Industry eyes calendar as ICD-10 countdown begins
Fifteen years after the Y2K panic, the healthcare industry is once again closely watching the calendar. Not since Jan. 1, 2000, have so many industry professionals had their eyes on a deadline as they do on Oct. 1, 2015.
Questions abound regarding the financial repercussions of the coding format conversion across the provider spectrum, but especially for small hospitals and physician clinics. The biggest fear is that a blizzard of claims denials will not only cause major cashflow disruption, but substantial revenue damage for those that can least afford it.
Some sympathizers in Congress introduced legislation in the spring to cut physicians some slack in the process and in early July, the Centers for Medicare & Medicaid Services responded by granting some flexibility with claims submissions – finally acceding to some demands from the American Medical Association, a longtime and vociferous ICD-10 opponent.
[See also: ICD-10 hops Congressional hurdle]
Specifically, a statement from the agency assured that "Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family."
"It creates a buffer so that if you're not perfect, you still get paid," she said. "If you have a system problem or administrative problem tied to ICD-10, they are allowing prepayment requests and authenticating after the fact, giving some relief. It's a way to help weather the storm."
To be sure, "CMS has a number of instruments and remedies at their disposal and advance payment is one," said William Davis, vice president of consulting services for MedAssets. "They are trying to ease the burden of claims payment."
With that July announcement, CMS and AMA announced that they are joining forces to offer additional guidance that will allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using ICD-10 codes. The physician association is working with the agency to educate providers through webinars, on-site training, instructional articles and national calls to help physicians prepare for the transition.
[See also: AMA's long war of words against ICD-10]
"As we work to modernize our nation's healthcare infrastructure, the coming implementation of ICD-10 will set the stage for better identification of illness and earlier warning signs of epidemics, such as Ebola or flu pandemics," said Andy Slavitt, CMS acting administrator. "With easy-to-use tools, a new ICD-10 ombudsman and added flexibility in our claims audit and quality reporting process, CMS is committed to working with the physician community to work through this transition."
AMA President Steven J. Stack, MD, meanwhile, said the association appreciates CMS listening to physician concerns and its willingness to ease the ICD-10 transition. The predominant concerns, he said, are "inadvertent coding errors or system glitches may result in audits, claims denials, and penalties under various Medicare reporting programs. The actions CMS is initiating can help to mitigate potential problems."
CMS' free help includes "Road to 10," a primer aimed specifically at smaller physician practices that describes clinical documentation, clinical scenarios, and other specialty-specific resources to help with implementation. CMS has also released provider training videos that offer ICD-10 implementation tips. The AMA also has a broad range of materials available to help physicians prepare for the deadline.
Series of false starts
Delayed three times in the past five years, there are some who still believe they will be given yet another reprieve on ICD-10, despite the government's insistence that they won't. Those who were ready before last year's postponement are expecting it to through as planned – and hope there is no further delay.
"We're tired of waiting and do not want it to be delayed again," sighs Juana Colon, corporate director of health information management for Orlando Health. "We are ready to proceed."
Colon, a 26-year veteran at the health system, remembers well the Y2K panic: a widespread fear that antiquated computer time clocks (ubiquitous at the time) would default to the year 1900 instead of rolling over to 2000, and automatically shut down, causing an IT blackout. As the industry held its collective breath, the event turned out to be anti-climactic and the impact was minimal.
This time around, though, worries about ICD-10 causing the same type of potential chaos appear to be more well-founded. And many providers are braced for a dramatic fall-off in revenues once the deadline hits. Some projections have been as high as 40 percent revenue loss in the first few weeks. Uncertainty reigns throughout the provider, payer and vendor sectors.
For the past five years, Colon has been working to get Orlando Health ready for the transition. Over that time, CMS has put the industry through a series of stops and starts, delaying the ICD-10 coding implementation three different times.
The most recent delay, a one-year pushback contained in the Medicare Sustainable Growth Rate "Doc Fix" bill in April 2014, came even as CMS had just insisted at HIMSS14 that the date was set in stone. The sudden reversal caused some consternation among the providers and vendors who had worked furiously to be ready, while enabling those who weren't prepared to exhale a huge sigh of relief.
The regular sequence of false starts set off tirades among those who worked furiously to prepare – including vendors who'd spent hours helping their clients be well-positioned for the switch.
