maryland medicine vol 15 issue 1

MarylandMedicineThe Maryland Medical Journal Volume 15, Issue 1

ALSO INSIDE:

In Memoriam Tribute Timothy Danforth Baker, M.D.

ICD-10

Timothy Danforth Baker, MD 1925–2013

John W. Buckley, MDIn MeMorIaM TrIbuTe

One of us has died. Timothy D. Baker had a fatal stroke December 17, 2013. For the past few months, he had not felt well but had retained his sense of humor, adapting to the infirmities of his age. He was an active editorial board member of Maryland Medicine and Maryland Medical Journal for decades. International public health fame did not change his loyalty to MedChi and to the Baltimore City Medical Society. He contributed articles and advice and never pulled rank. He could hold his own with the usual banter and bicker of editorial committee meetings. He was also loyal to the Johns Hopkins Bloomberg School of Public Health. No matter what the health concerns, he commuted regularly from Broadmead to his office at Hopkins. There was work to be done!

Timothy D. Baker grew up in Baltimore. He was fascinated by and devoted to public health by the time he earned his M.D. at the University of Maryland. Graduate education took him to Hopkins, then to London, then to New York City. His career started in the Syracuse area. There he began his travels, first local then abroad to assess the health conditions of a region: the good, the bad, and the pre-ventable. Later in the 1950s, he returned to Hopkins and became a fixture at the school of public health. He taught, he wrote, he lectured, he edited, he consulted, and he inspired generations of Hopkins students. He became THE professor of international health. When called upon by government agencies worldwide, he went, offering practical plans for manage-ment of local diseases.

While Dr. Baker received many hon-ors and awards, he was not particularly professorial. He was without pretension; the same person with the less educated laborer (he had worked in a factory during his student days) as he was with academic deans. He became a Mr. Chips of the Bloomberg campus, always available to students and faculty alike. His advancing

kyphosis made him a recognizable figure; walking with his home-carved wooden staff for support. (He once had to sur-render a favorite staff at an airport security checkpoint as a dangerous weapon.)

Tim married Susan in 1951. They eventually settled in Roland Park where they reared three children and filled their home with memories and with books. Susan followed her husband as a public health expert. They formed a sort of Hopkins Dream Team: he the guru of international disease, she the scientific advocate for safety in a man-made world of chemicals and machinery.

In his many roles, public and private, Tim was always the same. He had a quick wit, some wry skepticism, and a fondness for stories about man’s foibles. He had a love of the outdoors—hiking, camping, and skiing—enjoying the simpler plea-sures of a less crowded existence. As a rock hound, he was expert at discovering local minerals and gems, which he would cut and fashion into jewelry. Homemade earrings became a calling card for him and a prized possession of favored faculty and staff. He knew well the minerals of Maryland and those of southeast Nova Scotia, where he could retreat with his family to escape city life.

As an editor, Tim was always honest, yet supportive of effort with his critiques. As a teacher (and we were all, in a way,

taught by him), he had a knack for chal-lenging his students. He would assign a problem or project of which the student thought himself incapable. The results were often a revelation to all, and the world of public health moved a little bit ahead. He was also relentless. He did not like to give up and he pursued his goals until completed. And, he reminded others to do likewise.

Tim Baker was determined to avoid being old and useless. He moved to a retirement community a few years back with some reluctance (“the final solution” he joked), but he refused to retire. He worked until the day he died. He never grew old. He was only eighty-eight.

Dr. Timothy Baker belonged to many: to Susan, to his two sons, to his daughter, to his two grandsons, to his students, and to public health officers around the globe. He also belonged to us at Maryland Medicine. We have lost a colleague. We have lost a good friend.

Memorial gifts may be made to the “Timothy D. Baker Scholarship in International Health” at the Johns Hopkins Bloomberg School of Public Health via online at www.jhsph.edu/giving. Please include “Timothy D. Baker Scholarship” in designation box, or by check made payable to “Johns Hopkins University” and mailed to: External Affairs Department, Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore MD 21205.

Features

Depar tments

Introduction 11Stephen J. Rockower, MD

ICD-10: How Did We Get Here, Or What Are We Doing? 12 Stephen J. Rockower, MD

ICD-10: The Final Nail In The Coffin For Our Profession? 15W. Jeff Terry, MD

Op-Ed: There’s No Code for Quality Care 17Congressman Dr. Tom Price, Sixth District, Georgia

Preparing for ICD-10: Checklist for Successful 19 ICD-10 ImplementationA 4-page pullout section for practices to use for implementation of ICD-10.

ICD-10: Navigating a Successful Transition 23Deb Kenney, CPC, CPMA

The Truth About ICD-10 and Your EMR Vendor 25Michelle Boucher

ICD-10: Are Your Practice Management & Billing 27Systems Ready?Russ Thomas

What Are Payors Doing to Implement ICD-10? 29

ICD-10: Personal Perspective 31Barton J. Gershen, MD

2013 MedChi Necrology 32 2013 Maryland Medicine Index 35

I N S I D E Volume 15 Issue 1

In Memoriam Tribute: 3Timothy Danforth Baker, MD John W. Buckley, MD

President’s Message 6H. Russell Wright, Jr., MD

CEO’s Message 7 Gene Ransom, III, Esq.

Editor’s Corner 9Bruce M. Smoller, MD

Word Rounds 33Barton J. Gershen, MD

The Last Word 38The Most Bizarre ICD-10 Code Awards

BREAKING NEWS: New Law Buys More Time For Physicians to Prepare For ICD-10

As we were working on this issue of Maryland Medicine, U.S. Congress passed and President Obama signed into law H.R. 4302. The fed-eral law delays ICD-10 (developed by the World Health Organization and adapted for U.S. use by the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services) by at least one year based on a pro-vision in the law that will prevent the U.S. Department of Health and Human Services from implement-ing the revised code set before October 1, 2015.

Although the delay gives physi-cians the extra time necessary to prepare for implementation, prac-tice management experts caution that physicians should begin prepar-ing their practices now. Assessing a practice's coding-related processes and getting documentation proce-dures up to speed can be helpful in the existing ICD-9 environment.

More Late Breaking News

As we were sending the issue to press, Kathleen Sibelius announced her resignation as Secretary of Health and Human Services after a five-year tenure.

6 Vol. 15, Issue 1 Maryland Medicine

This issue of Maryland Medicine is focused on the switch to ICD-10. Unless CMS (Centers for Medicare and Medicaid Services) issues a postponement, this will occur October 1, 2014. MedChi, along with the component societies, has been working diligently to provide tools and training to assist doctors and their practices to ease the transition. Please take heed and “Be prepared.” (Props to the Boy Scouts of America.) If you have not already done so, contact MedChi and your software pro-vider to ensure your practice will be ready.

At my inauguration in October 2013, I spoke about the value of volunteering and giving back to the community. I main-tained that the value of our volunteering is an algebraic sum—the value exceeds the sum of the individual experiences.

On a recent trip with my family to New York City, I was reminded of the importance of volunteering. We had the opportunity to visit the 9/11 Memorial. Nearly all of us remember 9/11/2001—

where we were, what we were doing. Although time has dimmed some of the horror of that day, this visit brought back many memories.

As I read the names on the plaques at the Memorial, I was struck by the diver-sity of the victims. Nearly 3,000 people from more than ninety countries were named—men, women, children, and even one unborn child. I stopped to reflect on how much hatred and indiscriminate vio-lence there was behind the planning for and execution of the 9/11 hijackings and attacks. And then I began to reflect on how much our lives had been impacted.

If the hatred of the few who carried out the attacks of 9/11 could change our lives so much, think how the opposite could also change lives for the better. Giving to others, even one hour a week can have an enormous impact. One hour a week in a school, mentoring a child, providing free medical care, Scouting, or working with the homeless will make a difference.

Another way to volunteer and make a difference to our profession and our communities for generations to come would be to participate in MedChi’s Blue Ribbon Panel on the Direction of Medicine. MedChi President-Elect, Dr. Tyler Cymet, has sent out a call for nomi-nations to serve on a panel for MedChi to ascertain the best direction for medicine going into the future. This is an exciting undertaking for MedChi, which should yield valuable data for all of our current and prospective members. I encourage each of you to participate and volunteer.

Volunteerism in this country is unique; it brings us together. It’s as American as mom, pop, apple pie, and the Boy Scouts.

Step up. Give back. Pay it forward. Serve your country, your community, and your profession.

edITor’s cornerH. Russell Wright, Jr., MD

PresIdenT’s MessaGe

The Value of Volunteering

Editorial OfficesMontgomery County Medical Society

15855 Crabbs Branch WayRockville. MD 20855-0689

Phone 301.921.4300, ext. 202 Fax 301.921.4368

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All opinions and statements of supposed fact expressed by authors are their own, and not necessarily those of Maryland Medicine or MedChi. The Editorial Board reserves the right to edit all contributions, as well as to reject any material or advertisements submitted.

Copyright © 2014. Maryland Medicine, The Maryland Medical Journal. USPS 332080. ISSN 1538-2656 is published quarterly by the Medical and Chirurgical Faculty of Maryland, 1211 Cathedral Street, Baltimore, Maryland 21201, and is a membership benefit. All rights reserved. No portion of this journal may be reproduced, by any process or technique, without the express written consent of the

publisher. Advertising in Maryland Medicine does not imply approval or endorsement by MedChi unless expressly stated.

DISCLAIMER: Some articles may contain infor-mation regarding general principles of law. They are not intended as legal advice and cannot be substituted for such. For advice regarding a specific legal situation, consult an attorney licensed in the applicable jurisdiction and with appropriate training and/or experience in the legal area in question.

EDITORIAl STATEMENT

Maryland Medicine Vol. 15, Issue 1 7

Helping Independent Practices Thrive in a Rapidly Changing Industry

Gene Ransom, III, Esq.ceo’s MessaGe

ICD-10 is coming. It’s another nail in the coffin of independent practices. There was a time in this country when you could open a practice with a physician, a nurse, and office space. Now practices need electronic health records, billing special-ists, schedulers, software for various pro-grams, and they must cover overhead for malpractice premiums and other costs of doing business.

The health care industry is rapidly changing and becoming more complex. At the same time, physicians need to continue their positive patient interac-tions that will prevent diseases and keep patients out of the hospital. Independent practices also spur innovation and pro-vide security for employed physicians by offering an alternative career path. That’s why MedChi, the Maryland State Medical Society, established a Center for the Private Practice of Medicine (CPPM). The purpose of the Center is to provide the resources physicians need to thrive as clinicians and small businesses.

The Center is managed by MedChi Network Services, a subsidiary of MedChi and the largest state-designat-ed Management Services Organization (MSO). As an MSO, MedChi Network Services provides direct assistance to help physicians and their medical staff opti-mize their practices. Craig Behm, the Executive Director of MedChi Network Services, is excited to expand practice offerings to Maryland physicians: “Many physicians find that an electronic health record system is simply a tool to drive workplace efficiency and to enhance qual-ity. We are now bringing many more tools to our physicians with the goal of helping practices thrive.”

Private practices face new challenges and requirements every year. New pro-grams from the Centers for Medicare and Medicaid Services (CMS), such as ePrescribing and the Physician Quality Reporting System, add complexity to an already challenging profession.

Independent physicians who do not participate in, and meet the require-ments of, these and other programs will see their Medicare revenue go down as much as 6.5%.

While CMS implements programs aimed at lowering the national cost of health care, commercial insurance carri-ers are implementing programs to reduce the cost of their enrollees. Many carriers have started Patient Centered Medical Homes to provide care coordination between office visits. When planned and executed correctly, these programs show great promise; however, they also require physicians to adapt to whole new sets of care guidelines.

The Center for the Private Practice of Medicine teaches physicians and their staff how to navigate the programs from CMS, commercial insurers, and the state and federal government. The Center iden-tifies the opportunities and connects them with eligible practices so physicians can dedicate their time to helping patients.

The Center can also help any physician sign up at no cost for Maryland’s new Prescription Drug Monitoring Program (PDMP). The new Maryland PDMP is run by Chesapeake Regional Information System for our Patients (CRISP). CRISP has partnered with MedChi to help phy-sicians access the program. Maryland launched the PDMP in late December. The PDMP will enable physicians to access online information about their patients (allowing screening for substance use disorders) and to make referrals for patients who need recovery and preven-tion services. The service should also help prevent dangerous drug interactions.

“The PDMP is a core component of the State’s plan to address prescrip-tion substance abuse,” said Dr. Joshua M. Sharfstein, Secretary of the Department of Health and Mental Hygiene. “This program will help providers intervene in the cycle of addiction and get patients the treatment they need.”

MedChi Network Services also offers practice consulting services, such as rev-enue cycle management through collabo-ration with Health Prime International, a firm located in National Harbor, Maryland. The goal is to give physicians and their staff the tools they need to run a successful business, without the additional costs experienced by large groups and health systems.

If you are interested in signing up for this free service, or you would like to learn more, call Colleen George at 410.539.0872, or email her at [email protected].


