Within 30 days, the deadline that some healthcare providers have dreaded and others have eagerly anticipated will happen. Yes, that one – ICD-10 conversion and implementation.
No more delays. No more postponements. No reprieves. Well, except for that one-year “grace period” negotiated between the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) where clinicians will not face penalties or audits for coding-specificity errors, so long as they use the appropriate family of codes.
“ICD-10 implementation is set to begin on Oct. 1, and it is imperative that physician practices take steps beforehand to be ready,” said AMA President Steven J. Stack, M.D., in a July 6 prepared release. “We appreciate that CMS is adopting policies to ease the transition to ICD-10 in response to physicians’ concerns that inadvertent coding errors or system glitches during the transition to ICD-10 may result in audits, claims denials, and penalties under various Medicare reporting programs. The actions CMS is initiating today can help to mitigate potential problems. We will continue to work with the administration in the weeks and months ahead to make sure the transition is as smooth as possible.”
While that belt-loosening may have inspired some facilities to heave a sigh of relief, it’s only slowing – not stopping – the first monumental change in the International Classification of Diseases in 35 years that expands the coding system to some 68,000 codes.
But what if, after all the education, research, preparations, and training, a facility finds out in the 10th or 11th hour that it still isn’t quite ready – even to satisfy CMS’ easing of tensions? Maybe clinicians or information technology professionals discover some connectivity clogs, uncover some outpatient and physician office interface hiccups, or unleash some conversion complications?
One concern that emerged almost immediately following the CMS announcement of its joint agreement with the AMA was how the agency defined “family of codes.” So CMS released a document designed to clarify its provisions and alleviate, if not eliminate, any confusion.
CMS states that, “‘Family of codes’ is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition.”1 Also noteworthy: CMS clarified that the flexibility in code specificity is only during post-payment review and not during the claim adjudication process.
Whine and geez party
Even after several year-long delays and being roughly 60 days out from actual compliance and implementation, many healthcare organizations continue to complain, mumble, and rumble about this impending change.
Karen England, Revenue Cycle Consultant, Ingenious Med, acknowledges hearing “a lot of concerns and complaints on the change overall.
“People are saying, ‘I don’t understand why I have to learn this. It’s not going to impact patient care; it’s going to take up all my money. I don t have time for this.’ These complaints are exacerbated by the fact that the ICD-10 transition has been put off for so long – several times since 2005,” she says. “The change to ICD-10, is the biggest change in healthcare in a generation, and provider organizations seem to be in constant planning and preparation mode.”
Facilities seem to be obsessing over time constraints and workflow, with their overriding thought being, “‘I’m not going to get anything out of transitioning to ICD-10 clinically or financially,’” she says.
“The main complaint AHIMA has heard from our constituents is the frustration surrounding multiple delays in ICD-10 implementation,” says Sue Bowman, MJ, RHIA, CCS, FAHIMA, Senior Director, Coding Policy and Compliance, AHIMA. “Many believe the U.S. should have transitioned to ICD-10 years ago.”
Yet Bowman remains optimistic. “Many organizations are ready to make the transition, start collecting data, and using the better data that will be produced after ICD-10 is implemented so they can move on to other projects,” she says. “The additional costs that have been incurred as a result of the delays are a common complaint, as are the loss of momentum and skepticism regarding the firmness of any compliance date.”
Josh Berman, Director, Business Analytics & ICD-10, RelayHealth Financial, believes many cannot wait for the date to pass.
“We have been educating and sharing information with our customers and the provider industry since 2012,” he says. “The vast majority understand that delays breed procrastination, and therefore most that we speak to are looking forward to putting this change behind us. At this point, the complaints are most often leveled at the industry’s perceived indecision on some ICD-10 issues, including the prospect of another delay and [more] updates to guidelines on how ICD-10 will work. Most understand that in order to improve the growing cost of healthcare we must evolve – and evolve quickly.”
Crystal Ewing, Senior Business Analyst-Product, ZirMed, offers a mixed review, contending that providers remain in “various stages of readiness,” despite ICD-10 implementation happening just around the corner.
“Many providers, understandably, assumed that ICD-10 would be delayed yet again and put off important planning activities until recently,” Ewing says. “Now they’re having to play catch-up. The multiple delays and various ICD-10-related bills introduced over the past year created an atmosphere of doubt. It’s like the boy who cried wolf.”
Ewing further notes that some providers have yet to receive their upgrades even though most vendors’ products are ICD-10 compliant. “Providers are simply scheduled to receive the upgrade(s) closer to go-live,” she adds. “This was either the provider’s choice – in many cases because they did not believe go-live was going to happen – or because the vendor’s early-bird installation schedule was already full.”