As Mike Lovett, executive vice president and general manager of Horsham, Pa.-based NextGen exclaimed: "This rewards those who weren't organized … it lets them off the hook." The delay he said, "only clouds over what has to happen."
Ed Park, chief operating officer of Watertown, Mass.-based athenahealth, expressed similar frustration.
"It is alarmingly clear that healthcare is operating in an environment where there is no penalty for not being able to keep pace with necessary steps and deadlines to move the industry forward," Park wrote after that surprise 2014 deadline delay. "Our system is already woefully behind in embracing technology to drive information quality, data exchange and efficiency and delays like this only hinder us further."
So it became hurry-up-and-wait for those who'd dutifully completed the arduous steps toward ICD-10 readiness, leaving them wondering what to do for the next year – how much more training they would do and what the costs associated with it would be. Others have put hiring on hold as their current ICD-9 coders continue for another year.
At Orlando Health, Colon and ICD-10 Manager Lynda Bjorklund decided that hand-wringing wasn't productive, so they have forged ahead, continuing training and working on getting physicians used to the new format.
"While we would have preferred to have been done months ago, our purpose has been to move forward like it will happen tomorrow," Bjorklund said. "The delay was something that was beyond our control – so we look at it from a positive standpoint – now our coders have more time to practice and further enhance the skills they already have."
If the deadline is kept intact and "go time" actually happens, Orlando Health will find out quickly whether its extra preparation has been effective. As staff mobilize to meet the new standards and coding requirements, a lot of moving parts have to find a way to synchronize and operate efficiently – an occurrence Bjorklund concedes is a very tall order, even for those who are ready.
A "goal line strategy" looks at all the potential scenarios while evaluating the risks and threats upon commencement and the team is anticipating what could happen on day one, week one, week two and month one.
Orlando Health is establishing coding resources and a coding hotline for physicians. Its staff understands that accounts receivable days outstanding levels will suffer and are working with payers to determine the risk metrics and targets they want to meet on day one. Even so, they expect a dramatic rise in denials that first day.
"Not everyone understands the enormity of ICD-10," said Bjorklund. "It is much more than a claim going out the door. There are multiple workflows involved and collaboration needs to happen, with everyone performing their best. We won't know the impact until weeks down the road."
To aid physicians in coping with the new format, Colon's team has implemented computer assisted coding, an advanced technology to review the codes with a natural language processing engine that reads the medical record and suggests the appropriate codes.
The team serves as validators for the NLP suggestions to ensure accuracy. Since starting a clinical documentation improvement program in 2005, Colon's department has collaborated with medical staff to "train them how to think with the documentation in order to justify and clarify the care provided to the patient," she said. That interface, she said, "has made a world of difference in increasing their understanding and enhancing the documentation."
Firm deadline? Or not?
Presuming CMS allows ICD-10 to happen as scheduled, it won't be from a lack of congressional attempts to intervene. During May and June alone, the U.S. House of Representatives floated three ICD-10 bills that called for either a "transition period," a "grace period" or stopping ICD-10 implementation altogether.
The most dramatic bill for ICD-10 stoppage is similar to a 2013 proposal prohibiting HHS from replacing ICD-9 with ICD-10, which died before reaching committee. Observers expect the 2015 measure to meet a similar fate, though the transition and grace period bills could find support.
The transition bill, HR 2247, known as the "Increasing Clarity for Doctors by Transitioning Effectively Now Act" – yes, that's "ICD-TEN" – would require HHS to provide "transparent testing to assess the transition … from ICD-9 to ICD-10."
It would not, however, delay the Oct. 1 deadline and would not call for CMS to accept dual 9 and 10 coding. What it calls for is "comprehensive, end-to-end testing" to assess whether Medicare fee-for-service claims in ICD-10 is fully functional. CMS would then report to Congress on the results. During an 18-month transition period and any ensuing extensions, no reimbursement claim submitted to Medicare could be denied due solely to the "use of an unspecified or inaccurate subcode," according to the bill.
The grace period legislation, HR 2652, titled "Protecting Patients and Physicians Against Coding Act of 2015," came out in early June and seeks to create a two-year grace period where healthcare providers' ICD-10-based claims submitted to Medicare and Medicaid would not be denied due to coding errors. Implementing this grace period would ensure physicians are not negatively impacted while ICD-10 is "fully implemented within the healthcare system."
