ICD-10 Feature Story: Ticking Time Clock-or Bomb?

When it comes to ICD-10, Children's Hospital Colorado is about as well-positioned as any major health system can be in transitioning to the International Classification of Diseases and Related Health Problems - 10th revision, set to take effect by federal fiat on Oct.1, 2014.

Faced with a major challenge to both its clinical documentation and its revenue cycle, Children's Hospital's ICD-10 transition team-led by a group of four senior level executives at the top of the organization-has been hard at work for over two years. The Aurora-based pediatric hospital has hit important milestones such as completing its information systems impact assessment and establishing the remediation timeframe among key software vendors. It's now tackling clinical documentation improvements among physicians, implementing computer-assisted coding staff, training its coding staff, and discussing testing scenarios with some of its commercial payers, says Melinda Patten, director of health information management and one of the effort's executive sponsors. (The others include the CEO, CIO and CMO.)

That's why, come October of next year, Patten feels comfortable that the hospital will be where it should-at least internally. "We'll have our documentation in a good place and have the specificity we need," she says. "We will have our physicians and coders trained; we'll code in 10 and then drop the bill. But after that, we lose control. Payers say they'll be ready, but that is the unknown."

In an industry which has endured multiple delays of ICD-10 (after major industry resistance, the Centers for Medicare and Medicaid Services most recently postponed the go-live date from 2013 to 2014), Patten has plenty of company in pondering the many questions.

Many describe ICD-10 as the mother of all information systems and operational challenges. That's partly because the codes figure directly in reimbursement-a long and winding food chain linking providers, clearinghouses and payers. Get it wrong and the worst-case scenario is that revenue grinds to a halt. But there's more at stake than I.T. remediation and interfaces. Getting the codes right in the first place requires ever-more detailed documentation on the part of the medical staff, a group already beleaguered with meaningful use reporting requirements. Even if documentation is precise and notes, for example, such minutiae as which side of which finger was the subject of a skin biopsy, it will fall on the shoulders of coders to pick the best code. They can choose from among the tens of thousands of available new codes, (which are structured in very different way than predecessor ICD-9, the industry's longstanding coding and classification system).

Experts concur that because ICD-10 reaches virtually every nook and cranny of the modern health care organization, its implementation needs the sponsorship - and budget - that only top executives can deliver. Even with that, industry progress on the transition is mixed at best. Among group practices, which lack the resources of larger health systems, the transition is well behind schedule, according to multiple industry watchdogs and associations. Even for those organizations that had set out to meet the 2013 go-live date, there are far more questions than answers.

Here are some common concerns: Coder productivity, physician overload, insurers' payment plans, transition costs, cash flow impact, and perhaps biggest of all, trading partner testing.

Given the scope of an ICD-10 transition, the industry overall is struggling to stay on target with the many steps required to be prepared. Industry surveys, from such groups as WEDI and the Medical Group Management Association, reveal that large portions of the industry are behind schedule, at least when compared with widely recommended timeframes.

Bob Schywn, a principal at Aspen Advisors, a consulting group which is participating at several ICD-10 transition efforts on the hospital side of the industry, describes the effort needed as exhaustive and all-encompassing.

"It's surprising that we are still hearing from large health care organizations that they are just getting started to understand what ICD-10 is all about," he says. "That's concerning because there is a fair amount of work. If you are not knee deep in it by now and don't understand the risks, the last year will be fairly hairy for you."

Schwyn says the biggest challenge is getting organizations to understand ICD-10's vast impact. "It impacts health information management directly and there often is a coding focus," he says. "There are also implications downstream for finance and for claims. I.T. has a supporting role across the different work streams. But on the front end, clinical documentation is a huge driver."

All hands on deck

The consultant adds that a successful transition effort must be orchestrated by a multi-disciplinary group with stakeholders across I.T., finance and the compliance departments. "There will be a lot of scrambling to get this right," he predicts. A complicating factor is the large number of other industry initiatives underway at the same time. "At the same time you are doing ICD-10, you have a focus on meaningful use, value-based payments and health reform, all driving the need for additional data specificity. It is a perfect storm."

Novant Health is one organization trying to stay ahead of the ICD-10 curve. Based in Winston-Salem, N.C., the 13-hospital health system spans a three-state service area and has a payer mix which varies widely by region. Novant began its ICD-10 work in earnest in early 2010, establishing an executive sponsorship group with the CEO, CMO, CFO and CIO among the members. Laura Pait, senior director, HIM and revenue cycle services, represents the hospital as co-chair of an enterprise project management group. Her physician counterpart represents the ambulatory side of Novant. The government's decision to postpone its 2013 deadline was a mixed blessing for Novant, which had set out to meet it. "We had to re-engage the team," Pait said.

