Ten Months to ICD-10: Will Physicians, Vendors and Payers be Ready?

Practices are training staff and physicians and meeting with system vendors and health plans as they prepare to use new codes.

Ten Months to ICD-10: Will Physicians, Vendors, and Payers Be Ready?

Practices are training staff and physicians and meeting with system vendors and health plans as they prepare to use new codes.



Some disruption in cash flow is likely when physicians nationwide start using ICD-10-CM codes on October 1, 2014. Ten months out, the level of disruption is unknown.

For retinal physicians, any disruption in cash flow could be devastating because they have so much cash tied up in inventory for injectable medications, says James F. Vander, MD, one of 20 retina specialists with Mid Atlantic Retina and Wills Eye Physicians in Philadelphia.

Dr. Vander believes Mid Atlantic Retina is like other retina practices: It will be prepared, but he and other retinal physicians and practice administrators are worried about how prepared their payers and system vendors will be.


“We have begun the process of preparing our practice and are just beginning to ensure that our payers are ready,” Dr. Vander says. “Right now, we have no idea if the payers are prepared. In our market, which is eastern Pennsylvania, southern New Jersey, and northern Delaware, we have a relatively small number of payers serving our patients who are not covered by Medicare.”

The issue of preparation is critical for retinal physicians because in recent years they have treated patients with injectable medications, an effective but costly treatment option.

“We are the middle men between pharmaceutical companies and health plans in the process of providing very high-dollar injectable medications to our patients. In that role, our accounts receivable and our accounts payable have both gone up tremendously,” Dr. Vander explains.

“On October 1, we will not slow down our use of injectable medications, but because we have such a high-dollar volume tied up in inventory for these medications, a three-month line of credit is not likely to cover our accounts payable because we lay out so much cash to keep medications on hand,” he says.


Practices need to make a large up-front cash investment to ensure they have adequate supplies of retinal medications on hand. Yet stocking three months’ worth of injectable medications would be cost-prohibitive, Dr. Vander says.

“Therefore, we are working closely with our payers to test their ability to process ICD-10 claims well in advance of October 1. That way, we can have relative certainty of payment,” Dr. Vander explains. “In addition, we’re like a lot of practices in that October 1 falls toward the end of our fiscal year. Given how our accounting department is set up, we can’t have a big lag in payment at the end of October.”

Other retinal specialists are doing what Mid Atlantic Retina has done, which is have staff members and physicians meet with the practices’ information systems vendors, billing companies, and payers to ensure that all are prepared to process ICD-10 claims without delay.


Currently, all physicians in the United States submit claims to Medicare and other payers using the outdated and obsolete ICD-9, which was implemented in 1979. The Department of Health and Human Services requires all practices to use ICD-10 starting on October 1, 2014. The United States is one of the last industrialized nations to make the switch.

Like Mid Atlantic Retina, Associated Retinal Consultants, PC, of Royal Oak, MI, has a team of staff members working with its vendors and payers, says Alan J. Ruby, MD, one of 19 physicians in the practice that serves all of Michigan.

“We’re in the midst of our preparations but believe we’ll be ready because just in the past year and half, we installed an electronic medical record system and hope the new EMR will make the transition to ICD-10 relatively easy for us,” Dr. Ruby says. “Our software vendor, MDIntelleSys [Clearwater, FL], says it’s prepared. We expect to be as well.”

Staff Preparations

The practice has yet to test its readiness, but it has been following the issue closely, Dr. Ruby says. In November, staff members attended the annual meeting of the AAO and returned with a checklist of steps to follow, says Nancy McLaughlin, the practice administrator at Associated Retinal Consultants.

Will ICD-10 Drive Physicians to Retire and Staff to Quit in Frustration?

After cash-flow shortages, one of the most challenging issues retinal physicians may face could be staff shortages, if staff members quit in frustration or retire while a practice is converting to ICD-10.

Nancy McLaughlin, practice administrator for Associated Retinal Consultants, PC, of Royal Oak, MI, warns that staff turnover in times of stress is not unusual.

“We have had a fair number of staff decide to retire as a result of our transition to electronic medical records,” she says. The practice converted to a new EMR system over the past 18 months.

“ICD-10 is one more transition that staff will have to go through and, as a result, there may be more people who decide to retire,” Ms. McLaughlin adds. “As we saw with our new EMR, technology is changing rapidly in physician practices and it’s an adjustment for everyone. Some have adjusted more quickly than others. We learned, for example, that we need to put the appropriate staff training in place to make sure the staff has the support they need for these types of transitions.”

Lisa Asbell, RN, president of trainRX, a coding consulting and training company in St. Petersburg, FL, agrees. Physicians, support staff, and other seasoned professionals may simply retire or seek jobs in other fields, rather than contend with another challenging conversion from one way of operating to another, she says.

