ICD-10 Compliance: From Provider Uncertainty to Certainty
By - Tick tock goes the ICD-10 clock.
As the ICD-10 implementation October 1, 2015 date looms closer, hesitation within the healthcare industry blossoms as providers struggle to stay in the game. Can general uncertainty around the implementation date be resolved?
Jim Daley, Director, IT WEDI Past-chair and WEDI ICD-10 Workgroup Co-Chair of BlueCross BlueShield of South Carolina, spoke with RevCycleIntelligence.com this week about how to address widespread uncertainty regarding the ICD-10 compliance date and what those providers falling behind should concentrate on.
“There were very firm statements last year that the date wasn’t changing and this was it. All of a sudden, the date changed,” says Daley. “There’s always going to be some level of doubt.”
An increased interest in ICD-10 from Congress, a review of transition activities via the Government Accountability Office (GAO), and a lack of delay in the Sustainable Growth Rate (SGR) repeal bill are all positive indications the date should stick this time around, confirms Daley.
“Medicare did end-to-end testing. That was a concern. Is Medicare even ready?” asks Daley. “They did their acknowledgement testing and the end-to-end testing and showed that the systems work and there was only a 3 percent rejection rate for ICD-10. There’s been a lot done to show Medicare is ready.”
Within recent testimony from the House of Representatives’ Energy and Commerce Subcommittee on Health hearing, Daley emphasizes there was only one unfavorable ICD-10 opinion. All others confirmed widespread support and readiness, says Daley.
From ICD-9 to ICD-10…in a weekend?
Daley adds piloting a vendor ICD-10 system that is, indeed, ICD-10 ready can be simply executed. He supports this claim with data from one small provider who began seamlessly implementing ICD-10 over a weekend.
According to testimony from Edward Burke, MD, of Beyer Medical Group, “We used ICD‐9 on a Friday and ICD‐10 on the following Monday. No training, no expensive consultants, just a dedicated group of professionals who accepted the challenge. And what we got was a normal day at the office.” Burke adds there was no special training involved or any money spent in preparation. “We did not see less patients and our practice did not suffer. As providers, it was not frustrating or scary. It just ‘was,’” confirms Burke. Burke's example demonstrates speculation swirling around high anticipated costs of ICD-10 implementation is merely theory, confirms Daley.
Daley also mentions other pieces of information in support of his claim, such as a recent survey from the Professional Association of Health Care Office Management (PAHCOM), which reported ICD-10-CM/PCS in small physician offices is “drastically lower” than earlier widely circulated estimates.
Additionally, such early estimates from a 2014 update of an American Medical Association (AMA)-sponsored Nachimson Advisors study projected that practices’ approximate estimated costs would range between $22,000 and $105,000.
Talking the ICD-10 talk
“There’s been a lot of hype about the cost of ICD-10 and some very large figures about the cost of implementing ICD-10, particularly for physicians,” Daley states, adding that hard evidence of reasonable costs confirm actual expenses can be much smaller than initially estimated.
The reason for a sizable difference in financial estimates may be easily explainable, Daley confirms. Such estimates generally include a variety of “soft” expenses of time spent by physicians learning about ICD-10 and improving documentation and anticipated costs for a temporary shortfall in productivity as well as “hard” expenses if software updates are not included in the vendor contract.
Another reason earlier financial estimates may lack accuracy is there are many free or economical means of becoming ICD-10 ready which may not have been amply accounted for. Such resources include free educational websites such as WEDI and CMS, $1.99 (or free) smartphone apps that allow for easily conducted ICD-10 code searches, comprehensive ICD-10 training ranging from three hundred and fifty to seven hundred dollars, and freely available downloads of the ICD-10 Diagnosis Code book, according to the American Health Information Management Association (AHIMA).
In reference to the aforementioned findings, Daley confirms costs for small providers can be “less than $10,000 as opposed to some talking about $200,000 in cost. The numbers are all over the board.”
Costs for large institutions are significantly greater and can run into the millions. Daley says the idea that implementation will involve an abundance of supplemental time for documentation purposes, selecting the proper codes, and purchasing new systems is overstated. Although new systems are required in some instances, the practice of medicine isn’t changing and providers should already be documenting most of what is needed for ICD-10 Daley confirms.
“You’re most likely already getting new systems/upgrades as a result of purchasing EHRs for Meaningful Use. Many contracts include upgrades for federal mandates that come as part of your contract in buying the system,” explains Daley. “A lot of factors weigh in on this. I’m sure you could find someone who spent a lot of money on this. Across the board, numbers are magnitudes lower than some of the earlier estimates.”
To test or not to test?
The WEDI survey found half of hospitals and health systems had begun external testing efforts, says Daley. But, only a tenth of those who categorized themselves as physicians had started.
“A third of the physicians said they weren’t sure if they were going to do external testing,” maintains Daley. “If a large block says I don’t need to do it or I don’t have time, then they’re not going to be testing and you’re going to have a much smaller number that complete this step.”
Many organizations delayed testing efforts, expecting another delay would come, says Daley.