Novant's four main workgroups report up to Pait and her co-chair. These include: 1) an education and training group that oversees work not only for the coding crew, but multiple other business owners also affected by ICD-10; 2) a financial impact group, which is analyzing likely service line reimbursement shortfalls; 3) clinical services, which focuses on documentation by physicians, both employed and community-based; and 4) technology, whose task is to "ensure all systems and apps are cued up," Pait says.

The I.T. effort alone is so big it sports its own project management office to keep things on track. To complicate matters, Novant will be standardizing on a common EHR from Epic during the next three years, Pait says. Novant began the Epic project with its ambulatory practices first and those will be complete this year, meaning all physicians will be on a common platform. "That's the good news," she says. "We had 10 different physician EHRs before. But the hospitals face a major, complex web."

The hospital transition to Epic will commence October 2013 and by the time the 2014 deadline rolls around, about half of them will be live on Epic, with the remainder still operating on three different legacy systems. Beyond these core hospital information systems, Novant has identified approximately 60 other bolt-on applications that will also require ICD-10 upgrades. "We have a confidence level of 80 percent that all our system vendors will be ready," she says.

Run silent, run deep

Despite the many moving parts, Pait thinks that Novant will "be as ready as we can be" by October 2014. "We have the senior leadership's support," she emphasizes. But even so, there are aspects of internal preparation that concern her. "My biggest concern is the 'silent pockets,' areas where business owners have not realized that ICD-10 touches them. It's easy to talk about coders and physicians. But we may have bolt-on applications to help with such things as strategic planning and I'm not sure these owners are aware. Even with all the distractions of the Epic go-live, we are trying to make ICD-10 an equal conversation."

Children's Hospital Colorado also faces a large number of silent pockets. According to Patten, the health system inventoried about 4,000 systems, applications and stand-alone databases when it launched its ICD-10 transition in 2010. Although it will wind up remediating about 100 of these through its enterprise corporate governance effort, the health system must still educate the business owners of the remaining systems about the need to analyze their longevity under ICD-10.

At its affiliated school of medicine, for example, many physicians maintain independent databases as part of research projects. Novant's Pait points out that independent analytics databases housing ICD-9 data will somehow need to be cross-walked to ICD-10 when they begin accepting data from the new code set. "That is why education and training are so huge."

The scope of the ICD-10 transition accounts for many organizations' delays in preparing, no doubt. But the mixed progress in moving to the new code set extends far and wide. For their part, payers must be ready to accept ICD-10 claims as well. That leaves claims clearinghouses stuck in the middle between providers and payers. And some clearinghouses wondering what will happen on October 1, 2014.

"We are seeing delays on the payer side and we are not getting a lot of feedback from them on their testing plans," says Jackie Griffin, director of client services at Gateway EDI, a clearinghouse which processes some 25 million claims a month, facilitating data exchange between some 200,000 providers and 3,000 payers. While larger payers have been reaching out to Gateway - which began conducting readiness surveys earlier this year - the plans of many payers, frets Griffin, "are very vague."

She paints an even more checkered portrait of group practices' preparations. "Small practices are not thinking about ICD-10 yet. Many of them expect another federal delay, even though CMS has said repeatedly there will be none."

Griffin's contention about small group practice procrastination is upheld by survey data from the Medical Group Management Association. Its 23,000 group practice manager members span some 13,000 practices with 280,000 physicians, "from the very small to the largest multi-specialty groups in the nation" says Robert Tennant, senior policy advisor. MGMA released a survey in June showing widespread delays in moving to ICD-10. Just over half have not even started the work, Tennant says, with "significant progress" being reported by under 5%. About one-third report they are "somewhat done."

Practices facing ICD-10 must contend with an expensive transition, Tennant says. "About 30 percent will have their upgrades covered with their maintenance agreements," Tennant says. "Among the others, the cost will be about $10,000 per physician for both the practice management system and EHR." Thus, a 10-physician practice is looking at a potential outlay of $200,000 to remediate the two systems, he adds. "That is a heavy lift for the practices," he says.

Even among group practices in transition mode, doubts remain about trading partner readiness. Among those surveyed, 60 percent say they have heard nothing from their clearinghouses about ICD-10 and 70 percent are in the dark with their payers. "These are the critical trading partners that need to be aggressively communicating their transition plans," he says.

