After years of hand-wringing, delays, and think pieces, the ICD-10 implementation deadline has come and gone. All seems quiet on the healthcare coding front, but it’s a mistake to believe that the most important days of ICD-10 are in the past.
Unlike the somewhat similar “crisis” of Y2K, ICD-10 has had post-implementation implications for hospitals, doctors, and payers, so we’re going to review those with you, as well as introduce you to a few ways you can prepare your organization for success in an active ICD-10 environment.
The Reason For Concern
The October 1st implementation deadline may have passed without the entire U.S. healthcare system crashing, but those who were concerned had every right to be.
While the system promised to replace the more billing-focused ICD-9 with a more physician-central approach, it did so with a loss of relative simplicity…
- Codes extended from 5 to 7 digits.
- “X” placeholders were implemented.
- Combination codes were expanded.
- Code count exploded from 14,000 to 69,000 codes.
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The 100-year-old coding system had grown to a point where even experienced coders were getting nervous.
Organizations from the College Of Healthcare Information Management Executives (CHIME) to legislators began to weigh in on the concept of a delay and take action. Healthcare was split between voices who felt delays were a waste of time and resources (as well as an unfair burden on organizations that were able to prepare on time), and others who felt the system placed burden on providers who simply needed more time to get their practices ready. Even senators began to express concern over transition and processing issues, on top of cash flow issues that would inevitably leave smaller providers hurting.
After the first delay in 2012 and additional Congressional postponement, we find ourselves where we are now…figuring out how exactly we’ll function in this new, highly complex world of coding.
A New World Of Challenges
Moving into the first full year of ICD-10, the U.S. healthcare system will be facing multiple challenges, but two of the most prominent will fall around shortages in personnel needed to properly handle the new coding system as well as a reimbursement environment that is still in the process of revealing itself.
A Need For Coders
The coder shortage started well before 2015.
ICD-9 was in place for 36 years and most of the coding industry’s practitioners and educational institutions reflected that. The Labor Department estimated an increase of almost 38,000 health information technician jobs between 2010 and 2020, a number heavily impacted by the ICD-10 implementation. Many organizations were not able to find coders to meet their needs and ended up turning to outsourcing and off-shoring as solutions. We are still facing and environment where a significant number of healthcare organizations are looking for viable, long-term solutions to support them in their efforts to maintain productivity and revenue cycle health as payors begin to clamp down on claim filing requirements. Providers and payors are in a bind with many more experienced coders choosing retirement over the daunting task of re-learning their jobs and having to train new hires.
Even once the coding shortage is solved, healthcare stakeholders will be left addressing challenges around cashflow. While reimbursement rates based on Medicare percentages are least likely to be impacted, negotiated case rates tied to DRGs will be a different story. Individual practices and outpatient centers will continue to feel the effects of ICD-10 while billing, payment, and appeal processes are sorted out.
Federal regulators have given a nod to the ongoing battle the industry faces and have granted a 12-month coding error reprieve to play catch-up. This though, requires that healthcare entities be actively working to reduce errors, maximize their reimbursements, and ensure overall compliance.
As the industry works to adjust to full-swing ICD-10, we’re already seeing reports from large providers, smaller physicians, and payors on how things are progressing.
Hospitals Are Generally Quiet
Hospitals overall haven’t yet reported any major issues with the ICD-10 transition.
According to FierceHealthIT multiple information management and IT leaders at hospitals are reporting relative success. Linda Reed, Vice president and CIO of Atlantic Health System in Morristown, NJ says things are going well with her coders, both in-house and remote.
“Our main goal was to ensure patients were not impacted. We had an army of people at our main outpatient registration sites armed with cell phones to help patients contact physician offices, if needed. We also contacted all patients that were scheduled for any work two weeks ago to make sure they had the proper documentation.”
In Seattle’s Virginia Mason Medical Center, things are also calm so far. Medical director of health information, James Bender reports that they were able to map and clean up 200,000 future orders that were a major concern for the organization because of their lack of an ICD-10 code. Bender however, did mention issues around underestimating workflow needed to get the appropriate code onto paper requisitions for pathology specimens. Additional leaders have weighed in via Beckers Hospital Review:
Jim Daley, former WEDI Chair and Head of WEDI ICD-10 Workgroup believes it’s too early to tell what’s going on.
“It’s early to tell much — it will be several more days until significant volumes of professional claims reach payers. Inpatient claims will take longer than that to reach payers, since it takes time to prepare final bills for inpatient stays. So far, reports have been positive, although there have been some issues reported with vendor software that was delivered last minute…Many of the questions WEDI has been receiving through the ICD-10 database are related to coding: How do I code for this or that, etc. In particular, use of the seventh character for initial encounter, subsequent encounter, or sequels has been a point of confusion.”
Renee Rasmussen, VP Of Revenue Cycle at UnityPoint Health in West Des Moines, IA is seeing good return on their ICD-10 Program Team.
“We focused a great deal of energy on minimizing the impact of the transition process on our providers. For example, we set up small teams that proactively dealt with 97% of the open orders for services after October 1 that didn’t have the required ICD-10 terminology. So, our physicians only had about 3,000 of these orders hit their inboxes…Another area of focus was on education. We provided several CBT courses on ICD-10 documentation for our providers, and the vast majority of them completed that training ahead of October 1…We are anxiously waiting to confirm that the payers can process and pay our claims accurately and without a large increase in denials. We have teams prepared and on standby to react to any problems that are identified.”
Physicians Seeing More Disruption
Physicians overall have been one of the most vocal groups opposing the implementation of ICD-10 through support of delays and criticism of the coding set as a whole.
