Good News/Bad News?

By Charles B. Brownlow, OD (

Medicare Fee ScheduleThanks to the tireless efforts of our AOA leadership and staff (along with the AMA and other provider associations) the US Congress has finally ditched the flawed formula used for creating Medicare Fee Schedules each year.  For a decade or longer, the formula had created Medicare’s schedule in November of each year.  The release of each of those schedules, including significant cuts in reimbursement, would launch a flurry of lobbying activity by the health care providers in order to reverse the cuts.

Some years the lobbying was effective prior to the end of the year but in most cases it took until mid to late first quarter of the following year to make the corrections.  That resulted in Medicare having to reconsider and correct any claims submitted and paid during the months of the ‘wrangling’.  This year’s correction took longer, but it is more significant, in that it changes the whole process.  From now on, the official Medicare Fee Schedule will have an across the board 0.5% increase, with additional adjustments made via enhancements.  The enhancements will be paid based to providers who demonstrate completion of or compliance with incentives that the Centers for Medicare and Medicaid Services will announce each year.  So, the schedule will have a 0.05 increase, but actual payments to each provider will be adjusted up or down based on performance.  Good news?  Bad news?

ICD-10I was one of a very few who believed that the American Medical Association was going to swing its weight around at the last minute, in conjunction with the ‘Medicare Fee Fix’ and kill ICD-10.  I wasn’t surprised, though, when the last minute past on April 14 without any such ‘assassination’.  That means that barring any totally unexpected action by Congress in the next few months, October 1, 2015 will indeed be the date that ICD-10 will become the only method for coding diagnoses in the US.  After that date, ICD-9 will only be used with claims for services that were performed on or before September 30, 2015.

Many doctors and staff have been delaying their preparation, hoping that ICD-10 would simply go away.  For those of you in that situation, it’s time to gear up and get educated.  Personally, I think most of us will be pleasantly surprised at how smoothly that process will run. Here are some suggestions for getting ‘geared up’ for ICD-10:

Within the next month or so, whether you are currently using paper or electronic records you should…

  • Purchase the full ICD-10 manual (about $100, 1,100 pages, American Medical Association,, and provide time for each doctor and key employee to familiarize her/himself with the layout of the manual (Note: laminated quick find aids and listings abridged for eye care are all right, but should not be used without the full, unabridged manual)
  • Identify 20-30 diagnoses that are frequently identified in your practice (open angle glaucoma, macular degeneration, corneal foreign body, etc.)
  • Work in teams, with doctors and staff learning together
  • Avoid trying to ‘convert’ ICD-9 to ICD-10. Instead, use the Tabular Index (alphabetical) at the front of the manual to look up each diagnosis, eg, non-proliferative diabetic retinopathy with macular edema. The listing is under ‘Diabetes, retinopathy’ in the index, run your finger down to ‘non proliferative, with macular edema’ and find the code, E11.321
  • Turn to the page associated with that diagnosis and you’ll see ‘Type II diabetes mellitus with mild non proliferative diabetic retinopathy with macular edema’, with that code, E11.321
  • Continue through the other diagnoses you’ve identified
  • Refer back to the introduction and guidelines sections of the manual as questions pop up

If you are using electronic records, check with the company to determine

  • Whether they’ve done their testing and are prepared for the big day
  • Whether you will need to do anything special to be sure that ICD-9 and ICD-10 are applied appropriately up to and through October 1
  • Whether the EHR will permit you to choose a diagnosis with the software automatically suggesting the appropriate ICD-10 code
  • Whether the company will provide training guides for docs and staff related to ICD-10

In July or before, have additional sessions to list common diagnosis codes and refer to the AMA ICD-10 manual to identify the proper codes.  For those using electronic records, there should be additional training session guidelines established by the developers.  For those still using paper charts, there is already lots of information available from the AOA at and search for ‘ICD-10’.  There are many, many great articles, tips, webinars, etc. available there to assist in the training process.

I believe that the transition to ICD-10 will be easier than most people think.  ICD-10 is better than ICD-9 in several ways, including the ability to report a many-faceted diagnosis, such as the diabetic retinopathy example above, with a single six or seven character code, rather than two or three four or five character ICD-9 codes.  The closer we get to October 1, the more resources there will be available, as it will be to the advantage of all the players in the system; doctors, staff, insurers, Medicare, etc.; if all are well prepared and trained.  Good news?  Bad news?  It’s up to each of us to make sure the news is as good as it can be; by accepting the reality of ICD-10, preparing for it, and applying it.

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