Editor’s note: For the first part of this story, published last week, Healthcare Informatics also interviewed various industry consultants on what they’re seeing and hearing from their provider clients regarding the transition. That story can be read here.
For many patient care organizations nationwide, there was much concern leading up to the ICD-10 implementation deadline of Oct. 1, 2015. Indeed, since the Centers for Medicare & Medicaid Services (CMS) delayed the deadline for the transition to the new coding set three times previously, providers were justly unsure if all of their preparation and resources put into the conversion would go for naught once again.
Nonetheless, organizations such as the Maitland, Fla.-based Consulate Health Care, the largest provider of senior healthcare services in the state and sixth largest in the nation, specializing in post-acute care for more than 200 centers nationwide in 21 states, couldn’t take any chances—they had to be as well-prepared as possible. “We hardly just started our planning,” says Consulate CIO Mark Crandall, referring to the weeks and months leading up to Oct. 1. “We have grown through acquisitions, as many companies do in long-term care. So we have disparate systems that are responsible for forming and submitting data to CMS. We have to double test. There was a lot of preparation that went into that conversion. It’s been a process since the first announcement that the deadline would be Oct. 1,” he says.
Crandall says that a priority at Consulate was making sure that once the ICD-10 switch was flipped, that everything from a system standpoint would continue to flow as it was needed. “We learned a lot from the preparation because our business analysts and our project managers worked with our operation partners to figure out what were the most used ICD-9 diagnosis codes in our care centers. That gave us an idea of what the training would look like,” he says. “Although everyone talks about how many codes there are, we really needed to get a targeted look at the codes that were being most commonly used so at least our practitioners knew what was coming in regards to specificity.”
The ongoing preparation and training at Consulate, as well as the ultimate goal of getting the truest story about the diagnosis of the patient, unquestionably helped the organization be well-equipped for whatever was thrown its way in October, Crandall attests. “Sure, we had some technology hiccups in the first few days. But that was quickly remediated by one of our vendors. We weren’t really shocked by anything,” he says. There are good things and bad things about technology—it’s not always fastest pathway to best patient care,” Crandall adds. “If you heard of the functionalities out there, there is the 1:1 [ratio] built by our software vendors to ease the process for coders. But we found in our testing that it doesn’t always choose the best ICD-10 diagnosis code for the patient. We wanted to take advantage of the coding changes—not the technology changes—for what tells the truest story of the patient. And that takes training. For us, with the largest part of our portfolio being in Medicare and Medicaid buckets, it’s been important for us to get out ahead of these changes and always try to be part of pilot programs,” he says.
Similarly, for other organizations, the sky didn’t fall when the calendar hit October. At Boston-based Partners HealthCare, the biggest concern leading into the transition was that everyone was mapping what they were doing in the ICD-9 world to try to get equivalent comparisons in ICD-10, says Paul Dufresne, patient account manager at Partners. “That was the approach that people chose. But that can be subjective, and it could lead to missed diagnoses,” Dufresne says. However, he adds, these mapping issues were not nearly as bad as Partners anticipated. “We were expecting big-time disasters, and it wasn’t like that at all.”
Similarly in the Northeast, at the Newton, Mass.-based Atrius Health, ICD-10 didn’t prove disastrous either, says Michael Lee, M.D., director of clinical informatics. Atrius started its ICD-10 work in 2012 and was thus ready in 2014, at which point the government delayed the transition for a third time. But the planning that went on during that three-year-long undertaking proved beneficial when the deadline finally came, Dr. Lee says. “We spent a ton of time on mapping tables, getting diagnoses files correct, and the majority of time after that was on the revenue side testing transactions coming out of our systems, then testing those transactions arriving at our insurer systems, and then testing responses. We had that back end pathway worked out so we could get paid,” Lee says. “We were working on this for a long time so we were comfortable that we would be reasonably okay with the conversion.”
Michael Lee, M.D.
That being said, the mappings and connections between ICD-9 and ICD-10 codes have garnered the attention of Lee. “If you lined up your diagnoses for ICD-9 in one column, the things you see for ICD-10 are in different columns. Because of the multiplication of diagnoses, some of those mappings and connections to what we’re used to using and what we currently use are broken and need to be watched carefully over time,” Lee says. “Some of solutions are what you call utilities; those are computer programs that are running on the data to make sure it’s all connected correctly. They all have defects though, so there is a huge manual process to make sure the information is accurate,” he says.
