Coders teeter on tightrope of relief and tension

From “Now what?” to “What now?” healthcare organizations surely are scratching their heads over yet another delay in implementing ICD-10 codes necessary for filing claims and getting reimbursed for services provided.

Others may be downright exasperated and mildly vexed, and for good reason. Scores of provider, supplier, payer, and educational and training organizations have spent millions of dollars preparing for the expected medical coding upgrade whose implementation deadline continues to be pushed out. Some attribute the latest delay in part to the successful lobbying efforts of those struggling to prepare and closet conscientious objectors focusing on other priorities in closer proximity, such as the continued aftershocks of the Affordable Care Act.

But there’s no turning back the clock or the prepping efforts because deep down the healthcare industry knows ICD-10 in fact will become the fiscal law of the land as part of the Protecting Access to Medicare Act. The real questions are when and how can they put it off for so long before the lack of enactment grossly exceeds the costs of the pain of migrating toward enactment.

In fact, turmoil continues to roil among healthcare organizations as found by an ICD-10 preparedness survey conducted by eHealth Initiative (eHI) and the American Health Information Management Association (AHIMA), and sponsored by Edifecs. The survey showed that “a majority of healthcare organizations may be ready to begin testing for ICD-10, but there are varying timelines, indicating some are more prepared than others.” Further, 45 percent of respondents don’t have a good sense of their partners’ readiness, according to the results. (For more details, see HMT Dashboard)

Realistically, ICD-10 represents a vast expansion in number of codes and complexity over its predecessor medical coding system, so the implementation hurdles don’t change even as the deadline-based pressure release valve is pushed, which actually may strain other areas.

So how will the latest – presumably final – delay alternatively help and harm the progress toward improving reimbursement throughput? Health Management Technology posed that question to a host of ICD-10 conversion experts. 

HMT: With another delay, how do you justify or salvage the costs of preparation efforts to date?

O’Rourke: From my perspective, it’s a regulatory issue so there’s no real question of whether you justify it or not. We have to adapt and adjust to the ebb and flow of the regulatory requirements. I try to work with whatever it is that the regulatory agencies are presenting to us. As for salvaging costs, you basically take what you’ve done to date – that is, what work is pretty well done for moving forward – and then try to recalibrate your timing for what you have left to do. So we’ve stopped some things a few months ago, and we’ve acknowledged that we have another 15 months to go. So you ask, “How do I recalibrate to make our program as effective as possible in the next 15 months?”

Desrochers: If payer organizations were just remediating for ICD-10, it is very difficult to justify and/or salvage the expense. For every delay of the deadline, the planning, workflows and personnel needed to process claims using the ICD-10 format are put on hold. These resources are in a perpetual holding pattern, waiting on the next “deadline” instead of being deployed to address other critical business needs. These efforts, even if the 2015 date does not move, will only have to be started again for organizations using legacy technology, as the clock on ICD-11 starts ticking. However, for payer organizations that used ICD-10 as a chance to update their core technology platforms rather than simply remediate their legacy systems to address this one new standard, that money was well spent. They are reaping the benefits of next-generation technology that is enabling them to streamline their operations, attract and close new business, create both internal and external transparency, and drive satisfaction through enhanced customer service and member engagement – all while being ready for ICD-10 and whatever comes next. 

England: This current delay in ICD-10 implementation could very well work out in favor of physician groups who were nervously anticipating decreased productivity and delayed reimbursement with the onset of ICD-10. Many larger vendors, payers and many in the coding industry were prepared for an October 2014 implementation. The additional time has opened a window of opportunity for coders and physicians to work closely together to improve documentation specificity needed to select the appropriate code. Because of this, everyone should be more comfortable with appropriate documentation, assigning codes and preparing charges for processing. This will make for an efficient claims-generation process, enabling vendors and payers to process claims and reimbursements efficiently. The costs of training and preparation can be justified by making the best use of the additional time caused by the delay, thereby resulting in a more efficient reimbursement process post ICD-10 implementation.

Croxton: You continue to focus on accurate documentation, which is the “source of truth” regardless of ICD-9 or ICD-10. That is effort well spent. Adjust your timelines on additional ICD-10-specific training, and if training was completed, provide ongoing updates so the knowledge is not lost. 