Inquiring minds

Tennant's questions are being raised across the industry. For Pait at Novant Health, payer preparation and payment policy lurk as large unknowns. The health system is adding a fifth workgroup to its enterprise effort, dedicated to denials management. "We are expecting an increase in both physician and hospital denials," she says. Expecting to gear up about three months prior to the October 2014 ICD-10 go live, the group will monitor both pre-billing edits before claims go out the door and then later denials as they hit the payer. "We will have to distinguish between technology issues and coding accuracy issues," Pait says, meaning that some claims may be held up as the result of improper interfaces and data transactions, while others may make it through the clearinghouse to the payer, only to be kicked back during adjudication as the result of improper coding or inadequate documentation. "We will have to break it down fast, so our recovery efforts can be shared and we are not taking corrective action six months after the claim comes back."

The claims edit piece is a bit of a Catch-22 for Novant. Before it can tweak its own software to accommodate payer edits around medical necessity, Novant needs to know payer policies. "We have not gotten that far and payers have not gotten that far," she says. Meanwhile, Novant's payer contracts management staff are beginning outreach to its trading partners to set the stage to receive payment policies and related efforts. Those conversations will accelerate in the first quarter of 2014, according to Novant's timetable.

Denials management is also front and center at New York's Mount Sinai Health System, which maintains about 1,200 beds across two hospitals and is set to expand later this year when it merges with Continuum Health Partners. Mount Sinai began its ICD-10 work in 2011 then, a year later, established a cluster of six workgroups devoted to managing different aspects of the effort. Mount Sinai will upgrade nearly 50 information systems, says Julio Arniella, senior director of patient financial systems. "Anything that touches, looks at, or moves an ICD code has to be upgraded." Arniella serves on the denial management team with some 20 other staff.

The denials management group has assisted in determining which service lines are most likely to be at risk under ICD-10. It is beginning with an analysis of denials under the current ICD-9 set-up to identify which types of claims will call for increased attention under ICD-10. A contract management group which negotiates with payers is examining forthcoming changes in payer DRG set-ups and corresponding policy changes.

In New York, three DRG groupers are in play among the various payers, one of which, AP-DRGs (all payer), is not compatible with ICD-10 and is being sunsetted. "We are working with the payers to see if they are willing to do claims testing and neutrality testing."

"Claims testing" is submitting claims to the payer to see if they clear technical hurdles. "Neutrality testing" involves actually remediating an ICD-10 claim to compare its reimbursement with an ICD-9 counterpart. Mount Sinai has not yet begun either type of payer testing, but like most health systems, it works with a large diverse payer mix. "We are about 20 percent Medicare, 20 percent Medicaid, with the rest going to commercial plans and some self-pay patients," Arniella says.

Coder conundrum

A short-term concern around ICD-10 is coder productivity. For Meg McGill at Memphis-based Methodist Hospital, the impact will be enormous, reverberating all the way to AR. "We have been using ICD-9 for a long time," says McGill, corporate administrative director of HIM at the eight-hospital, 1,600-bed health system. She's a member of Methodist's ICD-10 steering committee, which includes representation from allied health, home health, ambulatory surgery centers, physicians, I.T., coding and patient financial services. Asked where ICD-10 delivers the biggest impact, McGill doesn't hesitate: "There will be a big impact on coders. It will be a huge learning curve and it will affect physician documentation. If the information is not in the chart to code, we will query the physicians for additional specificity. Coders will not be as productive. And the slower I am in coding, the slower the bills go out."

To soften the blow, Methodist is partnering with a software vendor, IOD, to develop a coding training tool. For its part, Methodist has provided some 1,000 de-identified charts to use in the training tool. "It will be a coding training tool with actual medical records instead of case studies," she says. "Trainees will code a chart in ICD-10 and the system will them if they got it right. If they got it wrong, the tool takes you directly to the chart and if you need more information, it will take you to the training tool where the idea is discussed."

Rather than take a scattered approach to the vast universe of ICD-10 codes, Methodist is focusing on its top DRG payment groups and high-volume procedures, McGill says. A separate clinical documentation group is analyzing physician documentation to identify likely gaps. But even if Methodist knows which areas of ICD-10 to focus on, the load on coders will be big, perhaps too big, McGill says.

"I am worried about the amount of change our coding staff can take," she says. "Several have already retired, rather than go through ICD-10. These are not clinically trained people." That's why, in addition to offering coding training, the health system is providing training to coders in anatomy and physiology, medical terminology and pharmacology, content areas which often remain outside the skill set of coding staff.

At its core, ICD-10 is little more than a regulatory mandate-one among many in play in the health care industry. Groups like the American Health Information Management Association have long championed the system for the increased specificity it offers in describing healthcare events. Not only that, ICD-10 includes a multitude of newer procedures and better reflects the complexity of diagnostic analysis, champions say.

But others in the industry - notably physician organizations like the American Medical Association and MGMA - have a more jaundiced view. "The government has not made a compelling argument for the return on investment of ICD-10," asserts MGMA's Tennant. "It will be extremely costly for practices."