“When converting to new systems, we know practice productivity slows way down for about six months or so,” Ms. Asbell explains. “That slowdown is frustrating and often requires us to work extra hours and cancel time off for holidays. Some practices work Saturdays or eliminate vacation time.

“That’s why anyone age 50 to 60 or more may already be thinking about retiring. If they don’t want the hassle, they may just give their notice or quit outright,” Ms. Asbell adds.

“Replacing someone in the middle of conversion will be challenging.” Plan ahead by having temporary staff on call if necessary, she advises.

“Another idea is to use a third-party billing company, at least for the first year,” Ms. Asbell says. Having a third-party would shift much of the responsibility from the practice to a vendor.

“Among steps we need to take, for example, are meeting with our practice management system vendor to make sure their system is ready to go. But more importantly, we need to do a significant amount of training with our staff and physicians to make sure they understand how to use the new ICD-10 codes,” she says.

“Fortunately, there are not as many codes for retinal physicians as there are for other doctors, in part because we’re working with just one organ,” Ms. McLaughlin says. “But the systemic codes, such as those for a patient with diabetes, are important and complicated. Many of our patients have diabetes, and a large number of codes relate to that one diagnosis. So we have to learn those codes.”


In the first few weeks following October 1, cash flow will be a concern, Ms. McLaughlin admits, but the practice has a line of credit if needed. “I’ll work with our physicians to figure out just how much they want to have on hand but typically we have a line of credit available to us just in case,” she says. “As far as cash is concerned, we’re prepared because changes in reimbursement are not uncommon.”

Dr. Ruby agrees, saying the practice has had plenty of experience over the past decade or more, when all practices experienced some temporary but not infrequent reimbursement problems.

“Since the changeover to the year 2000, physicians have worried about payment for all the different transitions the health system goes through,” Dr. Ruby says. “Because we’re a retina group, anytime a new drug is approved, there’s often a delay in reimbursement. For that reason, we have had always had a line of credit for emergencies.

“Our biggest fear is that with all these new codes for ICD-10, certain payers will not accept them,” he adds. “When a new drug comes on the market, it’s frustrating because you spend all your time just making sure you can get paid for services you’ve already delivered. And that’s just for one drug. But ICD-10 could affect all of our revenue. That’s why we’ll work with our payers to make sure they’ll be ready on October 1.”


For retinal physicians, Dr. Vander believes, the challenges associated with implementing ICD-10 might not change their daily activities as much as it affects those who work in billing, systems, and administration.

“The whole hysteria about ICD-10 might be a little bit overstated in terms of what doctors need to do,” he says. “We see patients and we document their conditions. Whether you have diabetes or macular degeneration, our job is to record that information using ICD-10 codes. I just have to figure out how to translate the diagnosis to a specific ICD-10 code.

“We know that with ICD-10, there are too many numbers to fit on a single sheet of paper,” Dr. Vander adds. “So now, we have a logistical problem of how to put the proper documentation in place. That’s not so much related to what the doctor needs to do as it is getting that documentation in place. But it’s not like we have to learn a whole new language because most of our billing revolves around a small number of codes.”

Most retinal physicians will make the adjustment relatively easily, Dr. Vander concludes. For billing and administrative staff, however, any disruption is likely to be worrisome because it involves cash flow and the changeover comes at the end of the fiscal year, he says. RP

CMS to Conduct ICD-10 Testing March 3-7

Earlier in the year, the Centers for Medicare & Medicaid Services (CMS) said it was confident its payment systems would make a smooth transition from ICD-9 to ICD-10 on October 1, 2014. There was no need to conduct end-to-end testing for ICD-10, CMS said.

But that confidence evidently was eroded when the federal website for the Affordable Care Act crashed dramatically after it opened for enrollment on October 1, raising questions about the possibility of another technology-related failure looming a year later.

After crashed, both the Medical Group Management Association (MGMA) and the American Hospital Association called on CMS to conduct testing with its contractors and health plans, to ensure that payments using ICD-10 codes proceed smoothly.

Now CMS has agreed, saying in an e-mail that it plans to do external testing with providers from March 3 to 7 and that those providers and suppliers who participate will receive electronic acknowledgements confirming whether their test claims will be accepted or rejected.

In a letter to CMS, however, the MGMA still insists that internal testing is not sufficient to ensure a smooth transition. Instead, CMS should conduct full end-to-end testing.

The agency has completed “rigorous and comprehensive internal testing” to ensure that its systems can accept and pay claims using ICD-10 diagnosis codes, CMS said, and it will do additional testing to ensure that all systems are working properly.

“CMS is committed to implementing ICD-10 on October 1, 2014, and that will not change,” CMS said. “We are also committed to continuing to process provider claims in a timely and effective manner once the ICD-10 code sets go into effect. We are working very closely with all industry stakeholders to provide industry support in transitioning to ICD-10.”