“It’s Still Early”
While the provider organizations interviewed for this article agree that the transition was mostly a non-issue, they caution that just two months in, it’s still too early to generate any major conclusions. For instance, although Consulate hasn’t experienced any rejected bills, the time hasn’t come for that yet, Crandall says. “We are seeing where some of our vendor partners are more sensitive to the specificity than we believe the government will be in the short term. But we are learning from that. Even if the analysis of that data from a population health standpoint won’t happen right away, we can use it internally to help craft the right care plan and be more conscious to the total cost for the patient,” he says.
While Dr. Lee says that he isn’t fully aware of denied claims since he isn’t on the billing side of Atrius, he feels confident that he would have heard of any problems in that area. He also agrees with Crandall that it’s still very early in the process. “People are concerned because there is more expectation about the specificity of documentation to match the diagnosis selection,” Lee says. It’s still too early to see that now though. We are only two months in, and some of those claims are just getting paid.”
Lee notes that Atrius did do training around how to document in ICD-10, but that doesn’t mean everyone does it right. As such, it would behoove organizations to pay close attention to how physicians are documenting as the industry continues to move forward with the new coding set. “We did the same thing we did in ICD-9 in terms of training, but ICD-10 is obviously more complicated. The documentation/coding compliance piece will be the biggest ongoing effort in order to make this all successful.” And while these are activities that patient care organizations stress anyway, more resources and education needs to be put into it, Lee says. “No doctor wants to learn more about coding and documentation. Everyone hates it. But you need that in order to get paid or in the future to not get penalized,” he says, noting the increased importance at his organization as 75 percent of Atrius’ contracts are in value-based payment arrangements.
Lee further notes that he hasn’t seen a decline in productivity yet in terms of doctors seeing fewer patients. “But there is no question that it takes more time to find the correct descriptive diagnosis that is supposed to be used for a given encounter,” he admits. “Some of those things are far more annoying than they need to be. When someone comes in for their sinus infection, to know whether it’s a recurring infection or a new one, for the most part, is meaningless for 99.9 percent of people who get them. Maybe in the future it could help us decide who need sinus surgery or something, but that is far reaching and infrequent right now,” Lee says.
Still, physicians are calmer than they were a few months ago, notes Dufresne. “It’s new—they didn’t want to do it at first. We gave them multiple training sessions and did dual coding for a while. That made it easier,” he says. Coding is behind right now because it’s taking longer to get to the ICD-10 code. That learning curve is challenging, Dufresne says. “Regarding documentation, they know the ICD-9 code like the back of their hand. They can quote what they have built already. Now with new codes, it’s more challenging and it’s a new system.”
Considering the magnitude of the transition, however, any issues that have arisen are not too out of the ordinary, Lee adds. “In the medical world, small mistakes can lead to harm. We continue to be concerned and continue to find errors here. You are trying to make a system that used to interpret things one way and interpret it a different way, and you need to compare the way you did it before to how you do it now. Patients have illnesses or conditions that occur over time. You need to make sure you’re tracking conditions correctly,” he says. And overall, Lee says, most people seem to be feeling comfortable with ICD-10. “The Earth still spins, it didn’t blow up, the power turns on in morning, and my computer works.”
Moving forward, Crandall says that ICD-10 opens the door for more collaboration and more open data sharing. At Consulate, ICD-10 itself hasn’t been the focus necessarily, but it’s more about an overall approach to make it as easy as possible for the data to be transitioned from one provider to the next. “And that’s very aligned with what the payers [want],” he says. “If we are ready to perform in that spirit of open data sharing and getting the most specific data that we can get to the right person, we are doing our job. We don’t provide patient care in IT, but I like to think we provide the absolute best tools,” he says.
Crandall continues, “Technology in general has been an opportunity for us to band together as a group. We all have similar challenges; we are not alone. ICD-10 has given us a great opportunity to bring clinical folks, rehab folks, [and others] to the table more significantly than ever before. That’s something that regulations do that people don’t note very often. In order to win, you must collaborate.”