Physicians continue to push back against the transition, even at this late stage, particularly for outpatient functions, according to Kerry Martin, President and CEO, VitalWare.
“A major concern for provider organizations is physician buy-in of ICD-10,” Martin says. “Physicians don’t want to learn or have to memorize the new, much larger ICD-10 code set. Their days are already filled with administrative chores taking them away from time with their patients.
“Another concern we have heard time and again, when speaking with provider organizations as the implementation gets closer, surrounds clinical documentation in the ambulatory and ED settings,” he continues. “Currently, documentation queries don’t typically take place in the outpatient world. However, with the additional specificity in the new code set, provider organizations are looking for solutions to facilitate outpatient CDI.”
Despite any prior planning, Siva Tunga, Senior Director, Product Management, Edifecs, says he expects the transition to extend well into next year.
“Many health systems have created financial models based upon mapping to anticipate impacts in commercial and CMS Medicare through various testing initiatives in the past two to three years,” Tunga says. “Providers are actively working on ICD-10 documentation and training assessment impacts, which will be an ongoing learning curve for the next 12 to 18 months. However, based on what we are hearing from providers and a recent WEDI survey, ICD-10 readiness still underwhelms. With several starts and stops to ICD-10 projects, some provider organizations might not have started the impact assessments with anticipation of another ICD-10 delay.”
11th-hour scrambling
So what can healthcare organizations reasonably do at the last minute to smooth out the transitional bumps and grinds?
“Think about the work that you do, the codes you use most in ICD-9 and the types of diagnoses you treat now, and incorporate that into your documentation,” England advises. “Think about the search terms you use currently to treat patients, and don’t focus exclusively on the new code sets in ICD-10 that you need to remember. Make a mental or physical list of your most frequently used codes and of the main diagnoses you are treating patients for.
“Develop real-time education or real-time feedback between physician and coding or billing teams,” she continues. “Have coders and billers provide immediate feedback to physicians for when they get something right or when there is room for improvement in their documentation and ICD-10 code selection.”
England also recommends identifying and appointing a physician champion to act as a mentor or resource for other physicians in their group for support.
“Clinicians will benefit from technology tools that ease the transition to ICD-10 for them, in mitigating productivity loss, saving frustration, and facilitating proper reimbursement,” Martin says. “With the right technology, not only will clinicians be able to document for appropriate ‘family of code,’ they will be equipped to successfully navigate through the transition to ICD-10.”
Berman advises providers to curb their frustration by not overdoing the process.
“Practice what really drives your revenue,” he suggests. “The number of new codes can be overwhelming, but the vast majority of facilities only use a small percentage of these codes on a regular basis. Even the largest facilities most likely have a subset of codes that they can practice to perfect and ‘protect’ the majority of their revenue. It’s fun to talk about all the crazy codes, but in the end we will only use a portion. Practice that portion to perfection.”
Ewing encourages clinicians and coders to familiarize themselves with the ICD-10 code format, especially if they’re relying on ICD-10 coding books or digital look-up tools. They should rely on mapping tools from ICD-9 too. “Run reports to identify which ICD-9 codes you use most frequently, and the three-digit category in ICD-9,” she advises. “Identify and mark or bookmark the associated ICD-10 ‘family’ in the code book or e-book you use.”
At the core, providers must create a baseline understanding of the risks and impacts of the transition, according to Tunga.
“Providers should identify areas of risk with the primary focus on ICD-10 coding accuracy, both positive and negative,” he says. “If the shift is too dramatic in a positive direction you could be at risk of audit, contract renegotiation, or having claims pended for an extended period of time. If the shift is too far in the negative direction, the risk for monetary loss is significant. With a target of financial neutrality, these changes are risks that should be on your radar.”
Providers also must accurately predict the potential areas where changes will emerge and work with payers and other trading partners making the transition, Tunga notes.
“By setting up an ongoing ICD-10 transition-monitoring system that will detect early changes, organizations will be well poised to take corrective actions that can minimize the financial impact,” he says. “The ICD-10 transition impacts payers, providers, and other trading partners in the healthcare ecosystem, and a successful transition requires collaboration between these groups to fully understand what is changing and how to best prepare. The use of data, coding, and financial conversations based on facts will help focus attention on changes that need to be addressed. Through these conversations, relationships between providers, payers, and other trading partners can be strengthened while simultaneously addressing important business issues.”
Bowman wonders whether providers are making too much about the progression that may be needlessly complicating current operations.
“I wouldn’t recommend doing anything differently than what providers would have done before CMS came out with the new guidance,” she says. “Assess clinical documentation, develop improvement strategies where necessary, and assign the best code based on the documentation.”
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