Death By a Thousand Codes

Bruce M. Smoller, MDedITor’s corner

Many regulations by governments are necessary, appropriate, and, ultimately, save lives, money, and improve the health and welfare of those who otherwise would have no voice. The regulation that controls the adoption of ICD-10 is not one of these. At the risk of duplicating the angry puzzle-ment of Dr. Rockower, Dr. Gershen, and the hundreds of thousands of physicians appalled by the monumental cost in time and dollars for this mess: WHY?

When you can capture a government spokesperson on the matter, which is something like catching a leprechaun and discussing his pot of gold, the com-mon explanation is that its uber preci-sion (injured while baking, struck by a horse; both actual codes) will ultimately save the government money. Of course the Consultants (spit three times and throw salt over your left shoulder) are the authors of studies (It’s a study…must be true!) showing that the enormous cost to physicians of setting up this nonsense in the electronic environment will pay some benefit down the road to the taxpayer because of the specificity inherent in the 68,000 codes we must pick through. Why is it that every time some regulator or politician decides to forge ahead with some besotted project, we physicians end up paying the freight, taking the time away from productive work or from being with our families, staying up nights trying to backfill codes?

The rationale for adoption of ICD-10 is that the specificity it requires will save money in the end and that the rest of the world has adopted it. Well, the rest of the world has adopted it, but not for billing purposes, as it will be used in this country.

There is a certain amount of post hoc thinking going on here. Even if hearings are called for early in the development of these increasingly burdensome exercises in regulation, the assumption is that doctors need to be corralled, for reasons that are never fully explained, but always have the faint aroma of paternalism in the face of excess. Believe me, we get the fact that medical care is expensive. We can be partners in helping to curtail those costs. What we can’t be is driven out of practice by ideologues who, even with the best of intentions, have not the slightest inkling of what it means to treat a patient.

The Washington Post in its February 16 edition ran an article about the ICD-10 and quoted several of the consultants who make a living off of the HHS [Health and Human Services] departments devoted to making doctors lives just a bit nastier. The silky explanations for why this behemoth will not be overly burdensome, is that doc-tors only have to learn the codes germane to their specialty. I wish that were true. The powers that be have already stated that all codes germane to a patient need to be listed for payment to take place. In the United States, using codes upon codes

upon codes for billing is done mainly for one reason by the insurers…the denial of or delay of claims to make money on the denial or the float in payments. The col-lection of data is ancillary, and a govern-ment, not an insurer, function. They may use the insurers as the point source for the information, but the insurers will use this for denials and delay as sure as they have in the past. Now there is a code: “death by delay of insurer for pecuniary purposes.”

There is one more thing that we, as practicing physicians, can do…. We can tell our patients. This is appropriate, for it is our patients who will ultimately suffer. Those same people who may see their government save a few cents by increased specificity, will experience the fatigue or inattention of their physician, who will be too busy entering data into a computer and looking up new codes to pay full attention to that description of hypothyroidism that the patient is trying to get across. Tell your patients, and enlist their aid in writing to this government to stop being foolish about medical care. This is not a political hot potato either. This began many years ago. Like a kind of Godzilla, it is only now seen for what it is, rising full form to sap more of the good medical care we can otherwise render. Oh wait…the code for that is YZ234.6…slow strangulation of the American medi-cal system by sea monster or government consultant!


EditorBruce M. Smoller, MD

Editorial Board

Director of Publications Susan G. D’Antoni

Managing Editor Susanna M. Carey

Production Nicole Legum Orders

MedChi, The Maryland State Medical Society

CEO

Gene M. Ransom, III, Esq.President

H. Russell Wright, Jr, MDPresident-Elect

Tyler Cymet, DOImmediate Past President

Brian H. Avin, MDSecretary

Benjamin Z. Stallings, MDTreasurer

Stephen J. Rockower, MDSpeaker of the House

Ira D. Papel, MDVice Speaker of the House

Michele A. Manahan, MDAMA Delegation Representative

George S. Malouf, Sr., MDAnne Arundel County Trustee

James J. York, MDBaltimore City Trustee

Anuradha Reddy, MDBaltimore County Trustee

Gary W. Pushkin, MDMontgomery County Trustee

Mark S. Seigel, MDPrince George’s County Trustee

Benjamin Z. Stallings, MDEastern Group Trustee

John J. LaFerla, MDSouthern Group Trustee

Howard M. Haft, MDWestern Group Trustee

J. Ramsay Farah, MD, MPHTrustee at large

Brooke M. Buckley, MDTrustee at large

Stephen J. Rockower, MDSpecialty Society Trustee

Benjamin H. Lowentritt, MDIMG Section Trustee

Jeffrey R. Kaplan, MDResident Section Trustee

Vacancy to be filledMedical Student Section Trustee

Taylor T. DesRosiersBylaws Council Chair

Shannon P. Pryor, MDCommunications Council Co-Chairs

Shital Desai, MD and Bruce M. Smoller, MDlegislative Council Co-Chairs

Brooke M. Buckley, MD and Gary Pushkin, MD Medical Economics Council Co-Chairs

Loralie Ma, MD and Richard Scholz, MDMedical Policy Council Co-Chairs

Ramani Peruvemba, MD and Ambadas Pathak, MDOperations Council Co-Chairs

Seth Y. Flagg, MD and David Safferman, MD

John W. Buckley, MD Beverly A. Collins, MD, MBA, MSTyler Cymet, DOBarton J. Gershen, MD (Editor Emeritus)

Mark G. Jameson, MD, MPHStephen J. Rockower, MDAnne Sagalyn, MD

Your worst nightmare is coming. ICD-10 (International Classification of Diseases, 10th Revision) will probably be the biggest change to your work environ-ment in the past twenty-five years. EHRs were a drop in the bucket, since they only slowed you down and made you inefficient. ICD-10 will do that and more, since you won’t get paid for your work while it is being figured out. If you thought the rollout of the Affordable Care Act went smoothly, you’ll love the implementation of ICD-10!

If you don’t know about ICD-10 yet, you are in big trouble. On October 1, 2014, every insurer will change the way they accept diagnosis codes from physicians—hos-pitals, nursing homes, and any and all health care providers. This effort to change has been planned for many years, but there has been significant “push-back” from the AMA and other physician groups. It must be noted that ICD-10 has been in use around the world for many years already. However, ONLY IN AMERICA will it be used in an outpatient setting and for billing purposes.

This issue of Maryland Medicine presents the history, the pros and the cons of ICD-10, and how it might (or might not) work in your practice.

We begin with a history of the classification of disease to inform you of the 200-plus year history of the ICD. The AMA’s estimates of the cost to physicians are included. Be sure to take your Tagamet as you read this.

Deb Kenney, a practice management consultant, presents some tips and tricks for implementing ICD-10 in your practice. Michelle Boucher, of Medical Mastermind of Baltimore, discusses how to integrate ICD-10 into your EMR and revenue cycle. Russ Thomas of Availity, a clearance house, also gives pointers on integration and contingency planning. Everyone who has any knowledge is recommending a sig-nificant line of credit to mitigate cash flow difficulties.

Jeff Terry, MD, from Alabama presents a strong rebuttal of the need for and advisability of the ICD-10 system, concentration of the problems surrounding the number of codes, and their use for billing purposes.

We also have some perspectives from some of the insurance companies (CareFirst, Cigna, and United Health Care) on how they have tried to integrate ICD-10.

Congressman Tom Price of Georgia, an orthopaedic surgeon before he entered politics, presents a federal perspective on ICD-10.

In this issue, John Buckley, MD, contributes a moving tribute to Timothy Baker, MD, who passed away earlier this year. Tim, an extremely well-respected epidemi-ologist at Johns Hopkins Hospital, was a member of the Maryland Medicine edito-rial board for many years. Tim and I collaborated on a number of issues of Maryland Medicine; he always had a kind word, a perceptive comment, and a gentle demeanor. He will be greatly missed.

We always want to hear from our readers. Please send comments, suggestions, criticisms, and/or praise to us at [email protected].

Stephen J. Rockower, MD, is an orthopaedist practicing in Rockville, MD. He is President-Elect of Montgomery County Medical Society, on MedChi's Board of Trustees, and a member of the Maryland Medicine Editorial Board. He can be reached at [email protected].

IntroductionStephen J. Rockower, MD


The International Classification of Diseases, Tenth Revision, better known as ICD-10, is coming to a medical office or hospital near you in October 2014. This will happen whether you like it or not, unless the government changes its mind, again.

What is the ICD, and how did it get here? In 1785, William Cullen of Edinburgh published his Synopsis nosoligiae methodicae, a treatise that became widely used in the classification of causes of death. This was revised by William Farr in a report to the International Statistical Congress in 1855. Farr had risen to prominence by discovering the relation-ship of people’s drinking water to cholera, noting the correlation between untreated sewage in the Thames River and the out-break of the disease (Note relationship to Charleston, West Virginia, today). Farr proposed five groupings of causes of death: epidemic diseases, constitutional diseases, local diseases, developmental diseases, and violence related diseases.

In 1893, the International Statistical Institute combined Farr’s classifica-tion with that of Jacque Bertillon of Paris as well as the current Swiss and German classifications. This Bertillon Classification of Causes of Death com-prising 161 titles was widely accepted. In 1900, an international conference revised this number to 179 groups, and recommended revisions to be made every ten years. The first revision occurred in 1910, and again in 1920, 1929, and the fifth revision was in 1938. By this time, the list had grown to only 200 causes of death.

The Fifth International Conference for the Revision of the International List of Causes of Death in 1938 also recognized the need for statistical orga-nization of morbidity or disease for use by health insurance companies, hospi-tals, military medical services, health administrations, and similar bodies.

(Note that treating physicians are not included.) Many countries had previ-ously established their own listings of illnesses, including the U.S. Department of Commerce and Labor’s work in 1910 of the International Classif ication of Causes of Sickness and Death. No one list was universally adopted until the 1938 conference recommended that one uni-form plan be adopted.

An expert committee was formed in 1946 to assemble the Sixth Revision, which was adopted in 1948 under the auspices of the newly formed World Health Organization (WHO). This began the now familiar alphanumeric classifications of three or four digits with alpha codes for further classifica-tion. At that time, there were 4,800 codes, including such distinctions as “Accidents by bites and stings” at Home, Farm, Mine or Quarry, Industrial Place, Recreation Place, Street or Highway, Public Building, Residential Institution, or Other. The Seventh Revision in 1955 grew the list to 4,900 codes, but the Eighth Revision in 1965 actually shrank the listing to 4,600 codes.

The now familiar Ninth Revision of the International Classif ication of Diseases in 1975 (ICD-9) retained the basic struc-ture, but added significant details in the fourth and fifth digit of the classification. In 1979 the U.S. Public Health Service released the “Clinically Modified” ver-sion. This swelled the listing to more than

17,000 codes, but allowed a great deal of detail for use in statistical purposes. It allowed information about underlying diseases as well as specific organ manifes-tations. This system has been in general use since then.

Even before ICD-9 was released, the WHO realized the basic structure was inadequate for statistical purposes. It was felt that a significant reworking was necessary, and that extended time was necessary for its formulation. The previous revisions had been released on roughly a ten-year schedule, but extra time was needed to prepare the new Tenth Revision. It was released in 1990, and has been in general use around the world since 1994. There are now more than 68,000 codes for clinicians to iden-tify. Work on ICD-11 is in progress, and it is anticipated in 2017.

The new ICD-10 system is designed not only to classify diseases and mor-bid conditions, injuries, and signs and symptoms, but also to separately clas-sify external causes of diseases as well as “factors … explaining the reason for contact with health-care services of a person not currently sick.” The change allows epidemiologists to better under-stand and classify what physicians are treating and how to better understand the health of populations.

As one can see in the table on page 13, the basic structure is similar to the ICD-9, but the lettering system has changed. At a minimum, each diag-nosis is classified by at least one letter, two digits, a decimal, and a third digit (A00.0). Additional digits or letters are added, depending on the specificity needed. Thus osteoarthritis of the hip (715.15 in ICD-9) becomes M16.1, with an additional fourth code of 1 for Left or 2 for Right.

Some codes require the use of a sev-enth character for codes in sections M, O, R, S, T, V, W, X, Y. If there are fewer

ICD-10: How Did We Get Here, Or What Are We Doing? Stephen J. Rockower, MD

WHO Headquarters, Geneva, Switzerland.


than six characters in the code (not count-ing the decimal point), the placeholder “x” is used to ensure that the seventh charac-ter is always in the seventh position. For example, “A” (for initial encounter) is in the seventh position in “S03.4xxA Sprain of jaw, initial encounter.” Note the dif-ference between the initial “X” codes of injuries and the placeholder “x,” which is to be used in the middle of a code. The final letter in the seventh position is used to indicate the encounter type (A=initial encounter, D=subsequent encounter, and S=sequela). The seventh position is most complex in dealing with fractures, as there are sixteen letters, differentiating whether the original fracture was closed or open, how complex the fracture was, and whether there is normal, delayed, angled, or no healing.

