Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

Does Successful ICD-10 Testing Mean a Smooth Transition?

By Jacqueline DiChiara

- The International Classification of Diseases (ICD) is used to standardize codes for medical conditions and procedures. The Centers for Medicare & Medicaid Services (CMS) is assisting and supporting industry stakeholders with the October 1, 2015 ICD-10 transition within the United States.

“CMS is ready for ICD-10. And, thanks to our many partners—spanning providers, health plans, coders, clearinghouses, professional associations and vendor groups—the health care community at large will be ready for ICD-10 on October 1,” says CMS Adminstrator Marilyn Tavenner.

An overview of ICD-10 adoption regulation

Following the proposed rule issued in 2008 by the U.S. Department of Health and Human Services (HHS) to transition to Oct. 1, 2011, stakeholders requested more adaption time was needed. In the 2009 final rule, HHS established the date of transition as Oct. 1, 2013, allowing providers an additional two years. In 2012 HHS moved the ICD-10 compliance date forward one year to Oct. 1, 2014 alongside President Obama’s efforts to alleviate regulatory burden. The April 1, 2014 Protecting Access to Medicare Act of 2014 (PAMA) forbade the Secretary from ICD-10 adoption before Oct. 1, 2015.

Reasons for the transition stem from urgency to modernize

Since ICD-9 was implemented in the seventies, it is now dangerously antiquated and exceptionally obsolete with regards to the needs of modern medicine. Unlike ICD-9, ICD-10 is designed to accommodate code expansion specific to patient diagnoses. This allows doctors to acquire higher volumes of information which will result in a more concisely coordinated understanding of an individual patient’s health across providers.

ICD-10 is slated to serve as a breakthrough in three specific areas – aiding the discovery of disease epidemic and adverse drug events, promoting new payment models focused on care quality, and enhancing fraud analytics.

Further delays will result in significant costs

Additional delays will be expensive for those physicians, hospitals, and health plans who have finalized all updated system changes in preparation for the ICD-10 transition.

As ICD-9 and ICD-10 claims submitted for the same dates of service cannot be processed by CMS and other commercial health plans, a period of transition allowing submission of either is simply impossible, says the CMS.

Successful ICD-10 testing forecasts smooth October transition

CMS has performed extensive and thorough internal and external testing to ensure CMS systems can accept and pay provider claims with ICD-10 codes when the October transition becomes a reality. CMS has also completed testing efforts with Medicare fee-for-service providers in March and November 2014. Additional testing periods will take place in March and June of this year.

On February 25, 2015, CMS released the “first successful” results of end-to-end ICD-10 testing results from January 26 through February 3, 2015.

“Overall, participants in the January 26 to February 3 testing were able to successfully submit ICD-10 claims and have them processed through our billing systems. To the extent that some claims were rejected, most didn’t meet the mark because of errors unrelated to ICD-9 or ICD-10,” says CMS Adminstrator Tavenner.

Testing results show 81 percent of 14,929 received claims from 660 health care providers, billing agencies, and equipment suppliers were successfully submitted and processed.

Most (fifty-six percent) of received claims were Professional.

Some implementation dates for home health claims contained ICD-10 codes but were not processed correctly. This issue is being resolved and testers will be able to resubmit rejected claims.

The most common reason claims were rejected was reported as “non-ICD-10 related errors, including issues setting up the test claims (e.g., incorrect NPI, Health Insurance Claim Number, Submitter ID, dates of service outside the range valid for testing, invalid HCPCS codes, invalid place of service).”

“Testing allows us to identify areas of improvement, and we will work with outside entities and stakeholders to improve those very small deficiencies identified. And we will continue to do testing, especially in those areas we identify as needing improvement,” says Tavenner.

Physicians still report lack of ICD-10 readiness reported this week on a new national Navicure survey about physician practices’ overall ICD-10 readiness.

Although end-to-end testing can help effectively determine payer readiness, only 21 percent of surveyed physician practices confirm they are on track with preparation efforts. Eighty-one percent expect they will, indeed, be ready in October. Thirteen percent said they did not yet know how to effectively transition.



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