ICD-10 Implementation Planning – Where Do We Begin?

These are the planning phases to consider in preparation for the ICD-10 Implementation.  Each of these four phases will outline time frames and steps you should take to better prepare  for the October 1, 2015 deadline.  You may consider partnering with an EMS Consulting Firm familiar with ICD-10 to help you develop a plan and navigate your company through the steps.

Phase 1 – Implementation Planning:

Start by assembling an Implementation Team.  This team should consist of representatives
and decision makers from the following departments:

  • Billing/Coding
  • Finance/Accounting
  • Clinical
  • Education
  • Quality Assurance/CQI
  • IT Department
  • Senior Management

Now that you have your implementation team in place, it’s time to start formulating a plan. Phase 1 is the pre-implementation stage and should be completed between the first quarter of 2013 and the second quarter of 2013.  If you haven’t already begun preparations, don’t panic.  You should have your implementation team assembled and working through these steps by the end of this month. Your implementation team should plan to meet monthly and discuss the progress of each step in this phase.

  • Establish deadlines for each phase – meeting the deadlines of preparation for each stage is critical to the success of the transition
  • Identify Resources – establish what resources are available to aide in the transition
  • Impact Assessment – discuss what effects your organization may expect in the months following the implementation date (cash flow interruptions, increased denials, etc.) and
    formulate a plan to continue business operations if the money suddenly stopped
    coming in (discuss the need for a dedicated line of credit)
  • Initiate Dual-Coding – your billing department should begin dual-coding in preparation as soon as possible
  • Begin Documentation Audits – Compile a list of the most utilized ICD-9 codes and map these codes to its ICD-10 counterpart.  Audit the documentation to see if the documentation is specific enough to support the ICD-10 code.  (This will highlight the areas that need attention during documentation training)
  • System Upgrades – determine if additional system updates will be required and set a deadline for implementation
  • Coder Training – determine where training can be obtained and register each member of your billing staff
  • Coder Materials – determine what materials your billers and coders will need.  Consider ICD-9 and ICD-10 coding books and EMS quick coder materials.  Make plans to purchase these tools as soon as they are available
  • Documentation Training – discuss the approach and formulate a plan, including updates to your current ePCR software applications

Phase 2 – Implementation Preparation:

Phase 2 involves actionable items developed in Phase 1 and should be completed by the fourth quarter of 2013 but no later than the second quarter of 2014.

  • Documentation training should be well underway
  • Coder training should be completed or near completion
  • Dual-Coding should be in full swing and coders should be more proficient
  • Continue documentation audits using dual-coding initiatives
  • Set deadlines for EDI testing

Phase 3 – GO LIVE!:

Phase 3 involves actionable items developed in Phase 2 and should be completed by the first quarter of 2014 but no later than the third quarter of 2014.

  • This is it!  This is what all of the planning and training has led up to.  All of the practice and dress rehearsals have lead up to this moment.  It’s show time!
  • Begin submitting claims with ICD-10 codes to payers who are ready to accept them
  • Closely monitor claims sent with ICD-10 codes for payer activity and trend patterns

Phase 4 – Post-Implementation Follow Up:

Phase 4 involves intense follow-up to monitor for patterns in the revenue cycle and
unforeseen challenges that have been discovered.  This phase should be monitored from the fourth quarter of 2014 through the fourth quarter of 2015.

The Major Differences Between ICD-9 and ICD-10:

The impending change from ICD-9 to ICD-10 will be the largest and most challenging transition of our careers.  When it comes to ICD-10, a good plan is important to your success.  Have you formulated a plan yet?  If not, don’t panic but be prepared to roll up your sleeves and get busy!

You may be wondering why it’s important to start preparing 13 months in advance. There are many steps in the preparation so the more time you allow, the better the result will be. Think of the preparation as dress rehearsal for the live show. The more rehearsal time you have, the better the live show will be. The same applies here because the financial health and very survival of your business depends on a flawless live show.

Let’s start with understanding what the major differences between ICD-9 and ICD-10 and how this will affect your daily operations during and after the transition.

ICD-9 Codes:                                                      ICD-10 Codes:

14,000 Diagnosis Codes                                      70,000 Diagnosis Codes

3-5 Characters in Length                                    3-7 Characters in Length

Digit 1 may be Alpha or Numeric                     Digit 1 is Alpha

Digits 2-5 are Numeric                                       Digits 2-3 are Numeric

Lacks Laterality                                                    Allows Laterality and Bilaterality

This transition will have significant challenges and will be the largest transition the healthcare community has ever undertaken. This will impact all areas of operation: billing processes, clinical documentation, workflow structures, quality reporting, revenue cycle and employee retention.

Preparation for this transition can help mitigate the impact.  There will be a learning curve with this transition so adequate training, patience and encouragement is paramount.  You can expect cash flow interruptions, an increase in denials, a significant decrease in productivity and employee burnout.

EMS Providers should begin preparing for strategies to accommodate decreases in billing staff productivity during coder training and in the months following the implementation date.

Completion of clinical documentation may result in decreased productivity and increased frustration as clinicians modify their documentation practices to accommodate the increased specificity required with ICD-10.

Not only will EMS Providers be impacted by this transition, Payers and Clearinghouses will also have to make significant adjustments.  System updates will be required to handle longer code sets and dual coding sets.

Every National Coverage Determination (NCD), Local Coverage Determination (LCD) and payer policy that is tied to medical necessity will have to be revised, thereby creating new payment rules and coverage determinations.  Your company will need to identify and adapt to these new policies and prepare for an increase in denials, appeals and underpayments.

What can you do to get ready?  Preparation is important in making a successful transition from ICD-9 to ICD-10.  There are steps your organization should begin taking as soon as possible to lessen the impact of the transition.  These steps will be outlined in further detail in a future blog post.