Seemingly, the best website for cross-walking (or translating) codes is www.icd10data.com. This site provides a tool for converting ICD-9 codes to approxi-mate ICD-10 codes, and vice versa. You can download listings of codes with tables to provide ICD-9 to ICD-10 listings and back (www.cms.gov/Medicare/Coding/ICD10/). These translations are approxi-mate, and extra alphanumerics may be necessary. Of course, there are a plethora of organizations willing to sell you the data and “help” you in this transition.

Chapter Blocks Title

I A00–B99 Certain infectious and parasitic diseases

II C00–D48 Neoplasms

III D50–D89Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism

IV E00–E90 Endocrine, nutritional, and metabolic diseases

V F00–F99 Mental and behavioral disorders

VI G00–G99 Diseases of the nervous system

VII H00–H59 Diseases of the eye and adnexa

VIII H60–H95 Diseases of the ear and mastoid process

IX I00–I99 Diseases of the circulatory system

X J00–J99 Diseases of the respiratory system

XI K00–K93 Diseases of the digestive system

XII l00–l99 Disea ses of the skin and subcutaneous tissue

XIII M00–M99Diseases of the musculoskeletal system and connec-tive tissue

XIV N00–N99 Diseases of the genitourinary system

XV O00–O99 Pregnancy, childbirth, and the puerperium

XVI P00–P96 Certain conditions originating in the perinatal period

XVII Q00–Q99Congenital malformations, deformations and chro-mosomal abnormalities

XVIII R00–R99Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified

XIX S00–T98Injury, poisoning and certain other consequences of external causes

XX V01–Y98 External causes of morbidity and mortality

XXI Z00–Z99Factors influencing health status and contact with health services

XXII U00–U99 Codes for special purposes

International Statistical Classification of Diseases and Related Health Problems, 10th Revision


ICD-10: The Final Nail In The Coffin For Our Profession?W. Jeff Terry, MD

The International Classification of Diseases, 10th revision (ICD-10), is now just around the corner with its implementation date set for October 1, 2014. ICD-10 is not part of the Affordable Care Act (ACA). It is owned by the World Health Organization, and its primary purpose historically has been for vital statistics and epidemiologi-cal data. ICD was first published in 1900, and ICD-9 was introduced in the United States in 1979. ICD-10 is being imple-mented by Secretary Kathleen Sebelius, the Department of Health and Human Services (HHS), and the Centers for Medicare and Medicaid Services (CMS). On January 16, 2009, HHS published a final rule in which Secretary Sebelius adopted ICD-10 as the HIPAA standard to replace ICD-9 with implementation set for October 1, 2013. On August 24, 2012, HHS issued a new final rule that officially changed the implementation date from October 1, 2013 to October 1, 2014 primarily because of advocacy from the American Medical Association (AMA). HHS made the fol-lowing statement in the Federal Register as part of the review process:

If 25 percent of physician claims were to continue to be submitted using ICD-09 codes after an October 1, 2013 compliance date, millions of claims would likely be returned and physicians might experience devastating cash flow problems. Lack of reimbursement could force practices to shut down, mak-ing medical services inaccessible to patients and/or forcing physicians to ask patients to pay up front, out-of-pocket, for medical ser-vices, which, aside from being barred by the terms of some insurance programs, would be extraordinarily burdensome to patients.1

HHS also stated:

A two year delay in the ICD-10 compliance date may also signal a lack of HHS’ ICD-10 commitment, potentially engendering industry fear that there could be another delay in, or

complete abandonment of, ICD-10 implemen-tation, with subsequent heavy financial losses attributable to ICD-10 investments already made. Industry representatives also expressed concern about the loss of momentum in progress toward ICD-10 compliance that would result from a 2-year compliance extension.2

HHS and Secretary Sebelius continue to speak of industry favoring ICD-10. They apparently do not consider physicians as part of the industry.

Resolution 216 from the AMA meet-ing in November 2011 was passed without dissent and called for our AMA to vigor-ously work to stop the implementation of ICD-10. Since that meeting we have passed other resolutions to (1) vigorously advocate that CMS eliminate the implementation of ICD-10 to alleviate the increasing bureau-cratic and financial burdens on physicians and (2) reiterate to CMS that the burdens imposed by ICD-10 will force many physi-cians in small practices out of business. In spite of this very strong stance in opposition to ICD-10 by organized medicine and very strong personal lobbying by the President and Board Chair of the AMA, Secretary Sebelius continues to forge ahead with the October 1, 2014, implementation date. This stance by Secretary Sebelius is amazing since the AMA represents every state medi-cal association and every national surgical and medical specialty society in this country. Physicians are the backbone of medicine in this country. Physicians are the ones with their feet on the ground working hard every day to care for our country’s population. Physicians are part of the “industry,” and we are the ones who best understand how the day-to-day government regulations are harming our profession as well as the care and access to care of our patients. Physicians are the part of the industry who work on Christmas, other holidays, weekends, and nights, while the rest of the industry is at home. Physicians are the ones who have to make coding decisions in the office under

short time constraints while the government and insurance regulators review our records with much more time on their hands to criticize our choice and deny payment for our care. The government and Secretary Sebelius have no idea how much harm they will do to our profession by implementing this tsunami of codes into our practices all on one day! I think they would have learned some lessons from October 1, 2013, when the implementation of the ACA exchange website failed. Either HHS did not learn from that experience, or they simply don’t care about the physicians and patients in this country.

Even if you think ICD-10 is the best thing that has happened to medicine, it is not being implemented properly and the negatives far outweigh the perceived posi-tives. Most of the arguments for changing to ICD-10 have to do with statistical things and very little with patient care. There has never been a study clearly showing that EMRs or ICD-10 will decrease errors or improve patient care. There will be definite costs associated with implementation, and studies have shown that our government is sticking each physician with a $23,000 tax bill for the privilege of implementing ICD-10 and practicing medicine the way Uncle Sam tells us to do it.

The actual transition will be complicated, and experts have said that it will take a year of preparation to make the transition, so if you haven’t already started then you have a problem. This transition will be one that every physician, hospital, insurance compa-ny, and anyone in the complicated medical payment pyramid will have to make all on


one day. It is important to understand that if you are not ready, and if all of your vendors are not ready by October 1, 2014, then your income plummets to zero. And if you do not have a friendly banker, then you are out of business. My bank has refused to give me a $1.6 million unsecured loan, which is what it takes to run my eight-physician practice for two months. I can’t say that I blame them, and I am not about to put up my personal assets and retirement funds as collateral.

The United States is the only country that will use all approximately 90,000 codes, and the United States is the only country that will use it for billing purposes, that will use it in the outpatient setting, and that puts the cost of implementation on physicians and the private sector. This distinction is important to note because the main reason given for implementing ICD-10 is that we are the only nation who has not done so. We are also told that we must move ahead with the new technology because we have outgrown ICD-9; however, if the technology is bad, will not improve patient care, and will make our practices less effi-cient then there is no need to implement it. Another major comment by CMS is that the “industry” has already invested mil-lions of dollars in this new system so we must move on with it. I have also invested much money preparing for the implementa-tion of ICD-10; however, the money lost after implementation to physicians will far surpass the money spent preparing for it. Perhaps someone in the health care system will save money on ICD-10, however it will be at the expense of physicians and patients. These statements as well as almost every other reason to implement ICD-10 are not accurate, and like everything else that comes out of Washington is full of politics. CMS also says that after ICD-10 implementation, physicians can expect changes in payers’ prior authorizations and approvals as they refine medical policies. Physicians may also see a significant increase in denials as a result of coding challenges. Audits of all types are increasing in depth and breadth, including Recovery Audit Contractors. After the transition to ICD-10, the specificity and detailed information levels will result in greater documentation scrutiny.3

Why are physicians treated differently? We can’t have ownership in hospitals, and Stark laws make many cost-effective ser-vices we can provide for our patients almost impossible. We can’t have private contract-ing with our patients, and if we even talk

about fees with one another then we are in violation of antitrust laws, whereas insur-ance companies use their massive numbers and monopolistic powers to control us and determine what we are paid for our services. There is no true competition or free market forces in health care. Previous attempts to control the legal profession’s contingency fee payments did not get to first base, nor does any significant medical liability reform. What would happen if our government tried to pass a law on industry mandating a new accounting system for every busi-ness that would cost every employer more than $25,000 to implement? It also would not get to first base, yet this is exactly what Secretary Sebelius and CMS are doing to our profession. If we do not comply, then basically we are out of business unless we can afford to be a 100% cash only practice.

Many physician practices (especially the rural one- or two-physician practices) do not have the time, money, or expertise to meet all of the requirements for meaningful use in EMR (electronic medical records), the PQRS (Physician Quality Reporting System) program, e-prescribing, HIPAA, OSHA, CLIA (Clinical Laboratory Improvement Amendments), and now ICD-10. Physicians are overwhelmed with all of the regulations being poured down on us from Washington and are slowly getting regulated out of business. Each regulation is just another nail in the coffin. Physicians in our country are looking at huge increases in capital outlays to meet EMR requirements and at the same time are looking at penal-ties for not meeting the meaningful use requirements, for not meeting a threshold for e-prescribing, for not reporting appro-priately in the PQRS program, along with a 2% reduction in payment due to sequestra-tion. If ICD-10 is implemented and physi-cians are not prepared, their payments will go to zero. That is a pretty steep penalty for a coding system that will not improve the care we give our patients in our offices.

There are two bills in the U.S. Congress that can put a halt to this insanity. They are H.R. 1701 and S. 972, entitled “The Cutting Costly Codes Act of 2013.” The two bills in Congress ask for a study within six months and recommendations for a replacement of ICD-10. There are several things that can be done. The main reason the American ICD-10 is so complex is because it will be used for billing. If we decouple it from bill-ing, then things will be simplified. That is just one idea. We can also come to the real-ization that doctors need to get their heads

out of the computers and start taking care of their patients again. All of these detailed codes are said to be helpful for research and statistics; however, they still do not meet the requirement of the scientific method that we use in medical research. These detailed codes are not needed in the day-to-day care that we give our patients in our offices.

We are a profession with a social contract between our patients and us, not between the government and us. We are losing our profession slowly but surely, and ironi-cally, because we are too busy caring for our patients to see it coming. Secretary Sebelius, Washington, and other non-patient care physicians in the health care system simply do not understand what they are doing and do not see the big picture. On October 1, 2013, they should have seen the enormity and complexity of the health care system. Patient care didn’t suffer (at least not yet); however, when things don’t go right on October 1, 2014 (and it will not—why else are we being told to have a line of credit and contingency plans), then patient care will suffer. Physicians are humans, too, and if our income goes to zero because of an ill-conceived coding system and problems in the payment pyramid of medicine, then it may be the final nail in the coffin for many of us individually, and potentially for our profession.

W. Jeff Terry, MD, has practiced adult and pediatric urology in Mobile, Alabama, since 1985. He has been active in orga-nized medicine since 1989 and has served as president of the Medical Association of the State of Alabama, president of the Alabama Urology Society, President of the Mobile Young Physician Society, and Chairman of the Alabama Independent Physicians Association. He has been a delegate to the AMA since 1995 and has served on the AMA Council on Medical Service.

References:

1. “A Change to the Compliance Date for ICD-10-CM and ICD-10-PCS Medical Data Code Sets, Proposed Rule.” Federal Register 77:74 (17 April 2012) p. 22989.

2. “A Change to the Compliance Date for ICD-10-CM and ICD-10-PCS Medical Data Code Sets, Proposed Rule.” Federal Register 77:74 (17 April 2012) p. 22990.

3. ICD-10 Implementation Guide for Small and Medium Practices, CMS 2012.


There’s No Code for Quality Care Congressman Tom Price, MD

Physicians are used to dealing with complex systems—the human body being the most obvious example. They devote their years of education and their craft to finding answers to tough questions, solu-tions to difficult and—for patients and their families—very personal challenges. The eagerness of physicians, scientists, and other health care providers to tackle the complex and at times unknown is driven by the knowledge that their time and commitment is in service to the health and well-being of others. Providing the best care for patients is the motivation.

So it is with particular concern and consternation that today physicians are being inundated with a new set of com-plex problems to solve. The purveyor of these new challenges is, generally speak-ing, the regulatory state. It’s the folks who are not so much in charge of actually caring for patients but the ones who have taken it upon themselves to be in charge of telling physicians more and more how to care for patients.

Their more widely known mandates and regulations center most recently on the implementation of electronic health records (EHRs) and meaningful use requirements. The sorts of items that can justifiably be applied to improving quality care if physicians have the flexibility, the time and the resources to comply in an orderly fashion. That’s a big “if.”

But then you have the complexities being handed down from upon high that have at best a tangential relationship to serving the needs of patients. Perhaps none will be more frustrating and costly to the delivery of care than the new ICD-10 diagnosis coding system that American physicians, hospitals and other health care providers are being told to adopt.

