Three months after Congress upended the healthcare industry by delaying implementation of the sprawling ICD-10 coding system, shockwaves from that surprise decision continue to roil the provider community.
Postponement of the system-wide coding transition was welcomed by some, particularly those smaller hospitals and practices that had not yet begun transition preparations. But others remain concerned about the significant investments they’ve already made in compliance, as well as the additional costs associated with extending the Oct. 1, 2014, go-live date by one year.
Confusion also exists about how best to move forward with coder training and other key preparation activities, given that those efforts were well-underway at many organizations when the delay was announced.
“A lot of providers and payers worked extremely hard on this and made tremendous investments to move toward ICD-10 compliance, so there is quite a bit of dismay and disappointment out there,” said Cindy Slocum, project manager for McKesson Business Performance Services’ ICD-10 Initiative. “I think the biggest question a lot of people have is, `where do we go from here?’”
Despite the loss to momentum, Slocum said physician groups can benefit from the delay by further strengthening their readiness efforts. Fine-tuning clinical documentation education and redoubling system testing, in particular, should produce dividends once the new codes are finally up and running.
“Strong documentation is the key, since it’s the data source from which everything else flows,” Slocum said. “If the documentation isn’t there, the coders can’t code, the claims can’t be filed and the money doesn’t come in.”
Surprise Addition to SGR Bill
The ICD-10 code set -- already in use throughout most of the developed world -- is designed to bring greater precision to medical encounter coding. In late March, the industry’s push toward compliance was derailed when language extending the go-live date by one year was tacked onto unrelated Medicare legislation. The Medicare bill was designed to forestall deep provider reimbursement cuts mandated by the sustainable growth rate (SGR) payment formula.
Exactly who was responsible for introducing the ICD-10 delay – the third since 2011 –remains unknown, although the Washington, D.C., publication Politico reported in June that “all indicators point to House Speaker John Boehner’s office as the source” of the insertion.1 Among those who had vigorously pushed for a postponement were the American Medical Association and the American Academy of Family Physicians. 2 3
The financial impact of the delay industry-wide has been estimated at anywhere from $1 billion to $6.6 billion by the American Health Information Management Association.4 The credibility of the Centers for Medicare & Medicaid Services (CMS) also has taken a hit. In late February, CMS administrator Marilyn Tavenner stated categorically that there would be no more ICD-10 postponements. 5
McKesson’s Slocum said practices should take advantage of the extra time by developing clinical documentation improvement programs. An effective starting point in this process is to identify the causes of existing ICD-9 denials and then work backward to ameliorate them.
“If you’re having problems with ICD-9, you’ll have the same problems with ICD-10,” Slocum said. “Conversely, if you reduce the errors you’re seeing in ICD-9, then you’ll reap the rewards in ICD-10.”
She noted that denials typically are triggered either when additional clinical information is required or when the claim has failed to demonstrate medical necessity. Once determinations have been made about where the problems are occurring and who is responsible for the deficiencies, steps can be taken to ensure that the issues are addressed.
A renewed focus on documentation offers an opportunity not only to strengthen existing claims but also to begin reinforcing the documentation principles at the core of ICD-10. Because ICD-10’s requirements are far more detailed than ICD-9, it makes sense to start working with physicians as soon as possible to ensure that they’ll be ready when the transition occurs.
Slocum noted that the majority of McKesson’s approximately 500 professional medical coders already are coding in ICD-10 (the codes are then converted back to ICD-9 nomenclature to complete the claims process). Thanks to this head start, McKesson has been able to identify six areas or categories where ICD-10 clinical documentation deficiencies are repeatedly occurring.
These include Laterality (left, right or bilateral), Specificity of Encounter (initial, subsequent, etc.); Specificity of Associated Symptom/Disease/Manifestation (co-morbidities, bleeding, etc.); Specificity of Complication (post-op, intra-op); Specificity of External Causes of Morbidity (accident, fire, assault, etc.); Specificity of Trimesters (first, second or third); and Fetal Extensions.
Making sure physicians in your practice focus on ICD-10’s documentation requirements is important. But it is also vital to work closely with referring doctors to ensure that they will provide appropriate documentation to support the services rendered. This is especially true for specialties that are highly dependent on referrals, like radiology and pathology.
In addition to documentation education, another important step that can be taken now is to begin testing claims submission with payers. Practices should contact the payers that represent the vast majority of their revenues to determine when they can begin submitted test ICD-10 claims.
The objective, Slocum said, is three-fold: To make sure the electronic submission process works effectively, to confirm that the group’s documentation and coding support the claims, and to identify any payer-specific edits that could result in denials or payment delays once ICD-10 goes live.
When it comes to coder training and dual coding, answers about how to proceed during the delay period are less clear-cut, Slocum acknowledged. Organizations that haven’t yet begun coder training should probably wait until early 2015 to begin the process, she said. However, those that have already started will benefit by continuing the process.
“It’s a dilemma, because if you stop training, you’re going to lose most or all of everything learned to date,” she said. “On the other hand, the costs associated with dual coding -- both in terms of dollars and productivity impacts -- can be significant. There are no easy answers, but the bottom line is if you’re financially able to stay the course, you should, because you’ll benefit in the long run from the ongoing training.”
A Qualified Partner
Slocum said that while some large practices may be capable of developing and implementing an ICD-10 transition plan on their own, most physician organizations can benefit greatly from the resources and expertise a qualified third-party consultant can provide.
“This whole process can be overwhelming, so you really should try to partner with an organization that fully understands the process and how to move forward with it,” Slocum said. “That way, practices can continue to focus their attention on the provision of healthcare.”
1 Ashley Gold, “A Washington mystery – Who was behind the ICD-10 delay?, Politico, June 10, 2014, http://www.politico.com/morningehealth/0614/morningehealth14238.html
2 Erin McCann, “ICD-10 delay rattles industry groups,” Healthcare IT News, April 2, 2014, http://www.healthcareitnews.com/news/icd10-rattles-industry-groups
3 Greg Slabodkin, “ICD-10 Delay: Here We Go Again,” HealthData Management, April 4, 2014, http://www.healthdatamanagement.com/blogs/icd-10-delay-here-we-go-again-47732-1.html
4 Press release, “AHIMA: Disappointed with Another ICD-10 Delay, Seeks Clarification on Date of New Implementation Deadline,” American Health information Management Association, March 31, 2014, http://www.ahima.org/~/media/AHIMA/Files/PR/N140331%20Senate%20bill%20passes%20_ICD10%20Delay_FINAL.ashx
5 Alison Diana, “CMS Won’t Budge on ICD-10 Deadline,” InformationWeek, Feb. 27, 2014, http://www.informationweek.com/healthcare/policy-and-regulation/cms-wont-budge-on-icd-10-deadline/d/d-id/1114041