The American Health Information Management Association has come out against all the measures, saying that they would only create unnecessary complications and delay of the inevitable. CMS' existing payment policies to grant advance payments for physicians experiencing cash flow disruption and financial difficulties should be adequate, said AHIMA CEO Lynne Thomas Gordon. Moreover, she says the grace period could potentially lead to inaccurate coding, improper payments and potential medical billing fraud.
Collaboration is key
Christian Omba, ICD-10 program director for UNC Healthcare System in Chapel Hill, N.C., says he is "cautiously optimistic" about making the deadline, so he does not want to see another delay.
"We want it to hold," he said. "We have spent an inordinate amount of time and resources to prepare. We are ready and want no further disruption."
Omba calls proposals for a grace period or transition delays "ridiculous," because "it's like the kids in high school who refuse to do their homework. Congress' involvement is analogous to a school maintenance worker canceling final exams because someone might pull a fire alarm."
With a professional background in the banking and finance industry, Omba has headed up his health system's ICD-10 efforts and methodically followed the blueprint.
"My first reaction upon taking this assignment was that the industry seemed to running around chaotically like headless chickens," he said. "Our effort has been very progressive and deliberate and our executives have been very supportive. Our pilot testing was then appropriated by HIMSS for national pilot testing. We've been dedicated to preparing, sharing best practices and offering lessons learned."
The key to the process, Omba says, has been collaboration from everyone in the organization and within the healthcare continuum.
"We followed the requirements and built a plan with checkpoints along the way," he said. "Collaboratively you can get there as an industry. It results in better patient care when everyone is engaged. That needs to happen. When the deadline comes, we expect some outliers but we don't anticipate any adverse impact."
'Niners' vs. 'Tenners'
One consequence of the multiple ICD-10 delays has been the uncertain status of coding personnel – both the current ICD-9 workers and new coders trained exclusively in ICD-10.
AHIMA estimates that there are some 25,000 students with certification from health information management associate and baccalaureate educational programs who are waiting to be hired. In particular, last year's deadline extension raised questions for hospitals on the verge of hiring "tenners" to replace the "niners," many of whom are expected to leave their coding jobs rather than learn the much more complex new system.
While there are no absolutes in describing the typical demographic profile of either coding faction, "niners" tend to be women in their 50s and 60s, while "tenners" are younger women in their 20s and 30s.
Yet Zack Wilson, president of Jacksonville, Fla.-based CSI Healthcare IT, says it should be noted that while the occupation is predominantly women, there are men who work in the field and that there are younger "niners" in their 30s and 40s who will make the transition to ICD-10. In the meantime, it is limbo for hospitals and both coding staff factions, Wilson said.
"A lot of 'niners' are keeping at it currently, even though they might leave when ICD-10 arrives," he said. "The hospitals have spent a lot of money on training to get their staffs up and running on 10 and it's adding up to double the cash because of last year's delay. And now we're seeing a delay in re-training in case I gets delayed again."
There is an army of new "tenners" who are anxious to start working but because they have no actual coding experience, are stuck in a long line to replace outgoing "niners" if and when they leave, added Kyle Johnston, regional sales director for CSI, which provides staffing and coding services. For the past few years, students have been signing up for ICD-10 coding training because they believe it offers job security, solid pay and – because 98 percent work at home – work-life flexibility.
"There has been a lot of buzz about it: Word has gotten out that this could be an awesome job," Johnston said. "It is a younger generation who sees this as an opportunity and just like with the occupational and physical therapists, there still won't be enough to fill the need."
As the hiring stalemate lingers, it is fair to wonder about what impact another potential deadline disruption would mean.
"I don't even want to think about it," Wilson said. "I would venture that it won't (happen), but if it (does) I agree with others who say we might as well wait and adopt ICD-11 in 2017."
Contrary to what some providers might think, payers are rooting for their success as the go-live deadline approaches. What payers don't want, says George Vancore, senior manager with Florida Blue, is a heavy squall of denials due to non-compliance.
As a result, the health plan has emphasized awareness, education and training – especially for physicians, who compose the bulk of not-ready-for-primetime providers.