The ICD-10 system has already earned a reputation as a bridge a bit too far—a sign that the regulatory state has become far too prescriptive to the point of being

comical. You’ve likely heard of some of the more humorous new diagnosis codes. ICD-10 applies specific codes to injuries related to burning water skis, injuries sustained through an accident with a military vehicle while riding an animal, or being struck by any number of different animals—for example, an orca.

Could those examples and any of the others listed in the ICD-10 system occur? One supposes almost anything is possible. But the “more is better” mentality that sits behind the drafting and implementation of this system portends a very arduous and in many cases financially perilous environ-ment for physicians and their practice.

Resources that might be applied to new innovative technologies, expanded capac-ity to serve new patients, or even chari-table payment scenarios will be diverted to pay for the adoption and implemen-tation of ICD-10. Those most likely to be squeezed are the private practices—particularly those caring for patients in rural or under-served communities—that operate on narrow margins. That shifts the delivery of care to hospitals where the quality can be equal but the costs dispro-portionately higher.

As an orthopaedic surgeon who prac-ticed medicine for over twenty years in the Metro Atlanta area, I know first-hand about practicing medicine both in a private and hospital setting. There are benefits and drawbacks to both. But what makes our health care system most ben-eficial to patients is the flexibility and diversity of care. The regulators are on schedule to continue destroying that flex-ibility and diversity of care.

We see it in the manner in which the Affordable Care Act (ACA) is defining quality care based on a Washington-centric point of view. And, we see it with the unwillingness on the part of the Centers for Medicare and Medicaid Services (CMS) to consider a delay in

the implementation of ICD-10 coding requirements. CMS Director Marilyn Tavenner recently confirmed that Washington would consider no more delays and that it was “time to move on.”

Thankfully, Congress has taken action—albeit in a limited capac-ity. Legislation recently signed into law included a one-year delay of the ICD-10 deadline. It pushes back the date at which medical providers must adopt the new coding system from October 1 of this year to October 1, 2015.

So where does that leave physicians trying to practice their profession and care for patients? According to a February 2014 report commissioned by the American Medical Association (AMA), a small medical practice will be on the hook for anywhere between $56,639 to over $226,000 in costs associated with the transition. For a medium size practice, AMA estimates pre and post-implemen-tation costs rising to as high as $824,735. And, the “typical large practice” can expect to pay anywhere in the range of $2 million to $8 million.

Perhaps in Washington that’s not con-sidered a lot of money. But in the real world where the cost of health care deliv-ery is already rising due to any number of other forces—including innovation and other regulations—adding hundreds of thousands to millions of dollars to the cost of care is incredibly troubling.

It should come as no surprise that an overwhelming majority of physicians were not ready for this year’s October 1 deadline. A survey by the Medical Group Management Association found that slightly fewer than 10 percent of medical practices claim to have made significant progress on implementing the overhaul of the ICD system. In other words, if you were to put aside the argument about

Congressman Tom Price, MDoPInIon


whether or not shifting to the new coding system was wise or necessary, folks still are not ready.

In Congress, there’s a broader effort underway to avoid this coming train wreck altogether. H.R. 1701, the Cutting Costly Codes Act of 2013—of which I’m a co-sponsor—would prohibit the Secretary of Health and Human Services from moving forward with the ICD-10 implementation.

What happens if a year passes, no action is taken to prohibit the imple-mentation, and further delays are not forthcoming? If Washington ignores the facts and the frustration shared by many in the medical community? The initial costs associated with adopting ICD-10

will likely seem like a drop in the bucket over the longer term as medical practices struggle to familiarize themselves with the new litany of codes. It is expected that the number of codes will grow from roughly 20,000 to over 150,000.

Any failures to properly apply the right diagnostic label may be met with rejection or withholding of payment for services already rendered. Furthermore, fines and other costly legal proceedings could be incurred by physicians and medical prac-tices whose only crime may be that they had unwittingly failed to comply properly with this complex new system.

Were the new ICD-10 diagnosis codes coming online in otherwise relatively calm waters in the nation’s health care sys-tem, the disruption could perhaps have been contained. But that’s not the reality physicians face today. With the imple-mentation of the Affordable Care Act,

America’s health care system and those participating in it have been thrown one curve ball after another—told to get on board or get out of the way.

Far too often that’s how a bureaucracy functions, and it is the strongest argu-ment against endowing regulators with the type of prescriptive power they are now preparing to wield. For the sake of patient access to quality, affordable care, we must continue to search for solutions that will let physicians do what they are trained to do—care for those in need. To be successful, physicians must engage in the public debate.

Congressman Dr. Tom Price represents Georgia’s Sixth Congressional District. An orthopaedic surgeon, he spent more than twenty years caring for patients.

No Code for Quality Care ...continued from page 17

The Maryland State Medical Society

Are You Ready for ICD-10?

MedChi conducted a brief survey recently to determine the readiness of its members for ICD-10. Are you more or less ready than those who responded? You be the judge. (Note: The survey didn’t intend to be scientific, and the response was low—sixty-four responses—it’s simply a representation of the readiness of those who shared their views with us.)

What impact do you think the conversion to ICD-10 will have on your practice?55.6% expect a significant impact, and a disruption in payment and other operational issues.

How ready is your practice for the transition to ICD-10?61.3% haven’t started preparing for the transition.

Have you and/or your practice staff participated in ICD-10 training?37.7% said they have attended training.

What organizations have offered training that you and/or your staff have participated in?The respondents indicated they have sought training from practice management education companies, their state, and specialty societies.

With which of your current vendors have you already discussed ICD-10 conversion in your practice?69.4% have discussed the transition to ICD-10 with their EMR vendors, and secondly with their revenue cycle management company or billing vendor.

Are you aware that there may be a disruption in payments from insurers due to problems associated with conversion to ICD-10 requiring you to have a line of credit at your bank?64.5% said they are aware that this may be necessary.

Are there any additional resources or education that you and your staff need to make the transition to ICD-10 more effective and less stressful?Many physicians commented that they need MedChi to advocate for a delay or to stop ICD-10. Others commented about the need for more detailed education and checklists.

ICD-10

Checklist for Successful ICD-10 Implementation- Importance of Documentation

- Transition Checklist

- Training & Implementation Resources

What is the key to a successful ICD-10 implementation? For physi-cian practices, it is documentation improvement for accuracy, com-pleteness, and specificity of conditions. Once you make the necessary changes to improve your documentation, the rest of the implementation should go smoothly. Documentation improvement will enable you to• accurately code diagnoses and procedures;• input the necessary information; • submit correctly coded claims to your health plans, and get paid!

There are other clear benefits from good documentation, including: accuracy in quality measurement, protection from payment reversals in any post payment audit reviews, and good patient information for other providers involved in a patient’s care.

In this era of electronic sharing of patient records, it becomes more and more important to have complete and accurate records to share, and to receive complete and accurate records from other providers of medical care.

How do we approach improving documentation in the face of the impending ICD-10 implementation? The good news is that this is a step that physicians can begin to take immediately. Better documenta-tion allows for more precise coding of ICD-9 diagnosis codes, CPT (Current Procedural Terminology) codes, and HCPCS (Healthcare Common Procedure Coding System) codes today; and better docu-mentation prepares us for the switch to ICD-10 coding on October 1, 2014, and ensures that the rest of the ICD-10 implementation will go much more smoothly.

This process of documentation improvement will differ from practice to practice and will depend on the types of patients you deal with, the sources of your documentation, and the quality of documentation today. Some providers have found that their current documentation is good enough for ICD-10, but most providers have demonstrated the need for improvement through documentation reviews.

Each practice should take the following steps:• Focus on the conditions (not specific codes, but general catego-

ries of diagnoses) that occur most frequently, consume the most time, or bring the most revenue to the practice.

• Obtain either the ICD-10 code book, or an ICD-10 app for computer, tablet, or smartphone.

• Review the ICD-10 codes and descriptions for the condition or range of conditions to understand the types of information that will have to be gathered.

let’s look at diabetes, as diabetes codes change dramatically in ICD-10 (as do orthopedic, cardiology, and obstetrics/gynecology codes.).

“Good documentation starts with a good grasp of what should be writ-ten down. While some unspecified codes are still acceptable to payers, the increased specificity in ICD-10 codes means that simply saying a patient has uncontrolled diabetes isn’t sufficient anymore. ICD-10 codes will ask for the type, complication, and manifestation, requiring providers to under-stand and document the difference between diabetes mellitus due to an underlying condition and diabetes induced by drugs or chemicals.

“In ICD-9, the fifth digit of diabetes codes not only indicates the type of dia-betes but also whether the diabetes is uncontrolled or out of control,” explains Melanie Endicott MBA/HCM, RHIA, CCS, CCS-P, Director of HIM Practice Excellence at the American Health Information Management Association

(AHIMA). “This concept is gone in ICD-10. Instead, the physician must docu-ment that the diabetes is inadequately controlled, out of control or poorly con-trolled. You have to code the diabetes by type and add ‘with hyperglycemia’.” (Source: “Top ICD-10 clinical documentation improvement pain points,” by Jennifer Bresnick, January 6, 2014, http://ehrintelligence.com)

As you can see, it is critical to review the documentation that you create, or that you have sent to you, to determine if you are document-ing the important concepts required for the correct codes in ICD-10. Without the documentation of the important concepts, you will be unable to select a specific ICD-10 code, or you will be getting questions from coders, billers, and health plans. Unless justification for the code has been documented in your records somewhere, it cannot be used for the coding process. And once the patient encounter is in the past, it may be difficult to recall the specifics of the patient circumstance.

Each source of documentation in a practice needs to be reviewed for the necessary specification and accuracy. If you rely on an electronic health record (EHR) to guide your documentation, you will need to determine how best to revise the record to collect the necessary docu-mentation. Some EHRs allow for individual customization of templates and screens by each practice. Some EHRs will require you to work with the vendor to make those changes. Remember, these are steps you can take now and not wait until October 1 to implement.

If you use paper records for documentation, your task is somewhat harder. Each of your providers must be trained on what they need to document for each condition. I recommend focusing as soon as pos-sible on your highest priority conditions and training on those early in the process. Each training session should probably focus on only one or two conditions. Follow up on the documentation to see if there has been improvement.

If much of your documentation comes from outside your practice (e.g., through referrals, consults, or hospital records), you have a more difficult task. You still must review the documentation you get to deter-mine its adequacy. Remember that every provider in the country will be required to implement ICD-10, so we hope all providers are reviewing and improving their documentation. However, you cannot assume that is happening. Someone in your practice should review the documenta-tion you are receiving from each source and determine if it will meet your needs for ICD-10 coding. If you find that the documentation from outside sources will need improvement, you should contact the source to determine if they have their own ICD-10 or documentation improvement process. There will be a need to explain why you suggest improving their documentation, and perhaps an offer to work together will benefit both of you.

Starting today, move through your list of conditions beginning with the most important. Make the necessary documentation improvement changes. This process will probably last through October 1, 2014, and beyond. Your practice and your patients will be much better off for it.

Stanley Nachimson provides independent leadership to the healthcare information technology industry on a variety of topics, including ICD-10 imple-mentation, new HIPAA transaction standards, EHR development and imple-mentation, and industry collaboration among plans, providers, and clearing-houses. Nachimson is the former CMS lead on HIPAA regulatory development and implementation. He can be reached at [email protected].

Documentation, Documentation, Documentation The Key to ICD-10 ReadinessStanley Nachimson

Getting Ready For ICD-10: Checklist for Successful Transition

This checklist is designed to provide a viable path forward for organizations beginning to prepare for ICD-10 implementation. We encourage those who are ahead of this schedule to continue their progress.

1. Identify resources from CMS, trade associations, MedChi Network Services, payors, and vendors to assist you and

your practice in a successful conversion (see pg. 4 of pullout).

2. Ensure top leadership understands the extent and significance of the ICD-10 changes.

3. Assign responsibility and decision-making authority for managing the transition.

4. Identify how ICD-10 will affect your practice. • HowwillICD-10affectyourpeopleandprocesses?Tofindout,askallstaffmembershow/wheretheyuse/seeICD-9. • IncludeICD-10asyouplanforprojectssuchasMeaningfulUseofElectronicHealthRecords.

5. Plan a realistic budget including, but not limited to:

• Softwareupgrades • Stafftrainingneeds

• NewcodingguidesandSuperbills

6. Obtain ICD-10 code books if you currently use ICD-9 books for code look-up.

7. Check your software for an ICD-10 look-up function.

8. Identify commonly used ICD-9 codes and explore related ICD-10 codes.

9. Identify paper and electronic forms to accommodate the ICD-10 code structure.

10. Schedule ICD-10 training for clinical and administrative staff:

• ClinicalCareandDocumentation • OfficeManagement • OperationsandBilling • CodingandRecordManagement • InformationTechnology • Compliance

• Finance

11. Review staffing levels and determine if there is a need to outsource for additional coding expertise during transition

to ICD-10.

12. Determine if existing billing system can submit and receive ICD-10 codes. If not, what upgrades need to be made and

at what cost?

