Industry eyes calendar as ICD-10 countdown begins

Less than six weeks from an oft-delayed deadline, health systems, hospitals, practices and payers finally seem (mostly, hopefully) to be ready
By John Andrews
07:38 AM
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Calendar and clock

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."

Amy Amick, president of revenue cycle management division for Alpharetta, Ga.-based MedAssets, says the CMS decision could help a lot of physicians bridge the gap from ICD-9 to ICD-10.

"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."