Remember, when it comes to ICD-10 preparations, your organization is either preparing to success by taking proactive steps or preparing to fail by doing nothing.


ICD-10 Documentation Training: What is different and why does it matter to me?


ICD-9 codes (and soon ICD-10 codes) are used to describe diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. All insurance carriers use ICD-9 (and soon ICD-10) codes to write medical policy and determine whether or not a claim is payable.

Billing staff use the PCR (Patient Care Report) to determine what ICD-9 or ICD-10 codes to report on a claim. There is a small set of codes and condition codes used for EMS billing, as compared to physicians. Once the ICD-10 transition is complete, the specificity of crew documentation will be of utmost importance when the billing staff is preparing to code a claim.

This transition will be difficult for billers and clinicians alike. When the billing staff is selecting a code to report an injury to the elbow, forearm or wrist, there is one code they are likely to use now. On October 1, 2015, they have many more specific choices to make.

Current ICD-9 Code:

959.9 – Unspecified injury of elbow, forearm and wrist

New ICD-10 Codes:

S59.809A – Other specified injuries of unspecified elbow, initial encounter

S59.819A – Other specified injuries unspecified forearm, initial encounter

S59.909A – Unspecified injury of unspecified elbow, initial encounter

S59.919A – Unspecified injury of unspecified forearm, initial encounter

S69.80XA – Other specified injuries of unspecified wrist, hand and finger(s), initial encounter

S69.90XA – Unspecified injury of unspecified wrist, hand and finger(s), initial encounter


Let’s take a closer look at those last two codes.  The X is the place holder in a code set.  This allows the billing staff to assign a code for the injury to a high level of specificity (left hand, left ring finger, severe injury).  If there are multiple fingers involved, the billing staff could have dozens of codes to choose from.  If the documentation is not specific, coding this injury becomes virtually impossible – and unbillable.

Next to patient care, good documentation is one of the most important parts of a clinician’s job. Most EMS providers don’t fully appreciate the many uses for their documentation.  A greater appreciation of the importance of accurate and complete documentation comes from a better understanding of its uses and applications in critical areas of an organization’s overall operations: Clinical, Reimbursement & Compliance.

Clinical: Let the Record Reflect!

First and foremost, documentation serves a vital clinical purpose. A copy of the PCR is given to the receiving facility for continuity of care. It communicates to the provider what treatment the patient has received.  The PCR should accurately and adequately document the care provided to the patient while in your care. It becomes part of the patient’s medical record here and at the receiving facility.  In the digital age, that record likely follows the patient everywhere they go. A complete and accurate record is important.

Reimbursement: Show Me the Money!

Documentation plays a vital role in reimbursement.  If your organization is plagued with poor documentation, it could be in poor health and not even realize it. An organization’s overall financial health can be quickly determined with a quick set of vital signs, just like your patients. Take a quick look at the profit margins. Is your company profitable?  What financial condition is your company in, Good, Fair, Stable, Serious or Critical?  If there are no margins, there is no mission. It’s really that simple. Your organization’s survival depends on its ability to secure reimbursement.

Compliance: We’re Watching You!

Compliance is one of the most important elements of the billing process.  There are regulations that dictate what elements are required before a claim can be billed.  The billing staff must review the documentation and determine if what is contained in the record meets the state and federal regulations before a bill can be rendered to an insurance carrier. Aside from the PCR, there are other requirements: PCS forms, ABN forms, signatures and surrogate signatures.

Before a claim can be coded and filed to insurance, the billing staff must determine if the PCR is complete and accurate. If not, it must be returned for addenda or additional clarification.  An intubated patient who has been administered paralytics and sedatives should not have a GCS of 15.


Here are some tips for documentation of Emergency Transports:

How were you dispatched?
What were you dispatched for?
What did you find once on scene?
What were the events leading up to the injury/illness?
Why does the patient require an ambulance?  Is transport by other means contraindicated, why?
What interventions during transport?
Why transported to receiving facility?  What specific service required?
If not the closest appropriate facility, why?  Is there an ABN on file?


Here are some tips for documentation of Non-Emergency Transports:

What were you dispatched for?
What did you find once on scene?
Why does the patient require an ambulance?  Is transport by other means contraindicated, why?
What interventions during transport?
Why transported to receiving facility?  What specific service required?
Is the patient bed-confined?
Is there any pertinent medical history?
Was the patient transported to the closest appropriate facility?  If not, why?  Is there an ABN on file?
Is there a completed PCS?

Things that should never be in your documentation:

  • Never make assumptions (i.e. never document patient is intoxicated.  Stick with observations, such as patient smells of ETOH)

    Never assume an injury is self-inflicted (unless the patient tells you).  Even if the patient tells you it’s a self-inflicted injury, it does not serve a vital clinical purpose, diminish the patient condition or change the way you treat your patient.  However, it may block the ability to be paid when documented

  • Never document a diagnosis unless that patient has been diagnosed by a physician (i.e. do not list primary impression as MI, CVA, fracture, etc. in the field)
  • Never use unapproved abbreviations (NSG, TMB, UTS, PUTS, etc.)
  • Misspelled words – use your spell check
  • Never sign the consent form for your patient
  • Never alter the PCS form in any way, shape, form or fashion


The most important part of a PCR is the narrative. This section contains the information billers (and claims processors) can wrap their minds around and really understand.  Narratives should outline how and why the crew was dispatched, contain how the patient was found, any pertinent negatives, describe the scene and outline the events leading up to the time they arrived.

Remember, without proper documentation and the ability to secure reimbursement, your organization may not survive the ICD-10 transition. Engage your billing, clinical and education staff to come together and make changes now to help ease the pain of this transition.

Check your organization’s vital signs regularly and know when to seek outside help.