13. Determine readiness of your vendors (software/systems, clearing houses, billing services) by asking the

following questions: • WillyousupportmycurrentproductsafterOctober1,2014? • WillyoucontinuetoupdatemyproductsafterOctober1,2014? • Willyouneedtoupdatemyproducts/applicationspriortoOctober1,2014? • WillupdatestakeplacewithtimefortestingpriortoOctober1,2014? • Willyoukeepmyproductsupdated? • WillIneednewhardwaretoaccommodateICD-10softwareupgrades?

• Whatisthecost?

14. Determine readiness of payors: • ArepayorsrevisingpoliciesorcontractsbasedonICD-10? • WhataretheirtestingplanstodetermineICD-10readiness?

15. Review changes in documentation requirements and educate staff by looking at frequently used ICD-9 codes and

corresponding ICD-10 codes (ongoing).

ICD-10 Transition & Training Resources

State Medical Society:MedChi, The Maryland State Medical Society www.medchi.orgMedChi & MedChi Network Services 1.800.492.1056

Component Medical Societies:Anne Arundel & Howard County Medical Society 410.544.0312Baltimore City Medical Society 410.625.0022 www.bcmsdocs.orgBaltimore County Medical Association 410.539.0872Montgomery County Medical Society 301.921.4300 www.montgomerymedicine.orgPrince George’s County Medical Society 410.544.0312All Other: Contact MedChi

Specialty Societies (For the impact of ICD-10 transition on your specialty, contact your national specialty society.)

ADDITIoNAL ASSoCIATIoN/oRGANIzATIoNAL RESouRCES:

American Academy of Professional Coders (AAPC) AAPC offers members a full ICD-10 Implementation Tracker and training options based on practice size to assist practices with their own project plans and charting their progress. www.aapc.org

American College of Physicians www.acponline.org

American Health Information Management Association (AHIMA) AHIMA offers a wide range of online resources and training events. Visit their website to check out their ICD-10 Implementation Toolkit, Checklist, and a link to HIMSS ICD-10 Playbook. www.ahima.org

American Medical Association www.ama-assn.org

Centers for Disease Control and Prevention www.cdc.gov

EHR Intelligence www.ehrintelligence.com

Healthcare Financial Management Association www.hfma.org

Healthcare Information and Management Systems Society www.himss.org

HealthcareITNews and HEALTHCAREFINANCENEWSwww.icd10watch.com

Health Data Management www.healthdatamanagement.comICD-10 Code Set Publicationswww.hitechanswers.net/featured-icd-10-products

PAYoRS:

CareFirst www.provider.carefirst.com

Centers for Medicare & Medicaid Services (CMS) Provider Resources offers everything from an introductory guide to ICD-10 to step-by-step implementation planning.www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

Road to 10: The Small Physicians Practice’s Route to ICD-10

CMS ICD-10 Implementation Guide for Small and Medium Practices (PDF)www.cms.gov/ICD10

Cigna www.CignaforHCP.com

Novitas (Medicare Carrier) www.novitas-solutions.com

unitedHealthcare www.unitedhealthcareonline.com

Physicians EHR www.physiciansehr.org

Precision Practice Management www.precisionpractice.com

TRAINING:

4Medapproved ICD-10 for Clinical Providers Trainingwww.4medapproved.com

Health Care Compliance Strategies, Inc. (HCCS)www.hccs.com

ICD-10 Instructional Podcastswww.icd10monitor.com

optumwww.optum.com

Practice Management Institutewww.pmimd.com

Precyse universitywww.precyse.com

The following resources have been compiled to aid you and your practice in the transition to ICD-10. If you have learned of additional resources that are helpful, please let MedChi know at 1.800.492.1056.


ICD-10: Navigating a Successful TransitionDeb Kenney

The year of ICD-10 is here! By now we’ve seen the webinars, attended seminars, read articles from industry experts, only to have our last hopes for a delay slowly disappear. The time has come to evaluate your ICD-10 implementation plan and make sure you’re on target for the October 1, 2014, transition date.

2013 should have been a year of planning and communication with your staff and senior leadership team. You had budgets to finalize, software to evaluate, and a GAP analysis to complete. If you have already started some testing and staff training, you may be well positioned to “go live.” If not, you may have a lot of ground to cover in a very short period of time.

The following is a list of steps, recommended by CMS (Centers for Medicare & Medicaid Services), that practices should have begun to take in 2013.

Planning – Early 2013

1. Identify resources and create a project team: Assign some-one to lead the way, even if you have a small practice.

2. Create a project plan and secure a budget: The ICD-10 effort will incur additional costs.

3. Study the impact through a GAP analysis: Understand how ICD-10 coding will impact various areas of your practice.

Communications – Early 2013 and Throughout Implementation1. Inform staff and involve physicians: Establish the ICD-10

“message” and spread the word to everyone in your practice, schedule monthly ICD-10 meetings to update on progress, and pull in additional resources to help with the implementa-tion plan.

2. Contact vendors and payors: Reach out to your EMR/Practice Management System vendors, claim clearinghouses and/or billing services, and all major payors based on your practice payor mix to see how they’re preparing for the change and what they will have available to help your prac-tice bill using ICD-10 codes.

Practice – late 2013 Through Implementation

1. Practice using your ICD-10 codes: Don’t assume that the first time your practice will use ICD-10 codes will be after the October 1 compliance deadline! Know what your com-mon diagnosis codes are in ICD-9, and try using both sets (dual coding) based on your current documentation as soon as possible.

2. Identify procedures with limited coverage: Do you provide services that have limited coverage policies that are based on diagnosis codes? Understand what those services are and check to see if payors have established new guidelines with ICD-10 codes. This will be important to your cash flow after October 1, 2014.

3. Begin testing claims: Work with your trading partners (pay-ors, clearinghouses, billing companies) to get test files created and submitted to evaluate the readiness of all parties. Certain carriers have established testing dates for practices to submit ICD-10 test claims. Find out if you are eligible to participate in these test runs. Start coding some charts in ICD-10 now to build up some test data based on real scenarios. The sooner, the better.

4. Review documentation: Once you know how your most common ICD-9 diagnosis codes will crosswalk to ICD-10, evaluate your documentation. Does it provide the specificity needed to assign an ICD-10 code? Often, there will be “one too many” codes when trying to map ICD-9 to ICD-10, rather than a strict one-to-one match.

Training – late 2013 Through Implementation

1. Review coder and clinician preparation: At this point, you should have a training plan drafted. Some practices will have secured external resources. Others may have created an internal expert, using a train-the-trainer approach. There’s not a right or wrong method. Find what works best for your practice and budget and solidify the training schedule to allow as much time as possible towards the recommended 6-9 months of training

If you are saying to yourself, “I haven’t even started…,” the ICD-10 transition could feel like a nightmare. As of late 2013, surveys have shown that about 30 percent or more of practices had not yet started the transition to ICD-10. If this describes your practice, it is time to get busy. If you ignore the impact this change can have on your practice, you will only be hurting your business. You could face cash-flow issues that are impos-sible to overcome.


There are some critical steps you can take now to catch up. It’s extremely important to carefully prioritize your efforts at this point and avoid focusing on the wrong areas.

1. Name a point person: Choose someone in your practice to head up the ICD-10 transition. This may be the practice manager or another leader in your practice. For smaller prac-tices, this will likely need to be a team effort. Many, including the physician(s), will need to contribute in some way, but it is important to have one person take the lead to make sure the project stays on track.

2. Create a Project Plan: There are many templates out there to choose from, but each will need some customization to make it fit your practice.

3. Identify high-risk codes: A list of high-risk codes should be based on the following:

A. Frequency of use: Look at your historical data to iden-tify top diagnosis codes and how they’re connected to your high-volume services.

B. Complexity of crosswalk from ICD-9 to ICD-10: Are the ICD-10 code choices staggering compared with the ICD-9 codes being used today? Has your practice been overusing unspecified diagnosis codes in ICD-9? The answers to these questions will determine how difficult your transition may be and you can then plan accord-ingly.

C. Financial impact: Identify the services that are revenue-drivers in your practice and focus on how to transition these smoothly. It is possible that this exercise can be repeated across the rest of the practice’s coding activities.

4. Work with your health plans: Don’t wait for payors to contact you. They are busy working on their own transition plans.

A. Develop collaborative testing plans with your major health plans: This will help identify reimbursement discrepancies, reductions, and incompatibility in code mapping.

B. Anticipate denials: Proactive monitoring may alert you to payor readiness. If you are seeing denials in ICD-9, how you can prepare for them in ICD-10 and avoid revenue suspension.

C. Identify coverage policy updates: Are payors pub-lishing limited coverage guidelines and when?

4. Contact your vendors

A. View your EHR vendor as a partner: You are depen-dent on one another in making a successful transition. Understand what they will offer in the way of upgrades and training and establish a timetable.

B. Identify upgrade costs: Determine whether upgrade costs are included in your current arrangement so that the cost of an upgrade will not get in the way. You need to establish additional costs in time to allow for train-ing or documentation modification needed to be fully functional.

C. Billing services: If you’re using a billing company, you need to know how they’re prepared for the change. Are they working with their software and clearinghouse ven-dors? If you are a hospital-based practice (e.g., radiology or pathology), do your billing services use interfaces with hospital systems to capture any of your billing activity? Identify their timelines for testing.

6. Training: Determine the who, what, when, and how

A. Who: Your staff will need training. Deciding who among your staff will need training is easy. Your coders, billers, providers, referral specialists, basically anyone who is working with ICD-9 today will need to be trained in ICD-10

B. What: What form of training do you choose? Some will opt for a train-the-trainer approach, while others may bring in outside experts to provide ICD-10 training to key staff members.

C. When: The when is now! Experts recommend six to nine months of training and we are now at less than six months away from the compliance date of October 1, 2014.

D. How: Introductory sessions and webinars and seminars can be helpful to get some general knowledge within the practice. Most experts consider dual coding to be an essential method of training. Determining what people need to learn ahead of the compliance date will equate to consistency and reliability in the long run.

7. Prepare for cash-flow impact

A. Line of Credit: Some experts recommend that practices secure a line of credit ahead of the transition. Consider establishing a line of credit of 10 percent of the prac-tice’s total reimbursement (approximately one and a half months of expenses) for the year in case you have temporary cash-flow issues.

B. Cash Reserves: Some specialty societies recommend having a three-month cash reserve, which should be sufficient time to identify payor issues or problems with claims transmission and resolve them.

If you are feeling overwhelmed at the daunting list of things to do to successfully transition to ICD-10, remember to try and keep it as simple as possible. You don’t have to memorize the 79,000 codes that are coming into play. Focus on your practice and the codes that you currently use. Review your Top 50 diag-nosis codes in ICD-9. There are numerous resources out there for you to minimize the need to “reinvent the wheel” (See ICD-10 Resources, p. 4 of ICD-10 pullout section).

Deb Kenney, CPC, CPMA, is a senior consultant at Medical Business Advisors, LLC, a f irm specializing in healthcare consulting and practice management issues for all types of healthcare provid-ers and entities. She can be reached at [email protected] or 301.468.2030.


Medical Mastermind has invested literally thousands of man-hours to make our software compliant with the new ICD-10 requirements. As an EMR vendor, we worry how physicians’ prac-tices, and their lives, will be impacted by ICD-10 without proper preparation and planning. If I could look you in the eye, I would tell you, “Get on this right now!”

We understand the enormity of ICD-10, and we want our clients to be as successful as possible. However, the length that vendors go to facilitate success varies widely, from providing only the ability to accept ICD-10 codes to providing much more than standard practice.

Some of the ways vendors are going above and beyond for their physicians include:

• Dual coding: Dual coding is a feature that will be key to sufficiently manage the transition. Dual coding allows both ICD-9 and ICD-10 codes to be submitted on the same claim for primary and secondary payers. For example, if your primary is ICD-10 and your secondary is ICD-9, you’ll need to submit two claims separately if you are not dual coding. Although this might sound simple, if you multiply that by the number of claims you process this way, and if your PMS is not able to provide this function, you are in for a lot more work.

• Extra programming: Cross-reference files are inadequate to easily facilitate the entire ICD-9 to ICD-10 equivalencies. The GEM (General Equivalence Mappings) cross-reference file provides a comprehensive crosswalk to only about one-third of the 68,000 codes (see Figure 1). Figure 2 shows there

is still a significant need for advanced querying capabilities your vendor may provide to help map the remaining codes (see Figure 2: Sample Coding Comparison).

• Practice, practice, practice: PMS/EMR vendors should enable an area outside of a claim to practice coding from ICD-9 to ICD-10, allowing both practitioners and billers to understand the different ways they will need to chart and bill before “going live.” A practice area will have your specialty’s code sets for both ICD-9 and ICD-10 loaded and mapped, showing you the way to express each correctly within a claim.