Tennant notes that groups like his and the American Medical Association have not resisted ICD-10 because of any inherent problems in the code set. "It's a superior code set," he says. The resistance, he argues, stems from the implementation challenges. ICD-10 proponents cite the fact that the United States is the last major nation to move to the classification system.

But Tenant dismisses that idea as a "complete falsehood," noting that other countries adopting ICD-10 did so with a far more limited version of the coding system and that national governments helped defray the cost. "Here it is all on the backs of providers," says Tennant.

For Tennant, however, the bottom line is indeed the bottom line. "The most worrisome aspect is reimbursement," he says.

That's one reason Tennant reserves his strongest criticism of CMS for its decision to side-step any transactions testing. (CMS declined to comment for this story.) The agency announced the policy decision earlier this year. "What message does CMS send by saying we will flip the switch on October 1, 2014 and hope everything goes well?" he asks. "That is highly unlikely," particularly given the industry's transition to 5010, the technical claims format predecessor to ICD-10, which went into in effect in 2012.

Asked his opinion of the CMS testing announcement, Schwyn, the consultant, says "CMS is a little short-sighted. Most organizations are thoroughly engaged in preparing their own environments. But the challenge is full end-to-end testing with payers."

Arniella, at Mount Sinai, is even more blunt. "For us to feel comfortable next year, I want to submit my claims to Medicare. Until you test with specific payers - and Medicare is 20 percent of our business - you don't know what will pop up."

Providers Plan Dual Coding

Melinda Patten is keenly aware of the ICD-10 deadline, quickly citing the exact number of days to the October 1, 2014 deadline from CMS. Patten is director of Health Information Management at Children's Hospital Colorado, a 536-bed facility with 2000 medical staff. She serves on the hospital's ICD-10 project management team with a focus on coding. The hospital is currently implementing computer-assisted coding software from Optum that will use natural language processing to help coders analyze charts and make suggestions about appropriate diagnoses and procedures based on physician documentation. The software currently directs coders to ICD-9 codes, but will support ICD-10, she says.

Patten is leaning on an outside firm, the Haugen Group, to assist in training the coders. And the hospital is looking to get ahead of the curve by doing "dual coding," a strategy that some hospitals are beginning to adopt as they stare down the code proliferation of ICD-10. Children's, Haugen explains, will begin the dual coding in October 2013 with a select group of coders. They will also code charts in ICD-9, which will appear on claims generated from those charts, and add corresponding ICD-10 codes, creating databases of services against which the hospital can analyze coding quality.

Novant Health, a 13-hospital delivery system based in Winston-Salem, N.C., is taking a similar approach, says Laura Pait, senior director, Health Information Management. Beginning in January, 2014, Novant will begin a dual coding effort across its hospitals-which will be mid-way through through an enterprise deployment of a new EHR from Epic. Novant uses coding software from 3M, and the system can retain two sets of codes, Pait says.

While bills will go out in ICD-9, the dual coding effort will facilate efforts to audit coder progress in learning the new system. In addition, the retained database of ICD-10 coded charts can serve as fodder for future tests with payers, Pait adds. Novant is talking with one of its big payers, Aetna, which would like to run transaction tests in the future. "When they're ready to test, they can pull straight from the retained data," she says.

Insights from 5010

Beginning Jan. 1, 2012, the 5010 claims format presumably went into effect in the industry. The ANSI transaction standard enhanced certain claims-related transactions, such as eligibility inquiries and remittance advice. It also set the stage for ICD-10 by expanding the data fields for ICD-10. But well past one year after the deadline, useage of the 5010 format is still lurching forward, causing many to wonder about the long-term success of ICD-10. The reasoning is simple: 4010 can't accommodate an ICD-10 data field; thus no payer can accept it.

Gateway EDI, a claims clearinghouse which processes some 25 million claims a month, still receives 4010 files, says Jackie Griffin, director of client services. Many of them come as a print image file, which the clearinghouse can scan and map to an appropriate 5010 data field. Part of the issue is that practice management system vendors, whose software inaugurates the claims transaction, have not yet updated their systems. "A lot of vendors still in 4010 are upgrading to 5010 as part of their ICD-10 effort," she says.

Gateway dispatches claims to nearly 3,000 payers, the vast majority of which accept 5010 transactions, she adds. But a number of low-volume payers-perhaps some 300, she estimates-are still on 4010. Gateway played a big role in helping its provider trading partners transition to 5010. "It was 80 percent technical and 20% provider," she says. "ICD-10 is the opposite. It's 80 percent provider." Clearinghouses are electronic data exchange facilitators, and it would fall on the providers' shoulders to submit the correct claim in the correct format in the first place.