaining necessary software updates?

The new coding also will mean more collaboration between anesthesiologists and other hospital staff. “Selecting the most appropriate ICD-10 code will likely require greater communications with surgeons or other physicians,” says Marc L. Leib, MD, an anesthesiologist in Phoenix, Ariz. 

Example: “Anesthesia providers aren’t accustomed to always giving additional diagnosis information in their charts, such as whether a patient’s fracture was displaced or non-displaced,” says Kelly Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla. “Those kinds of details will be necessary for even the anesthesiologist’s coding under ICD-10.” 

Step Up Your Documentation

“Because ICD-10 coding requires more information, anesthesiologists would benefit from beginning to document now as if their claims were being submitted with ICD-10 codes,” Lieb says. “By doing so, that will be second nature when such documentation is required after the transition.”

First steps: It is a good idea to make your coding staff take a look at their current top 10 ICD-9-CM codes along with their current documentation, suggests Tony Mira, president and CEO of Anesthesia Business Consultants and Miramed Global Services in Jackson, Mi. “See if an ICD-10-CM trained coder can readily convert them to the new system based on their current documentation. If not, why? What are the critical pieces of information missing in the current documentation?”

For example, if your anesthesiologists frequently work with orthopedic surgeons, laterality is important; does the documentation clearly identify right or left limb? “If you need to expand or capture more information to identify a billable ICD-10-CM code, you want to start making those documentation changes now to minimize the potential revenue impact following the Oct. 1, 2015, effective date,” Mira says.

Final advice: The impact of converting to ICD-10 will vary from practice to practice. “Adequate preparation and training is crucial to minimizing the financial impact. If you have yet to develop an implementation plan there is still time, but you must act now,” Mira says.