ICD-10 Specialist on Impending Transition: “It’s a Process Change”

Sept. 16, 2015
ICD-10 is just a few short weeks away, and many in the industry are feeling the heat. One ICD-10 expert takes a look at what to expect when Oct. 1 hits and what impact the transition will have on healthcare.

Recently, the Centers for Medicare & Medicaid Services (CMS) announced a third successful round of week-long ICD-10 end-to-end testing, saying that it accepted 87 percent of submitted claims from the testing period of July 20 through 24. During the first ICD-10 end-to-end testing week, 81 percent of claims were accepted by CMS, while 88 percent of claims were accepted during round two.

While it might seem as if the successful end-to-end testing results would quell the healthcare industry’s angst over the ICD-10 transition, recent ICD-10 readiness surveys from the Workgroup for Electronic Data Interchange (WEDI) and from Duluth, Ga.-based Navicure revealed that levels of preparation and readiness for the transition are not high within healthcare organizations.

As such, there seems to be varying degrees of optimism for ICD-10 implementation as the industry awaits the Oct.1 deadline, now just a few weeks away. Physicians, in particular, are feeling the heat of another regulatory burden— a recent survey from the Texas Medical Association (TMA) found that just 10 percent of Texas physicians are confident that their practice is prepared to transition to the new coding set on Oct. 1.

Josh Berman, director, business analytics & ICD-10 lead at Relay Health (a part of the Alpharetta, Ga.-based McKesson Corporation's technology solutions segment) is heavily engaged with stakeholders of all sorts across the industry, having also previously worked for Cleveland Clinic where he focused on physician billing, Medicare compliance, EDI transactions, and payer negotiations. Berman recently spoke with Healthcare Informatics Senior Editor Rajiv Leventhal about what significance CMS’ testing results might have, what strategies organizations can deploy to continue to get ready, and what we could expect to see at the beginning of next month. Below are excerpts of that interview.  

What did you take from CMS’ end-to-end testing results?

I think my opinion might differ from most, as I never believed that testing was of high value, most because it’s a process change, not a technology change. When you’re doing a technology change, you can test; for a process change, it’s not that easy. CMS did a good job and did their due diligence, but people are equating that to readiness on both the provider and payer side, and that’s just not the case.

We probably tested the industry’s most claims, right around 200,000 claims. On average, our clients tested 90 claims, so that’s a big number.  But we process 55 million claims per month, so providers decided to send was a really small amount of the whole that they do every day. That’s fine when you’re testing a technology, but it’s not fine when you’re testing a process.

Josh Berman

What are you hearing regarding organizations’ readiness?

On Sept. 1, my phone started going crazy. It’s one of those magic calendar dates that people pay attention to. People are definitely scrambling. What I hope people finally get is that this is not about a payer if you’re a provider or vice versa; this is a process change about yourself. I’m not sure everyone has that locked in. If you made me pick, and this is based on testing results, it will be the ability of providers to get ICD-10 claims out their doors with the same speed and efficiency that they are doing with ICD-9. But if you talk to providers about what their biggest problems are, everyone will say that the payers will mess it up.

So what are the payers saying?

Payers are saying that they are ready. Many payers said that in 2012 that they updated their systems with new tables, they processed the claims that providers sent them, and sent those back based on what the providers sent. Payers have been saying this for a long time—that they are processing the claims quickly, but it’s on the providers to code correctly. Payers that have invested in testing like I would have if I were them—the good ones—did their testing and gave results back from the 50,000 foot view. And those results said that your coding is not right.

What will the impact of that be when Oct. 1 hits?

It’s hard to say. The best way to go live with something is to simply go live. You can test all you want, but until you go live you just won’t know. People go live and are prepared for the worst. I jokingly call it ‘buying pop tarts for the hurricane that’s coming.’ If you bought enough pop tarts, you probably won’t need all of them and you’ll live through that hurricane and be able to return some of them. I tend not to worry about those types of people for these types of tumultuous changes. If you are prepared that way, you can adapt quickly. People love to talk about coding from the standpoint of there are 68,000 codes, but you are never going to use ‘got injured in the opera’ for example. If you are concentrated and prepared for it, you’ll be fine. Sure there is a learning curve, but you can adapt quickly.

Why do you think there is so much concern over the increased number of codes?

We are driven by what’s pushed in the media, and that’s a tough balance these days. Are you really ever going to get bit by a shark? I don’t know about that. The driver on the 68,000 codes has always been, ‘what’s going to get me a click?’ And the answer to that is the talk about the outliers. It’s not interesting to say that you’re never going to use the vast majority of these codes. But in reality, you’re not going to use the vast majority of codes.

To be fair though, doctors have been outspoken against ICD-10. That’s not the media’s doing, right?

Well, that’s an interesting point. The separation of business office and care throughout the years has been a big problem. The two are very separate. And it’s an interesting separation; you have seen some revenue outsourcing companies take off since doctors really want to just focus on care. A lot of the advantages, truth be told, are variances in payment and value-based care, those things that are coming in future. You have to have vision and a vision specific to the business world.

With such little time left, what can organizations do to still get ready?

First and foremost, the culture we are in is to worry about the other person across the street. You have to first ask yourself if you can do everything you can possible do efficiently? And I’m not sure that we’re there on that.  The second thing would be, do I have the staff to catch up if the people I can’t keep track of, like the payers, don’t do it right? You have to make sure that you’re ready, and then, what kind of pop tarts do you buy for that hurricane? If I was running a hospital I would certainly have testing. Medicare had unlimited testing, they said send as many as you want. I would have taken advantage of that and said, next week I am sending 1 million claims. Then I would see how efficiently they went through compared with ICD-9.  Once I proved I could do that, I wouldn’t have bothered with 90 claims to each individual payer. Then, I would analyze what problems will be and how I can staff for them. Today, the hospital handles medical necessity denials. Can they handle them when they are double, if they are? You have to be staffed appropriately.

Do you have any predictions for what might happen Oct. 1?

There will be populations of providers that cannot get claims out their door.  How fast they fix that, I don’t know, but that will happen. There will also be a very small amount of providers who don’t submit claims, and a very small amount of payers that have trouble processing claims. The good news is that on the back end, I believe it will be something small, some switch that can be flipped. Payers won’t be broken completely, but there will be some bumps.  Some providers are living check-to-check and a small bump can cause a lot of problems. We have been talking about this for so long though, maybe it will be like Y2K where nothing really happens? It sure feels like that in the grand scheme of things.

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