"The large health systems will be fine – they may experience some anomalies, but they will submit their claims without incident," Vancore said. "The individual physicians have a different situation: Their financial risk is non-existent in this space because the individual practice bills with HCPCS codes (and) aren't changing with ICD-10. But the rub is that the diagnosis codes are ICD-10, so they need to know those."
With more than 170,000 codes in ICD-10, Vancore realizes that such a dynamic expansion is intimidating to the physician community, so much so that many have become paralyzed with confusion, indecision and fear. Yet he maintains that there is no reason to fear the new format and that the "noise" surrounding ICD-10 is more of a distraction than anything else. What physicians need to focus on, Vancore says, is the codes that are most relevant to their practice.
"They have to determine how many they will actually use," he said. "If you are a specialist, learn the codes that relate to your specialty. If you are a family practitioner, concentrate on the ones that most accurately represent the codes you use today."
Florida Blue has been prepared for ICD-10 since 2013, Vancore contends. "I can flip the switch on tomorrow with 12 hours' notice," he says.
In the two years since then, Florida Blue has used that time to conduct tests with "any willing provider" who wants it, along with holding seminars, roundtables and "lunch and learn" sessions for those who need to be brought up to speed.
In order to discover how prepared the provider community is for ICD-10, Vancore and his team conducted a short survey of 600 physicians earlier this year and the results confirmed his suspicions: Nearly 35 percent of respondents said they haven't done anything, don't know where to start and have no idea how to proceed.
Converting to ICD-10, "is not that hard," Vancore insists. "I will work with them, get them to attend my training sessions and get them converted in two weeks. They have to make sure their clinical documentation is prepared. Anyone who sends me an ICD-9 claim on Oct. 1 will be identified as non-compliant and become a named entity in my action plan for CMS. If they can't send me an ICD-10 enabled claim, I can't pay them."
The physician sector definitely has more challenges in adopting ICD-10, but at the same time they also have some advantages, says Larry Allen, vice president of information technology and CIO of Healthcare Network of Southwest Florida, which operates 15 centers across the state.
As a fairly large clinical enterprise, Healthcare Network is in good shape to start ICD-10 and was ready at the time of the last delay. Yet Allen acknowledges that a lot of independent practices are woefully behind due to a lack of bandwidth and resources.
"They are not afforded the luxury of having staff and bringing themselves up to speed," he said. "They are entirely vendor dependent. They need vendors to guide them through the process and learn the format based on their denials."
There are two negative impacts that physicians will feel from not being ready, Allen says – noncompliant coding will prevent them from collecting revenues that are rightfully there and missing co-morbidities associated with chronic diseases, such as diabetes and hypertension.
"This will hurt because the margins are already slim in primary care," he said. "They don't have anywhere to go for help."
Even so, Allen believes that physicians are in better shape than unprepared health systems because they are smaller, don't have the baggage of a bureaucracy and are therefore more nimble in responding to the situation.
"Ultimately, physicians will do better than hospitals because their learning curve is not as steep," he said. "They can respond quickly because it is in their best interest to do so."
Anticipation, not urgency
MedAssets counts a significant number of small and mid-sized hospitals among its client base and representatives say in light of successful tests conducted throughout the year, they should be in good shape at the deadline. Of the approximately 2,800 hospitals who tested their ICD-10 readiness in January and April, the results were higher than 99 percent acceptance rates for everyone, including small hospitals, and Amick expected similar results for a third test in July.
"We see customer readiness," she said.
"With the delay that happened last year, it has served some organizations well – especially the smaller ones," Amick said. "The smaller they are, the more challenged they are, so the extra time has helped. We've seen the conversations change greatly over the last six months, from when people hadn't started to now talking about finishing touches on testing and how to think about the disruption we will endure."
The post-deadline period is being dissected into 30-day time frames as a measuring stick on progress, Amick said, with each marker serving as its own finish line.
Preparation is what transforms a sense of "urgency" into a sense of "anticipation," Davis said, with providers having a sense of how things will go and have mitigation plans in place to make the transition as smooth as possible.
If there is a sense of urgency, "it is in the readiness of the staff and how to approach the extra time it will take during the transition," Amick said. "Some hospitals have prohibited vacations and limited time off immediately following the deadline. They need to make sure they have as much capacity as possible."