Amick: We have invested in readying our products and creating supporting materials to assist our customers in the transition to ICD-10. We find our customers split between those who complete their readiness efforts now (with the exception of pushing training out to perform just-in-time) and those who halted efforts. Whether you are an advocate of the delay, or frustrated by it, the delay does afford customers more time to focus on improving overall revenue cycle performance to drive financial returns today. These returns will only increase when ICD-10 finally comes and you’re fully prepared to make the transition.

The delay also gives more time to establish dual coding processes where payments continue to be made based on ICD-9 codes, but where providers can also analyze what actual reimbursement will be under ICD-10 codes. That brings more visibility into reimbursement impacts than many providers would have had if the Oct. 1, 2014, compliance deadline remained in place. This allows providers to minimize a significant financial impact resulting from the switch to ICD-10 by offering early insights to how they may be able to improve their documentation and revenue cycle processes, as well as staffing.

Quirk: ICD-10 and MU 2014 upgrades were the big distraction for this year. Most vendors bundled them together, so there shouldn’t be any lost IT time. No one got to the point of patient impact, since the delay came early enough. Workflows and staff training should continue as they result in more accurate coding, which will ease the transition in the future and [healthcare claims] coding for now.

Hyman: While ICD-10 was delayed, the costs associated with preparing for the transition are not lost. The ICD-10 transition forced organizations to create interdisciplinary teams to assess the impact of the transition across their workflows. This provided an ideal opportunity to improve their processes and procedures to support the conversion – all of which drove clinical and financial improvements. In addition, staff members who have undergone training can use the additional year to further their expertise in ICD-10 to ensure they can accurately code and bill using the new standard.

Haugen: I’ve seen two ways our clients have decided to handle the ICD-10 delay. Some organizations, such as critical access hospitals and smaller physician practices, are viewing the delay as an opportunity to reprioritize IT projects and use the next nine months to catch up on unmet deadlines. For instance, perhaps it has needed to update the EHR/EMR to meet the ICD-10 coding requirements and hasn’t done it because training the employees for the new codes was the priority. The delay has given those organizations the chance to breathe a bit and get better prepared for ICD-10.

Meanwhile, the larger hospital systems and physician networks are able to be more forward thinking about ICD-10, established EHR/EMR update roadmaps, refined change leadership plans and updated employee education plans. They are ahead of the curve now and have the opportunity to look at what they’ve put in place and see where they can improve their efforts.

In either scenario, the delay offers a real opportunity for organizations to review and refine how they communicate about ICD-10. Instead of communicating the need to meet the deadline, the primary message should be focused on improving clinical documentation. This is an opportunity for healthcare leaders to commit to a new level of provider documentation and make ICD-10 an integral part of EHR adoption. Adopting ICD-10 will support the organization’s efforts to meet the deadline and ultimately improve patient care.

Fielding: The investments to date have absolutely been necessary. They have aided in planning and impact assessment as well as for acquiring technological solutions and ensuring their readiness. With these foundational investments in the rear-view mirror, focus can now turn to industry-wide testing efforts to help mitigate the risks of an unsuccessful migration. The probability of success is now much higher due to the extended time afforded for preparation.

Pazera: Preparing for ICD-10, only then to face another delay, is having a big financial impact on health systems and physician groups who have already invested in coder training. Many of these organizations required coders to sign a contract committing to staying with the organization through Oct. 1, 2015 – what should have been the first full year of ICD-10. Now that the deadline has been delayed, these contracts will need to be renegotiated. If contracts aren’t renegotiated, other hospitals may offer coders higher pay or a signing bonus, and the provider will have to reinvest in new coders and finance another round of ICD-10 training.

The good news is that much of the ICD-10 preparation providers have undertaken needed to be done, regardless of the deadline. For example, practice management systems [PMS] needed to be upgraded to be able to accommodate ICD-10 codes, regardless of the deadline extension. The problem comes  for those providers who have already implemented their PMS upgrade. These upgrades may have been set to take effect on Oct. 1, 2014, so providers should contact their vendors to ensure that their system can accommodate the new deadline.

From a clearinghouse perspective, we had to get our systems ready to accommodate ICD-10, regardless of when the deadline actually occurs. Our organization is fully ready to handle ICD-10 transactions, so we are focusing our attention on educating our providers to help them prepare their own organizations.