• Free updates, to a point: It is not unrealistic for a vendor to charge for features or services beyond what is required for basic compli-ance. For example, Medical Mastermind provides both a free update and the ability to purchase additional assistance in the form of an “ICD-10 Success Package.” This package includes expanded crosswalk capabilities, assistance with payer testing, coding docu-mentation, and more. Costs for this type of assistance typically range from $5,000 to more than $50,000, depending on the size and scope of the engagement. Whether your practice needs this type of help or not, it should be available. Also, find out what your vendor will and will not support. If you hire your own IT company and they run into trouble, will your vendor help? Will they charge you? How might that disrupt your ability to continue billing?

What can you do if you know you just won’t be ready? Consider using a professional billing service for several months to get you through the transition. Engaging a billing service, even temporarily, while your office becomes acclimated and comfortable with ICD-10, is a note-

The Truth About

ICD-10 and Your

EMR Vendor

Michelle Boucher


worthy way to help mitigate billing disruption and accounts receivable backlogs. Billing services are already getting certified and should be ahead of the ICD-10 curve in preparation and testing, assuming their billing software is ICD-10 ready. A billing service works with clearing houses and payers on an ongoing basis, and will know who has tran-sitioned and who is still on ICD-9. They can work with you and your internal biller on a daily basis to ensure the continual flow of revenue. Or, you may elect to simply switch to an outsourced billing service per-manently to handle your accounts receivable going forward.

Why are there are so many resources, articles, white papers, webinars, courses, press releases, social media content, blogs, ad nauseam, for ICD-10? ICD-10 is the single biggest, most disrup-tive change to the healthcare industry in the past thirty-plus years.

Preparing early, proactively embracing change, and continually educating and training is the best way to manage and succeed in an ICD-10 world. Start today.

Michelle Boucher is the Vice President of Marketing at Medical Mastermind, Inc. Michelle has more than twenty-five years of marketing and executive leadership experience in software, hardware and consumer products. She can be reached at [email protected].

Figure 1: General Equivalency Mapping (GEM) codes provide assistance understanding how to properly code from existing ICD-9 codes to ICD-10 codes. Some mapping is bi-directional. Source: Medical Mastermind, 2014.


ICD-10: Are Your Practice Management & Billing Systems Ready?Russ Thomas

We are only six months away from a major industry conver-sion to a new expanded code set—ICD-10—with implications across the entire health care industry. I know I’m not alone in my concerns about the state of readiness for the ICD-10 conversion.

Recently, I’ve heard too many people speculating that we will get an extension. To me, it’s not a very good strategy to bet on reprieves from the government. This transition is too important to gamble your business on, because ICD-10 has the potential to affect every aspect of the physician revenue stream. There is significant risk for disruption in claims reimbursement and cash flow for physicians if they and other partners are not prepared for the transition.

There are clear warning signs that the industry isn’t on track to be collectively ready for the October 1, 2014, deadline. I was dis-couraged to see December 2013 survey results from the Workgroup for Electronic Data Interchange (EDI) that showed some 80 per-cent of survey participants had not begun transaction testing; and only about 50 percent had conducted an impact assessment, widely considered step one in preparing for this change.

Critical Dependencies

I believe physicians and their staffs are doing their best to get ready, but the reality is that medical office teams are often limited by critical dependencies. Many organizations are waiting for their vendors to update billing systems to accept ICD-10 codes. And not all payors have made testing widely available.

Meanwhile, the clock is ticking.If you haven’t already, contact your practice management sys-

tem (PMS). Your practice management system vendor can tell you whether it supports ICD-10 claims, or when an update will be available that will allow you to submit ICD-10 claims. Most of the vendors we work with say they expect to have their updates completed by the end of the first quarter. If your practice manage-ment system isn’t planning to update, or is otherwise not going to be ready to meet the mandate deadline, you may need to make the switch to a vendor that will be.

Key Questions to Ask

Here’s the most challenging part of what’s ahead: A successful transition requires readiness of all health care stakeholders. You could do your part to be ready and still encounter complications on October 1. In addition to communicating with your practice

management system vendor, you (and/or your billing and coding staff ) need to make sure you are asking the right questions of your revenue cycle management vendor.

Does your billing vendor support ICD-10 and legacy for-mats? To continue to send EDI claims to your payors, your bill-ing system will need to be updated to support ICD-10 codes. However, your billing system vendor might not be prepared to submit in ANSI 5010 format. Therefore, to accommodate the various states of provider readiness, your revenue cycle manage-ment application or clearinghouse may need to support non-ANSI 5010 formats after the transition to ICD-10. This would require that your clearinghouse support the ICD-10 compliance versions of the CMS-1500 and UB-04 legacy formats.

Does your system provide error translations and suggested actions? To transition to ICD-10, your coding and billing staff will need time to become familiar with new processes and requirements. Availity is identifying and investigating more than one hundred new payor errors each month. We expect error rates on returned claims to increase as a result of the ICD-10 transition. You can save time and frustration if your revenue cycle management application or clearinghouse is able to translate these new ICD-10 errors from payor into plain-language, action-able messages.

What should your practice be doing to prepare with major payors? Check payor websites. Find out when they are testing and whether you need to test with them, and learn about their escalation roles and procedures. Determine who to call for sup-port after October 1. As an example, CareFirst has published guidelines and has a detailed FAQ on their website. Check with your provider representative to determine each payor’s require-ments for timely filing, claims submissions, appeals, and claims reprocessing.

Does your system application have the flexibility to accom-modate a potential delay in ICD-10 implementation? Your revenue cycle management application or clearinghouse needs to be flexible enough to accommodate ICD-10 contingency needs of providers and payors, and ensure exceptions. You need to prepare


for the unexpected with a solid contingency plan by identifying risks across critical areas of your business, how payor and vendor business processes and systems may affect your revenue stream, cash flow and patient care delivery. Ask your practice management system how their organization is preparing for ICD-10 and what you should do to prepare.

Does your system provide the ability to search ICD-10 codes? Time is a precious resource. Your revenue cycle manage-ment application needs to provide online tools to search for ICD-10 diagnosis and procedure codes so that your billing and coding staff can quickly respond to errors and information requests from payors. Access to ICD-10 codes will eliminate the need to refer to outside materials or systems.

This, Too, Shall Pass

I could argue that there are a lot of reasons to be a naysayer on ICD-10. It feels as though we just got through 5010 and Meaningful Use. And only now are we beginning to implement health reform and a host of other mandates. Personally, like many of you, I’d like to just call a big time-out with ICD-10 and any other mandates for a while, to let practices and billing services stabilize.

Unless and until such a time-out occurs, we have to find a way to get through ICD-10. ICD-10 may be poorly timed and will likely be complicated, but we will get through it together. If we each do our part, we are helping ensure our collective success.

Russ Thomas is CEO of Availity, a healthcare information net-work. Prior to his appointment as CEO in 2012, Thomas had been the company’s president and COO since 2008, when he joined Availity. He can be reached at 904.470.4557.


What Are Payors Doing to Implement ICD-10?

As the October 1 deadline approaches, physicians are focused on upgrading software and systems, training staff, and improving documentation. Payors are also working hard on the International Classification of Diseases, Tenth Revision (ICD-10) implemen-tation plans and projects. Maryland Medicine reached out to the major payors in the area to learn what they are doing to get ready for the transition to ICD-10 on October 1, 2014.

Medicare

The Centers for Medicare & Medicaid Services (CMS) has a web site dedicated to providing agency-wide information and education on ICD-10 implementation.

On this web site, you can view background information on the new standards, regulatory information, the latest outreach messag-es from CMS, educational resources, resources specific to ICD-10. CMS plans to add additional information as it becomes available.

http://www.cms.gov/Medicare/Coding/ICD10

On July 21–25, 2014, CMS will offer end-to-end testing to a small sample group of providers (Note: check the CMS website for changes to testing schedule and updates).

End-to-end testing includes the submission of test claims to CMS with ICD-10 codes and the provider’s receipt of a Remittance Advice (RA) that explains the adjudication of the claims. The goal of this testing is to demonstrate that

• providers or submitters are able to successfully submit claims containing ICD-10 codes to the Medicare FFS claims systems;

• CMS software changes made to support ICD-10 result in appropriately adjudicated claims (based on the pricing data used for testing purposes); and

• accurate RAs are produced.

The sample will be selected from providers, suppliers, and other submitters who volunteer to participate.

For updates and the latest news, you can

• sign up for the CMS ICD-10 Email Updates or subscribe to the Latest News Page Watch at the CMS web site; and

• follow us on Twitter (@CMSGov).

CareFirst

CareFirst is on-track with preparations for the ICD-10 transition, and will be ready by the October 1, 2014, mandate. CareFirst has completed or is completing updates to the Claims Gateway and our Adjudication Platforms. We are currently performing internal tests of all our systems. Additionally, we are planning for end-to-end testing with our trading partners and selected providers.

You can find the latest information from CareFirst’s ICD-10 program on our Provider Portal page (www.carefirst.com/icd10). In particular, providers are encouraged to check out the content on our Resources tab, which includes:

• Provider Frequently Asked Questions (FAQ): This handout covers many of the common questions we have gotten from providers, including topics such as ICD-10 training, testing with providers, and implications to con-tracts and medical policies.


• CareFirst ICD-10 Claims Submission Guidelines: This policy document explains which code set to use for a claim, whether a claim with services that span the October 1st date should be submitted as a single or split claims, and the implications to topics such as member payments and provider claim filing and appeals windows.

If you can’t find the answer to your questions on our ICD-10 page, you can email our project team directly at [email protected]. Between the content on our ICD-10 page and other useful resources available to the industry, we can all be ready to make a smooth transition to ICD-10 in October.

UnitedHealthcare

To support physicians and small community-based critical access hospitals during this transition, UnitedHealthcare offers an ICD-10 Self-Assessment Toolkit at UnitedHealthcareOnline.com to assist in becoming ICD-10 compliant:

• ICD-10 Education: On-demand educational resources designed to provide general information regarding ICD-10 and the implementation process.

• ICD-10 Tools: In collaboration with the American Academy of Professional Coders (AAPC), the largest cod-ing organization in the country, we have created a suite of tools including ICD-10 code selection decision trees and detailed clinical documentation improvement webinars.

• ICD-10 Resources: A listing of industry-wide ICD-10 resources.

• ICD-10 Partnerships: In addition to AAPC, we are work-ing with Optum to offer value-added solutions for cost-effective adoption of ICD-10.

ICD-10 questions can be sent to [email protected]. CIGNA

Paper Claim Submission—Revised CMS 1500On January 6, 2014, Cigna began accepting paper claims sub-

mitted on the revised CMS 1500 Health Insurance Claim Form (version 02/12). To provide health care professionals time to transi-tion to using this form, we will continue to accept and process paper claims submitted on the old CMS 1500 Health Insurance Claim Form (version 08/05) for a period of time. Later in 2014, Cigna will notify providers of the date when we will no longer accept this form. Once that date is determined, providers will need to use the revised (02/12) form to ensure accurate and prompt claim payments.

Nonbillable Codes No Longer AcceptedAs of October 2013, Cigna began no longer accepting nonbill-

able ICD codes. A nonbillable ICD-9 or ICD-10 code is defined as a code that has not been coded to its highest level of specificity.

TestingCigna held successful clearinghouse and vendor testing in

October 2013 to help ensure we could correctly receive and send files, transactions, and codes. We performed additional testing in February and March 2014.

continued on page 32


ICD-10 Personal Perspective: What’s Eating Doctor Grape?

PersonaL PersPecTIve

In the last few years, American physi-cians have become restless, tense, and dysphoric. They have felt the earth begin to tremble. Confidence that all was right in their world has begun to waver. What has caused this generalized disquiet, this sense of foreboding?

In 1957, the year I graduated from medical school, physicians had a sense of satisfaction with their role in society. They were recognized as quintessential members of their communities, avatars of excel-lence, men and women of unquestionable knowledge and moral character. When an attending physician entered a room, nurses and house officers stood in a gesture of deference. As members of hospital staffs, physicians played a fundamental role in medical decisions. They were universally respected and admired.

Students apply to medical schools for a number of reasons. A secure income and the anticipated prestige are certainly part of their final assessment, but by far the pri-mary motivation is the desire to heal sick people. In medical school, that purpose is emphasized a thousand times over. Each class we take, each conference we attend, each instructor we meet, each patient we encounter - underscores that belief. It is axiomatic, and it has become the common principle that guides our daily existence. To prevent, ameliorate or cure each patient becomes the justification for our lives. It is who we are. It is what we do.

For centuries, the expansion of medi-cal knowledge, the discovery of etiolo-gies, and the innovation of diagnostic and therapeutic techniques, have been received by a grateful public with appreciation. Edward Jenner’s and Jonas Salk’s vaccines, René Laennec’s stethoscope, Scipione Riva-Rocci’s sphygmomanometer, and Willem Einthoven’s EKG instrument, were all received enthusiastically; César Roux, Joseph Lister, William Halsted, Theodor Billroth, Robert Zollinger, Michael DeBakey, Denton Cooley, Alfred Blalock, Walton Lillehei, Dwight Harken,

Russell Brock, John Kirklin, Frederic Mohs, Christiaan Barnard, and so many other surgical pioneers have each received wholehearted public admiration. Coronary angioplasty, devised by Andreas Gruentzig in 1977, was favorably received; the EEG, CT scan, MRI, sonography, and doz-ens of additional laboratory tests have been employed to confirm diagnoses and enhance survival. Patients and their families understand the implications such advances have meant to their lives, and they will tell you so.