“As time compresses, you have to cut back on the things you’re doing. The first thing you’d better be doing is making sure your own shop is ready. Don’t worry about what the other people are doing,” Daley states.
Every provider does not necessarily need to test to make sure the payer systems are working, confirms Daley.
“You can’t do anything about fixing the payer systems. The odds are the payers are already looking at that and fixing it and many other providers have already found any issues. What you can do is work on fixing your own errors,” Daley says. “The question is are you capable of testing your systems to make sure you’re ready without having a payer help you do that? I think the answer is yes.”
External testing, although of substantial value, is not necessarily a primary need, according to Daley.
“It’s a good thing to do, don’t get me wrong, but not really feasible for every provider and I know payers aren’t planning on testing with every single provider,” Daley adds.
Daley says there is expense involved regarding time, effort, and the cost of conducting testing with other parties. Organizations must therefore decide whether or not Medicare end-to-end testing will be productive depending on their individual objectives and needs.
“There was a limited number of participants and there’s time and effort required to do that. Medicare did accept everyone that applied for the end-to-end testing, but there’s effort involved so a lot of people said I’m not ready or I don’t care to get involved in that at this point,” emphasizes Daley.
The importance of taking action now
Regarding advice for future healthcare organizations, Daley emphasizes the importance of collectively establishing an action plan.
“Understand what needs to be done. Look at your organization to figure out where you’re using all of these codes. How can you plan for something if you don’t even know what you have to do?” Daley maintains, who says revenue preservation is a primary concern that requires prioritization of efforts.
“Some of the doctors have cheat sheets,” adds Daley. “Those might be a good thing to address because it probably doesn’t take that much time anyway. But you don’t necessarily need your cheat sheets to be updated to get paid. Those are for internal usage. It may make it easier for you to do your operations but they’re indirectly involved in the revenue cycle.”
Daley further maintains it is imperative to recognize not every code will be used. He recommends focusing only on codes that pertain to a particular specialty.
“The last I looked, there were 141,000 diagnosis codes and procedure codes in total,” Daley explains. “If you’re a physician, you’re billing based on [Current Procedural Terminology] CPT codes. You probably don’t have to learn the inpatient procedure codes unless perhaps you work for a hospital. In general, you’d be billing on CPT codes and really need to only look at the ICD-10 diagnosis codes.”
Daley recommends a measure of accountability will strengthen and advance incorporation of ICD-10 into revenue cycle management.
“Put somebody in charge. Assign responsibility. It’s much better than people pointing fingers,” adds Daley.
It is also vital for providers to know what services are available and where limitations are imposed, says Daley. Although codes can be flagged if erroneous and corrected as valid codes, correcting documentation is a manual task, he adds, saying a good medical practice should already be capturing established clinical concepts.
“If you are a physician and you don’t document that the broken arm was on the left side instead of the right side, no vendor software is going to be able to pick it for you accurately on a consistent basis,” confirms Daley. “You have to make sure you have these clinical concepts down in your documentation.”
Most. if not all, payers are trying to go in in a revenue neutral basis and are hesitant to adjust payment contracts, says Daley.
“If medical policy changes with ICD-10 implementation, then certain things that were covered before may not be covered or they may require an authorization,” says Daley. “If it is a special diagnosis or a special treatment, they may say now that I can distinguish that’s what it is, I’d like some more information to make sure it’s reasonable for what the patient’s condition is.”
Although Daley confirms such actions will not likely happen on a large scale basis, there could be a push to change a few policies based on this idea.
Keeping a firm grasp on metrics
Daley offers the example of there being a distinction between a nonunion of a broken bone and a malunion.
“Nonunion means it didn’t come together. Malunion means it came together in a bad way,” explains Daley. “And one particular payer, as explained to me by an orthopedic surgeon, said their medical policy used to say they’d approve a process that helped it heal for malunions.”
The implications of this were dangerous. “If it was healing the wrong way, they helped it heal the wrong way even faster,” says Daley. “Big mistake. They changed the policy to only approve the process for nonunion.”
Daley says similar instances may lead to differences in medical policy.
“For the most part it’s going to be pretty neutral,” he adds, stressing the importance of confirming clinical documentation captures the most essential information. “The delay was its own worst enemy. The bigger organizations are further along than smaller ones but a lot of people just because of the delay delayed even further,” adds Daley.
Daley emphasizes the need to proactively disseminate information to make sure it is there in people’s hands. This is more effective than just posting available information and letting them locate and retrieve it.
Daley says the healthcare industry needs continued outreach and the incorporation of push versus pull techniques. He additionally emphasizes the need for appropriate metrics.
“They need to know today what their metrics are. That way they can have early recognition if something changes after the cutover,” says Daley. “Look at staffing needs and have a response plan in place. Who handles something if something looks different? Who do you call? Confirm who your contacts are. Do you have a payer contact? Do you have a clearinghouse contact? And plan for that actual cutover.”
Tick tock, tick tock, says the ICD-10 clock. Will you be ready?