Waxenfelter: I personally see the delay as an opportunity for healthcare organizations to implement new programs, optimize existing ones, continue technology enhancements and provide more opportunities for employee awareness and training. Despite the delay, continuing at a steady pace can help mitigate employee burnout and allow time for organizations to reset. Leadership must proactively and consistently spread that message. 

HMT: How do you meet the latest deadline extension and maintain your team’s and organization’s momentum to upgrade?

O’Rourke: ICD-10 is one of our No. 1 priorities throughout the organization, and so a number of our major initiatives, including the development of an electronic health record, are embedded as a prerequisite to completing ICD-10. Our high-priority initiatives are so embedded that everyone involved is still working with a very high degree of energy to complete and meet this deadline.

England: I would modify my approach with the physicians’ training of ICD-10. The coding team should review physician documentation. They could code out in both ICD-9 and ICD-10. That information can be formatted into education sessions, shared with the physicians individually or as a group. Many physicians find it easier to relate to documentation from within the group. While the primary focus of documentation should be related to patient care and compliance, education around specificity needed for code selection and ultimately reimbursement in this manner can be seen as less intrusive than routine meetings or training sessions on the code set itself. In addition, continue talks with your vendors to understand how or if their timeline has changed. Maintaining some momentum during this delay will prevent a flurry of activity in the weeks prior to the actual implementation of ICD-10.

Croxton: Upgrade in a test environment and take the time to learn features not only regarding ICD-10, but in the release. Most vendors will include other functionality in their ICD-10-compatible release. It could be Meaningful Use items, for example. 

Amick: With respect to the delay’s impact upon readiness efforts, the most recent delay to ICD-10 has spurred primarily two different approaches. First, there are those who are continuing with their readiness efforts, and plan to complete readiness efforts excluding JIT training, and will circle back to complete that training shortly before a cutover to ICD-10. Second, there are those healthcare providers who have diminished the near-term focus on ICD-10, delaying readiness efforts. 

The additional one-year delay provides welcome breathing room for some organizations coping with ongoing financial pressures and concurrent 2014 regulatory mandates, including complying with provisions of the Affordable Care Act and attestation for Stage 2 Meaningful Use. However, there should be a steady focus on multiple initiatives (CDI, staff training, testing and contract modeling) in preparation for the transition to ICD-10. 

Quirk: The biggest key is ensuring your organization can handle the change coming. ICD-10 is nothing compared to the change coming from fee-for-service to value-based medicine. Organizations must put together a regulatory team to keep up on the new rules and a strong change management infrastructure to cover not only ICD-10 but also MU, PQRS, Value-Based Modifier and the elective regulations (PCMH and ACOs). 

Hyman: To help re-energize efforts, facilities should have trained ICD-10 champions to help promote conversion initiatives and serve as peer mentors to other staff. Having peers promote the value of ICD-10 to other staff can help increase engagement with conversion plans and allow organizations to be better prepared well in advance of the 2015 deadline. 

Haugen: Another opportunity with the delay is to ensure all EHR/EMR efforts are in alignment, such as process improvements, clinical content and workflows, and Meaningful Use. Healthcare organizations should meet on a regular basis to ensure efforts are aligned. This is not a simple task. But this extra time provides an opportunity to further collaborate and identify additional areas for education, communication and leadership to ensure adoption of this new coding set. 

Fielding: Providers need to recognize that ICD-10 is but a small component of a much larger evolution in healthcare. ICD-10 will not be stopped, and as the industry transformation rolls down the tracks, providers will need to get on the train or get left at the platform.

Pazera: We, as an industry, need to understand that the ICD-10 delay is not a snooze button. We must keep moving the needle toward ICD-10. Review your implementation plan, and assign new deadlines to guide your efforts. If you hadn’t previously budgeted for ICD-10 preparation in 2015, add it to the budget. Continue communications with staff to keep ICD-10 top of mind. Something as simple as coding a few ICD-10 claims each week or spending Friday lunch hours reviewing relevant codes can keep your staff’s ICD-10 knowledge fresh.

Waxenfelter: Many of our clients are repurposing resources to other activities during the lull; most of the initiatives that became critical in light of the transition to ICD-10 can and should continue in the wake of the delay. Clinical documentation improvement (CDI) programs, physician champion networks, technology upgrades, training and process improvements will directly benefit organizations, prepare them for adopting the new code set and continue momentum into the ramp up in 2015.