However, in 1965, an event occurred that would ultimately shake the foundations of medical care, and threaten to displace the physician from his pre-eminent status in patient care. It was known as Public Law 89-97, title XVIII of the Social Security Act, and its opening sentence read:

AN ACT TO PROVIDE A HOSPITAL INSURANCE PROGRAM FOR THE AGED UNDER THE SOCIAL SECURITY ACT WITH A SUPPLEMENTARY HEALTH BENEFITS PROGRAM AND AN EXPANDED PROGRAM OF MEDICAL ASSISTANCE, TO INCREASE BENEFITS UNDER THE OLD-AGE, SURVIVORS, AND DISABILITY INSURANCE SYSTEM, TO IMPROVE THE FEDERAL-STATE PUBLIC ASSISTANCE PROGRAMS, AND FOR OTHER PURPOSES.

It is better known as Medicare and Medicaid.

The initial reaction from many physi-cians was fear that this law would ulti-mately lead to “socialized medicine.” As time passed, and that fear was not realized, physicians became more comfortable with the program. In fact, those of us who had treated indigent patients without charge, now realized that we could be reimbursed for those same efforts, which eased much of our apprehension. Medicare became an astonishing success.

Inexorably, as the nation’s population aged, enrollment in Medicare has grown. In 1966, 19 million were enrolled in the program. In 2011, that number reached 48 million. In addition, the rising costs of new diagnostic and therapeutic choices, have substantially added to the burgeoning health care expenditures. We now face the double-edged sword of costly procedures utilized by an ever-expanding Medicare population.

In an effort to control overhead, Congress has enacted numerous regula-tions that effectively restrict a physician’s autonomy and limit her options for patient management. From the Independent Payment and Advisory Board direc-tives, mandated electronic health records, restrictions imposed on hospital admis-sions, constraints on lengths of stay, and limited reimbursement for many diagnos-tic and therapeutic alternatives, the physi-cian has lost substantial independence in the management of her patient. Add to this list the anticipated and bewildering ICD-10 codes, which will cost physicians an estimated $85,000 to $2,500,000 to install - and one begins to understand the growing anxiety of American physicians.

However, the major problem is not the physician’s declining income. It is the excru-ciating dilemma created by the costs of medical care. Until the latter years of the 20th century, a physician’s only duty was to pre-vent, ameliorate, or cure a patient’s disease. That was his job. However, the rising costs of medical care gradually began to intrude on that simple formula. Increasingly, the government has urged physicians to help mitigate those costs, but that has caused a problem. Do frequent headaches justify an MRI? Does recurrent diarrhea require a colonoscopy? Does atypical chest discomfort require a nuclear stress test? Does unex-plained weight loss compel a whole-body CT scan? The physician must now respond to a moral quandary: the health of his patient versus the health of the economy – a question that is almost impossible for him to answer.

Barton J. Gershen, MD


For centuries, a medical team consisted of doctor, nurse, and patient, and it was tacitly understood that ultimate decisions were to be made by the physician. Today, he is considered simply part of a large team of “health care providers,” including nurses, physi-cian assistants, pharmacists, physiotherapists, social workers, etc. The physician’s central role in decisions has been blurred, mem-bers of the team have demanded pivotal responsibilities, and his importance is even challenged by government bureaucrats. In the past, a conference organized to evaluate a patient’s illness ensured that the attending physician would sit at the head of the table. In today’s environment, she may not even be invited to the meeting. Regulations that intimately affect patient care now originate from numerous government agencies.

The small tremor that physicians felt in 1965 was a harbinger of a huge earthquake that has now occurred in medicine. We have found ourselves the victims of a paradigm shift, a tectonic movement that has displaced the physician from his historic role in patient management.

In 1969, Elizabeth Kübler-Ross wrote her seminal volume On Death and Dying in which she discussed five stages of grief following the loss of a loved one. These stages are (1) denial, (2) anger, (3) bargaining, (4) depression, and (5) acceptance.

Physicians are reacting to the loss of their professional persona in ways that correspond to the five stages described by Kübler-Ross. At present, we are all in stages two through four, experienc-ing feelings that fluctuate between anger and depression.

If acceptance follows, the role of physicians will never again be the same.

Is there no balm in Gilead? Is there no physician there? Why then is there no healing for the wound of my people? ( Jeremiah 8:22)

Barton J. Gershen, MD, Editor Emeritus of Maryland Medicine, retired from medical practice in December 2003. He specialized in cardiology and internal medicine in Rockville, Maryland.

MEDCHI NECRoLoGY 2013

ALLEGANY CouNTY

Robert D. Cendo, M.D. leslie l. Mould, M.D.

ANNE ARuNDEL CouNTY

BALTIMoRE CITY

BALTIMoRE CouNTY

CALVERT CouNTY CARRoLL CouNTY

Guillermo Zambrano, M.D. Wilbur H. Foard, M.D.

CECIL CouNTY CHARLES CouNTY

Ernesto M. Ablang, M.D. Frederick M. Johnson, M.D.

DoRCHESTER CouNTY

John W. Heisse, M.D.

FREDERICK CouNTY

HARFoRD CouNTY HoWARD CouNTY

Thomas E. Jordan, M.D. Clement B. Knight, M.D.

MoNTGoMERY CouNTY

PRINCE GEoRGE'S CouNTY

Ralph W. Jordan, M.D.

ST. MARY'S CouNTY

J. Roy Guyther, M.D. William J. Marek, M.D.

WASHINGToN CouNTY

George Way, M.D.

Anna Bryan, M.D.Francis Kopack, M.D.

Robert l. lyles, M.D.Nicholas P. Moutsos, M.D

Simeon B. Alvaran, M.D. Albert Antilitz, M.DTimothy D. Baker, M.D., M.P.H. Walter E. Dandy, M.D. John M. Dennis, M.D.Franz X. Groll, M.D. Jacob C. Handelsman, M.D. Martin Helrich, M.D.

Theodore Kardash, M.D. Jerel H. Katz, M.D.Joshua R. Mitchell, M.D. Antonio Olmedo, M.D. (2012)Howard Patt, M.D.Ruth H. Singer, M.D., M.P.H. Theodore H. Wilson, M.D.

Joseph S. Ardinger, M.D.Danilo M. Coronel, M.D. William Dvorine, M.D. l. Myrton Gaines, M.D. Harold J. Hettleman, M.D. Theodore H. Kaiser, M.D. Edmund Kasaitis, M.D. Gerald D. Klee, M.D.

Kenneth B. Kochmann, M.D. David R. larach, M.D.Joseph C. Matchar, M.D. David R. Morales, M.D.Harry P. Porter, M.D.Joseph E. Schulte, M.D.Harry S. Stevens, M.D.

Henry V. Chase, M.D. Robert D. Crouch, Sr., M.D.

Sherman Kahan, M.D. Robert H. Varney, M.D.

Alfred D. Bonifant, M.D. Richard l. Cohen, M.D. Paul A. Dorn, M.D. Albert F. Fleury, M.D. David Goldenberg, M.D. Robert W. Palmer, M.D. Benito H. Prats, M.D.

Jerome Sandler, M.D. Arthur Schoengold, M.D.louis H. Shuman, M.D.Anu M. Singh, M.D. Yasuo Takahashi, M.D. Marvin Wadler, M.D.

DRG Inpatient Hospital StudyOur diagnosis related group (DRG) inpatient hospital study

is underway and will continue through the second quarter of 2014. This study will provide insights to inpatient hospital coding practices and how it affects payment. This collaborative process is underway with selected Cigna participating health care profession-als to analyze claims with ICD-9 and ICD-10 coding. We plan to analyze and release the study results once the data are available.

Webinars and Other ICD-10 ResourcesCigna will be hosting ICD-10 webinars throughout 2014. In

addition, self-study materials are available to help providers under-stand and prepare for the ICD-10 upgrade. Webinar dates, sign-up information, and self-study materials are available at: https://cignaforhcp.cigna.com.

What Payors Are Doing ...continued from page 29


The village of Pentonville lies in the northern suburbs of London, England. It was there on August 17, 1798 that a son was born to a devout Quaker couple. They named him Thomas and he grew to be a pious, altruistic, and highly intelligent young man. He was deeply concerned about the suffering of Negroes, American Indians, and the Australian aborigines. When he was twenty, Thomas wrote an essay, “On the Promotion of Civilization,” in which he stated: “my life’s aim will be to protect the primitive aboriginal people of all continents to which European traders are moving.” He later pledged to devote his life to The Aborigine Society, an international human rights organization founded in 1837.

Thomas fell in love with Sarah Goodly, an attractive second cousin, and soon asked for her hand in marriage. Sadly, the elders of the church refused to permit that marriage because of the “abomination” of consan-guinity. The couple was devastated, there was a poignant farewell, and a dejected Thomas left Pentonville. Soon afterward, he began to “walk the wards” of St. Thomas and Guy’s hospital in London, to begin his medical education. Among the sev-eral lectures Thomas attended were those of Sir Astley Cooper (Cooper’s fascia and Cooper’s Ligament). He was quickly rec-ognized as a bright, promising scholar, and in 1820, Thomas was promoted to the medical school at Edinburgh University. Here he wrote his first scientific paper, on disorders of the spleen.

Following his graduation from medi-cal school, Thomas was given a position in the pathology department of St. Thomas and Guy’s Hospital. In 1821, he traveled to France on sabbatical leave, and spent the year as a student of René Laennac, who had just invented the monaural wooden stethoscope. (Laennac was also famous for his description of the alcoholic liver – Laennac’s cirrhosis.)

Thomas quickly learned the art of stethos-copy and returned to London eager to inform his colleagues of this new diagnostic tech-

nique. In October of 1822, Thomas presented a paper at Guy’s Hospital on the principles of auscultation, utilizing a duplicate of René Laennac’s instrument. Unfortunately, his lec-ture was met with indifference by most of the physicians in attendance. (One should not be too surprised at this tepid initial response to Laennac’s invention. In the preface to the American edition of Laennac’s Treatise on the Diseases of the Chest, Dr. John Forbes wrote, “I am extremely doubtful that it will ever come into general use, because its beneficial appli-cation requires much time and gives a good bit of trouble both to the patient and to the practitioner. It must be confessed that there is something even ludicrous in the picture of the grave physician proudly listening through a long tube applied to the patient’s thorax, as if the disease were a living being that could communicate its condition.”) Nevertheless, William Stroud, who had attended that lec-ture, was so captivated by what Thomas had reported that he soon developed the first flex-ible monaural stethoscope.

In 1828, Thomas published a short paper in The London Medical Gazette entitled “On Retroversion of the Valves of the Aorta,” in which he first described a “musical, purring, thrilling, or sawing kind of noise” in associa-tion with retroversion of an aortic cusp. He termed it the bruit de scie, and it is some-times associated with his name.

Shortly thereafter, Thomas was appointed Director of Pathology at Guy’s Hospital. Officially, this title was known as “Curator of the Dead.” He spent the next fifteen years of his life meticulously conducting autopsies and joyfully teaching students on ward rounds. They unanimously voted him their favorite instructor. During this period, Thomas published his Lectures on Morbid Anatomy, and later wrote a two-volume opus The Morbid Anatomy of Serous and Mucous Membranes, which became a classic in the field of Pathology. He was an early and ardent proponent of preventive medicine, and in 1841 published On the Means of Promoting and Preserving Health, a seminal

book in this nascent field. To add to his many accomplishments, Thomas cooperated with Sir Joseph Lister in the development of an achromatic microscope (Lister is famous for Listerian asepsis; also the organism named for him, Listeria monocytogenes).

It was about this time that Thomas met an influential Jewish family. They became his private patients and their eldest son, Moses, soon became Thomas’s best friend. Moses and his relatives were wealthy silk merchants from Spain, who had immigrat-ed to England several years before. Once they had become established in London, Moses and his brother were granted a seat on the illustrious London Stock Exchange. They were the first Jews selected to that influential position.

Moses soon augmented his original fortune many times over. He then married into the influential Rothschild family and, at age 40, he retired to devote his energy and huge resources to public and private charities. He was instrumental in build-ing schools and hospitals and founding agricultural settlements in Palestine. As a result of his many humanitarian efforts, Moses was appointed Sheriff of London – a largely ceremonial post. Shortly there-after, he was knighted by Queen Victoria.

At approximately the same time, the Journal of the Medical and Chirurgical Society of London published Thomas’s paper entitled “Some Morbid Appearances of the Adsorbent Glands and Spleen,” which received favorable critical acclaim, and has proven to be a landmark in the history of medicine.

Then a catastrophic event occurred, which would end his career.