Now that the system is officially in place, doctors are reporting severe problems that are directly impacting patient care.
According to a SERMO poll, a survey of 200 physicians reflected 86% of them claiming a negative impact to patient care, likely due to time they’ve had to take away to address technical issues, payment problems, and coding snags post-implementation. Physicians are reporting issues ranging from 3-hour hold times to gross ambiguity around claim submission.
Medical Economics has compiled a list of some individual physician experiences through the transition. Here are a few highlights:
“All is quiet here, our Informatics medical director didn’t receive a single 911 call… from providers. Granted, we’ve been on ICD 10 for six months which has paid off.”
Maria Chandler, MD, MBA
Long Beach, California
“Will this code be specific enough for the payers? I will get to find out in a few weeks. I did open a line of credit for $150,000 for our three-provider practice anticipating a lot of rejections.”
Terry Brenneman, MD
Raleigh, North Carolina
“My assistant informed me at the end of the day that none of our ICD-10 charges went through. I am not sure any other profession working a 10-hour shift isn’t expecting to not get paid for their work!”
Mohammad Rafieetary, OD, FAAO
“I actually think some of the ICD -10 codes are more appropriate/more descriptive than the ICD- 9 codes were.”
Melanie Denton, MD
Charlotte, North Carolina
It is assumed though, that many of the physicians who are having easier times with the transition are affiliated with larger organizations and likely received more support leading up to the transition deadline. Smaller practices, and especially family practices who see wider ranges of medical issues, have had more difficulties to address in leaving ICD-9 behind.
Payors Are Doing Well
Echoing the idea that larger organizations have fared better through the transition, payors so far are reporting relatively smooth sailing according to HealthData Managment.
Two weeks in, and executives from Humana and UnitedHealthcare have reported to the Medical Group Management Association that they believe the switchover is going well.
Humana has announced a paltry .3% rejection rate of ICD-10 claims (which have made up 50% of their in-bound claims) and touts the number as proof that providers are getting things right. The insurer also notes that only 3% of their call volume has been associated with questions around ICD-10. Humana though, began preparations early. About one year ago, they created their ICD-10 command center that will be performing “hands-on” monitoring until the end of 2015, and then transition to “hands-off monitoring” beginning in 2016.
UnitedHealthcare has shared similar results with only a “slight uptick” in rejection rates and “very stable, very normal” call volumes.
Overall, health insurance companies have laid out over $1 billion in preparation for the code set upgrade. We have yet to see generalized results of how smaller payors have faired.
Preparing For The Future Of ICD-10
While the industry is still waiting to see how things shake out with ICD-10, there are a few ways you can prepare yourself and your staff for the upcoming years with a new code set.
Brace For CMS Changes
ICD-10 doesn’t originate with CMS, but they are an influential force in its application and monitoring.
Smart organizations will be mindful of small changes CMS is making to ICD-10 guidelines, especially since they’ve already started. According to ICD-10 Monitor, CMS has made adjustments including the addition and changing of the 7th characters and occurrence codes. A careful review of the guidelines for 2016 will reveal additional changes providers will need to stay on top of.
So how do you keep up?
Multiple sites (including ICD-10 Monitor) publish news and updates on the coding system, and CMS itself maintains a section of their website dedicated to provider resources (last updated October 1, 2015) and regular updates to coding requirements by year (2016 is available here and was last updated on October 8, 2015.)
Things have been quiet so far on the security front, but considering the inherent value of healthcare data, we can expect to see security issues related to ICD-10.
In preparation, organizations have purchased and upgraded both software and hardware, given vendors access to systems, and brought on new employees. Now is a good time to make sure that all of the changes made that impact your data and fall under HIPAA regulations have been checked against your existing security policies. All new coders and employees should be properly trained on HIPAA and internal security requirements as well.
You may also want to consider checking with vendors and other stakeholders to make sure that they have some sort of check system in place to evaluate new ICD-10-related software and personnel.
Next year promises to be a bumpy one, but you have access to some tech solutions that can make the adjustment easier, and even benefit you in the long run.
One of the primary complaints around ICD-10 is the amount of time finding the correct code can take. We’ve found this review of four different free apps designed to help you find codes more quickly, convert to ICD-9, and view full code descriptions.
Physicians looking for more robust answers to their coding problems also have the option of Computer-Assisted Physician Documentation (CAPD) solutions. A recent entrant, Nuance Communication’s Dragon Medical Advisor, provides real-time feedback on coding quality while doctors are documenting patient encounters. Like the apps, this solution cuts back on wasted time, but does so by asking questions and providing feedback during and immediately after the patient encounter.
Analytics will also become more important as the need to track productivity, sources of denials, case mix questions, and myriad other issues crop up. ICD-10 will undoubtedly create ripples in your organizations in multiple areas and advanced data analytics can help you identify problems and set yourself on the path to productive solutions.
Examine Your Strategy
Above all, keep and open mind to the idea that ICD-10 brings with it fundamental changes to your work that should be addressed at a strategic level. You will need to rethink your expectations of employee productivity as well as prioritizing accuracy and quality. This shift may need to be reflected in the most fundamental workflow documents and protocols in your place of practice.
Make sure your strategy prioritizes continuous education, especially around denials management and anatomy and physiology. Provide resources around these areas and training as needed so that your staff understands how to properly navigate the changing demands in all areas.
Above all though, lines of communication will need to stay open as feedback from all levels of your organization will be essential to successful use of the new code set.
The move to ICD-10 will mean fundamental changes for your practice and your network, so we encourage you to contact us to discuss how our software solutions can help you better manage all the moving parts and people in your world.