The medical director of Guy’s Hospital (officially termed “Physician to Guy’s Hospital”) suddenly died, and on Wednesday, September 6, 1837, the twen-ty-six members of the hospital’s Board of Directors met to vote for a successor. They unanimously elected Dr. Thomas Addison (famed for “Addison’s Disease”)

The Curator of the Dead and the Sheriff of London

Word roundsBarton J. Gershen, MD Editor Emeritus


to become the next medical director. The board then had to choose someone to fill the post of “Assistant Physician to Guy’s Hospital,” the position vacated by Addison’s promotion.

There were officially seven candidates. However, everyone con-nected with the hospital knew that only two names were actually to be considered at that meeting. One of them was Dr. Benjamin Babington, whose sister was married to Richard Bright (“Bright’s Disease”), and whose father had previously been an admired and respected Physician to Guy’s Hospital from 1795 – 1811. The other major candidate was the “Curator of the Dead” – Thomas, the Quaker physician.

The hospital treasurer spoke first and vehemently asserted his opposition to Thomas, specifically because of Thomas’s leadership in the Aborigine Society. Thomas received only two of the twenty-six votes, and Benjamin Babington became the new Assistant Physician to Guy’s Hospital. Thomas immediately resigned in anger. He never again set foot in Guy’s Hospital, published another medical paper, or taught another student.

Moses took his disconsolate friend away. They made several philanthropic trips to the European continent and to the Mideast. In the spring of 1866, Thomas made his last journey. There had been a severe infestation of locusts in Palestine, which had deci-mated that year’s crops. Moses and Thomas traveled there to see if they could somehow assist the starving population.

Thomas was not feeling well when they left England, and by the time they had arrived in Alexandria, Egypt, he fell gravely ill and could go no further. He remained with the British Consular Agent and was attended by an Egyptian physician named Dr. Socci.

On April 4, 1866, at 5:15 p.m. local time, Thomas died of severe dysentery. His anguished friend Moses wrote, “It has pleased the Almighty to take him from us, one so guileless, so pious, so amiable in his private life; so respected in his public career, and so desirous to assist with all his heart in the amelioration of the human condition.” Thomas was buried within a small cemetery at Jaffa, Palestine, near the Tabatha Girls School.

A grieving Moses had an obelisk erected before the grave. It says simply:

“Here rests the body of Thomas Hodgkin, M.D. of Bedford Square London. A man distinguished alike for scientific attain-ments, medical skills and self-sacrificing philanthropy.”

The grave is never overgrown with weeds, for it is perpetually attended by the residents of Jaffa, few of whom know anything about the man whose last resting place they attend. Hodgkin’s name, of course, was bequeathed to medical posterity for his original description of the disease which bears it. His initial report was based entirely on the gross anatomic description of six cases, which he had examined at Guy’s Hospital. (Microscopes of that era were exclu-sively used to view liquid specimens. The microtome, an instrument capable of slicing solid tissue into sections thin enough to be viewed under a microscope, was not invented by Schwann until 1838, long after Hodgkin had left Guy’s Hospital.)

In 1926, Dr. Herbert Fox, a New York pathologist, micro-scopically examined the tissue specimens from which Hodgkin had reached his conclusions. Fox reported that one of these cases was actually tuberculosis, a second syphilis, and a third was Non-Hodgkin’s lymphoma. In fact, only three of the original six speci-mens represented “Hodgkin’s Disease.”

Moses died twenty years after Hodgkin. His full name was Sir Moses Chaim Montefiore. There is a monument to his memory as well. It may be seen in the Bronx, New York.

It is called Montefiore Hospital.

Modified from Word Rounds article published in the Maryland Medical Journal, 1992.

Barton J. Gershen, MD, Editor Emeritus of Maryland Medicine, retired from medical practice in December 2003. He specialized in cardiology and internal medicine in Rockville, Maryland.


VOlUME 14, Issue 1GlOBAl HEAlTH’S ROlE IN MEDICINE IN MARYlANDAlso Inside: Tuberculosis in Maryland: Global and Historical PerspectivesPresident’s Message: 2013 Healthcare: The Rest of the Story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Brian H. Avin, MDCEO’s Message: Insurance Reforms Needed to Curb Cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gene Ransom, III, Esq.Editor’s Corner: Communication and Myths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Bruce M. Smoller, MDIntroduction: Global Health for Maryland Physicians: Why You Should Read These Articles . . Tyler Cymet, DOWhy Practicing Physicians Should Care about Global Health . . . . . . . . . . . . . . . . . . . . . . . . . . Tyler Cymet, DO and

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Timothy D. Baker, MD, MPHOverview of International Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Terrence Mulligan, DO, MPHTransitioning from a Practicing Physician to a Mission Director: Addressing Safety Issues . . . . . .Emily E. Tylski, OMS IV, and

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gautam J. Desai, DO Global Aging, Local Solutions: Maryland Physicians as the Agents of Change . . . . . . . . . . . . Roberto J. Fernandez, MPH, and

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yogesh Shah, MDThe Global Challenge of Non-Communicable Diseases in an Age of Austerity:

Why Physicians Should Contribute to the Global Policy Discussion . . . . . . . . . . . . . . Amber HullReverse Foreign Aid to Maryland Revisited Again . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Timothy D. Baker, MD, MPH,

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . and Ligia PainaResource Availability and Utilization: Local Versus International Needs . . . . . . . . . . . . . . . . .Alan Schalscha, DOTuberculosis in Maryland: Global and Historical Perspectives

Maryland Department of Health and Mental Hygiene . . . . . . . . . . . . . . . . . . . . . . . .Sara Mixter, MD, Jesse X. Yang, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . and Joshua H. Sharfstein, MD

Historical Perspectives: The Changing Face of Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Susan A. RaskinWord Rounds: Awards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Barton J. Gershen, MDThe Last Word: Interesting Facts from the World Health Organization

VOlUME 14, Issue 2 PROTECTING CONFIDENTIAl HEAlTH INFORMATION: Cybersecurity Concerns for PhysiciansAlso Inside: MedChi’s 2013 State legislative AccomplishmentsPresident’s Message: MedChi’s Efforts Paid Off During the Legislative Session! . . . . . . . . . . . . Brian H. Avin, MDCEO’s Message: Maryland’s Medicare Waiver: Why It Should Matter to You . . . . . . . . . . . . . . . Gene Ransom, III, Esq.Editor’s Corner: I Guarantee You . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bruce M. Smoller, MDIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stephen J. Rockower, MDMedChi’s Accomplishments During the 2013 Maryland Legislative Session:

A Recap of Legislative Initiatives Impacting Physicians and Patients . . . . . . . . . . . . . Stephen J. Rockower, MDDon’t Go Near the Watering Hole: Protect Yourself from Cyber Attacks . . . . . . . . . . . . . . . . . . . Stephen J. Rockower, MDCybersecurity and Your Practice: What You Need to Know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jonathan KrasnerStop, Look and Listen! You Could Be Breaking the Rules:

Five Inadvertent HIPAA Violations by Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tracey Haas, DO, MPHSteps to Protect Your Practice Against Cyber Attacks: Local Versus International Needs . . . . . . . Ruben MbonPrivacy/Data Breach Coverage: Protect Your Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ron KendallVoice Authentication – Enabling Secure and Convenient Access to Your

Personal Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ramani Peruvemba, MDMaryland Medical Assistance Increases Payment for Primary Care Services . . . . . . . . . . . . . . . Molly Marra and Maureen ReganWord Rounds: Red Roses, Beautiful Eyes, and the Tropics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Barton J. Gershen, MDThe Last Word: Frank and Ernest Cartoon

VOlUME 14, Issue 3 PHYSICIAN AGE, GENDER AND CUlTURE: What is the Impact on Clinical Practice?Also Inside: How Physicians are Reacting to Medicaid Changes President’s Message: Seven Things You Can Do for Yourself (and for MedChi) This Fall . . . . . . . H. Russell Wright, Jr., MDOutgoing President’s Remarks: Given at the Annual Meeting of MedChi. . . . . . . . . . . . . . . . . . . Brian H. Avin, MD CEO’s Message: How are Physicians Reacting to Maryland Medicaid Changes . . . . . . . . . . . . .Gene Ransom, III, Esq.Editor’s Corner: Speaking the Same Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bruce M. Smoller, MD

Index of Maryland Medicine Articles (2013)


Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anne Sagalyn, MDAging Physicians: Some Lessons from the Literature Outside of Medicine and

Potential Implications for Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Steven J. Durning, MD, PhD, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Eric Holmboe, MD, and . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rebecca Lipner, PhD

The Aging Physician: When Practice Doesn’t Make Perfect . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anne Sagalyn, MDDoes Gender Matter in Career Decisions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Beverly Collins, MD, MBA, MSWhy Does the Gender Income Gap Still Exist?

Female Physicians Paid $350,000 to $2.3 Million Less Than Their Male Peers . . . . . Beverly Collins, MD, MBA, MSEqual Opportunity Discrimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jane H. Chretien, MD, and

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Audrey P. Corson, MDAdvocacy for Women Physicians and Women’s Health:

The New American Medical Association’s Women Physicians Section . . . . . . . . . . . . . . . Shannon Penick Pryor, MD, Chair, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AMA Women Physicians Section

When Cultures Collide: What We Know About the Impact of Physician Culture on Clinical Decision Making . . . . . . . . . . . .Anne Sagalyn, MD

Word Rounds: Etymology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Barton J. Gershen, MDNotes From a (Guest) Editor: See One, Do One, Teach One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anne Sagalyn, MDThe Last Word: Members of the Editorial Board of Maryland Medicine were asked why they went into medicine.

These are their reflections.

VOlUME 14, Issue 4 NEW MODElS OF HEAlTH CARE DElIVERY IN MARYlANDAlso Inside: MedChi’s 2014 legislative Agenda President’s Message: A New Year’s Resolution That Doesn’t Require a Gym Membership . . . . . . H. Russell Wright, Jr., MDCEO’s Message: From Tobacco to Tanning Beds—It’s About Children and Cancer . . . . . . . . . .Gene Ransom, III, Esq.Editor’s Corner: Keep the Lights on for Me . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bruce M. Smoller, MDIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mark G. Jameson, MD, MPHCommentary on 2014 Legislative Agenda: MedChi’s Legislative Marching Orders . . . . . . . . . Stephen J. Rockower, MDMedChi’s 2014 Legislative and Regulatory AgendaMaryland Physicians Lead New Quality Improvement Initiative:

Innovative Pilot Program Tackles Hypertension Control in the Ambulatory Setting . . . Karen Kmetik, PhDCommunity Tailored Partnerships That Work: Implementing New Models of Primary Care in the State of Maryland . . . . . . . . . . .Niharika Khanna, MBBS, MD, DGOTransforming Communities to Support Health:

Highlights from Maryland’s Community Transformation Grant . . . . . . . . . . . . . . . . . . . . Donald Shell, MD, MA, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Vanessa W. Harris, MD, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sara Barra, MS, Erin Penniston, MSW, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Jeff Norris, PhD

Bug Bites: A Maryland Menu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Mark G. Jameson, MD, MPHWord Rounds: Eponymic Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Barton J. Gershen, MD

Personal Perspective: Today’s Physician—Knowledge Worker or System Professional? . . . . . . . . . . . . Tyler Cymet, DO, FACP, FACOFPThe Last Word: off the mark.com Cartoon

Index of Maryland Medicine Articles 2013...continued from page 35


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L A S T W O R DTHE

The Most Bizarre ICD-10 Code Awards

“The Most Bizarre ICD-10 Code Awards,” by Xavier E. Martinez, originally appeared at poweryourpractice.com. It is reprinted here with permission by the Care Cloud blog and poweryourpractice.com.

Bronze: Bitten by a turtle – W5921XSSilver: Bitten by sea lion – W5611XDGold: Struck by macaw – W6112XA (Pesky, talking birds)

ANIMAL

CATEGoRY

WATER SPoRTS

CATEGoRY

Bronze: Hit or struck by falling object due to accident to canoe or kayak – V9135XASilver: Civilian watercraft involved in water transport accident with military watercraft – V94810Gold:Burnduetowater-skisonfire–V9107XA

Bronze: Hurt at the library – Y92241Silver: Hurt at swimming pool of prison as the place of occurrence – Y92146Gold: Hurt at the opera – Y92253 (The fat lady can get a tad cranky when she doesn’t get to sing.)

STRANGE PLACES

CATEGoRY

Bronze: Prolonged stay in weightless environment - X52 Silver:Unspecifiedballoonaccident injuring occupant – V9600XSGold: Spacecraft crash injuring occupant – V9542XA (Eyes to the skies, people.)

AIR/SPACE

CATEGoRY

Bronze: Hurt walking into a lamppost – W2202XASilver: Stabbed while crocheting –Y93D1Gold:Unspecifiedevent,undeterminedintent–Y34(Well,thatclarifiesthings…)

JuST PLAIN

WEIRD

CATEGoRY

World Health organization

MedChiThe Maryland State Medical Society1211 Cathedral St. s Baltimore, MD 21201

Presorted StandardU.S. Postage

PAIDPemit No. 48

Merrifield, VAAddress Service Requested

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