Many stakeholders have worked hard, and with the ICD-10 finish line in sight, they’re looking for tools or policies to make remaining preparations easier and maintain cash flow.

Providers, payers and vendors are entering the home stretch for completing preparations for the transition to ICD-10 coding by October 1. There’s a mixture of anticipation and foreboding.

Many organizations have worked hard to meet the compliance deadline and don’t want another ICD-10 delay, while others aren’t ready and would relish another congressional intervention, similar to the delay imposed through legislation last year.

In the latter camp are many physician practices; organizations representing them are pushing for another delay, but that seems increasingly unlikely, based on testimony during a congressional hearing in February and comments from members of Congress.

At the recent House Energy & Commerce subcommittee meeting to assess the status of ICD-10, only one of seven witnesses testifying—a physician—urged further delay, contending that the vast majority of physicians are not ready to make the transition.

Also in February, Sens. Orrin Hatch (R-Utah) and Ron Wyden (D-Ore.), chairman and ranking member, respectively, of the Senate Finance Committee, issued a joint statement indicating that the ICD-10 transition is on track, citing a recent Government Accountability Office report concluding that Medicare and Medicaid programs will be ready for the switch.

“I will continue to keep a close eye on this issue but see no reason for another delay past the October deadline,” Hatch said. Wyden was a little more circumspect, saying, “We will continue to monitor the testing CMS is conducting as we near the October 1 implementation date.”

However, there’s no guarantee that Congress won’t delay ICD-10 again, as it did last year. For example, legislators will be considering the annual legislative attempt to fix the Sustainable Growth Rate formula, which governs Medicare payments to physicians. Any SGR bill could be loaded with riders, similar to last year, when an ICD-10 delay was attached to the bill and enacted. The bottom line: Will members of Congress be braver in disappointing their physician constituents—and prime campaign contributors—than they were last year?

Fewer insurance hassles?

Absent a delay in the transition, providers and payers are looking forward to the potential benefits an ICD-10-based system could provide.

During ICD-10 testing, providers and payers alike learn more about their internal processes, which opens opportunities to change processes, says Beth Malchetske, director of business integration and leader of the ICD-10 program at ThedaCare, a seven-hospital delivery system based in Appleton, Wis.

The granularity of ICD-10 in describing conditions has the potential to reduce the need for payer-requested pre-authorizations, medical necessity reviews and other queries, she believes. “If we are presenting a more detailed description of the patient’s condition and procedures, it will be clear what the medical necessity is,” Malchetske says, suggesting that her hope is that the need for such additional documentation will diminish over time. “I haven’t heard payers speak of it yet,” she adds.

Another potential benefit of the expanded code set, according to Malchetske, is that by using the analytics functions in patient registries, providers will have an easier time finding care plan options, because of the specificity of ICD-10 coding. Industry stakeholders should pursue common goals, such as using evidence-based care plans and submitting more detailed claims that don’t need payer follow-up, she says.

Using ICD-10 has the potential to change the dialogue about contracts between providers and payers. “In those conversations, we can point to accuracy of representing our patient populations and negotiate reductions in medical necessity and payment reviews,” she says.

Malchetske urges providers that have not yet started to make ICD-10 preparations in earnest to begin making the transition. It may be difficult for these providers to sufficiently conduct end-to-end testing at this late stage, but there’s still time for them to ask peers about the insurers and clearinghouses with which they have tested to better understand their ICD-10 readiness; then, they can run an ICD-10 test with one or more of their top five payers.

Training ramps up

The extra year to prepare for ICD-10 proved beneficial for UW Medicine, which includes University of Washington Medical Center and eight other entities. The organization was ready to go live in October 2014, but the compliance delay provided time to improve its preparatory stance, says Sally Beahan, director of health information management strategic planning and projects.

Now that UW Medicine is in the home stretch, Beahan’s wish is that the extra time and training will have enabled physicians to gain proficiency in documenting care at a level that helps the organization avoid payment delays. In February, the organization completed a training project that saw 1,900 physicians given 10 records each to document care. Their documentation was then coded, and the physicians subsequently gave feedback to the coders.

Physicians don’t care about codes per se, but about documentation, Beahan says. Thus, this exercise was beneficial for them, in light of their previous training on the specificity of documentation needed for coders to code accurately. Physician documentation has improved; for example, documenting laterality by specifying “right leg” or “left leg” instead of “the leg” is just one example of increased physician attention to documentation.

This spring, the university will analyze the top 50 diagnosis-related groups to assess how ICD-10 coding will bring shifts in reimbursement or diseases within the various groups. Organizations must examine many records in each DRG to get a more accurate picture of payment shifts, Beahan says. For example, anomalies in only five records of each group may suggest a significant change, but increasing the sample size by analyzing 50 records often shows no shift.

In late January, UW Medical Center started to move coders to all ICD-10 coding, using computer-assisted coding technology that automatically suggests a code, which coders may or may not accept. At the same time, the organization is continuing to bill in ICD-9.

The plan is to switch more coders to using only ICD-10 before September. UW Medicine and its affiliated hospitals have the same core wish as everyone else—to keep adding coders and get them into production mode. Beahan’s ultimate goal is that all coders at UW Medicine are proficient in ICD-10 by October 1.

Fear factor

With two sites and 16 physicians, Regional Urology in Shreveport, La., was ready for ICD-10 last October, and the practice expects to be ready this year, says CEO Joel Young.

Young hopes that all the fears that keep him up at night won’t become a reality. He says he’s more concerned that payers will be unprepared, and he worries about whether cash flow will remain relatively stable come October. The claims clearinghouse used by the practice has made substantial back-end changes for ICD-10. However, Young remembers the far less complicated transition to the HIPAA 5010 transaction sets, when substantial payment delays occurred, and the issues that arose then are not making him feel any better as October 1 draws near.

“We fear that we will put in correct diagnosis codes but won’t be reimbursed in a timely manner, will have an increase in denials and increasing follow-up requests,” he says. “Unfortunately, our obligations don’t stop while we’re not being paid.”

Regional Urology has done some end-to-end testing and will do more in the weeks ahead. “We can test all day long, but until funds are pumped into our accounts, that’s when I’ll feel comfortable,” Young says.

Consultant, vendor views

Consultants and vendors offering ICD-10 technologies and services, as well as clinical documentation improvement programs, also have ICD-10 wish lists.

Penny Osmon Bahr, director at Avastone Health Solutions, has worked with ThedaCare and other clients on ICD-10 testing for more than two years. She would love to have a dashboard tool that would track which versions of specific EHRs or practice management systems have been tested with which clearinghouses and payers. Such a tool would serve as a repository of testing information to build confidence for those that may not be able to do extensive testing with insurers, she says. It also could serve as a system that warns of vendors and payers that are not ready for the coding changeover.

Osmon Bahr would like to see stakeholders make better use of a tool created by the Workgroup for Electronic Data Interchange (WEDI) created to analyze DRG shifts. DRGs describe hundreds of specific types of care in a hospital, based on diagnostic categories such as respiratory or cardiology, and help standardize and more precisely identify each treatment performed, and that influences which ICD-10 code is used.“It’s a good foundational tool but should be pushed out more to industry,” she contends.

Every organization preparing for ICD-10 has a wish list that starts out the same, says Betty Schulte, vice president of client relations at Amphion Medical Solutions, a Madison, Wis.-based outsourced coding and transcription vendor.

“We are all looking for more credentialed and experienced coders as ICD-10 implementation nears,” Schulte says. “Our clients’ top request is for more coders to make up the productivity loss expected with implementation.” At any time, a client could call Amphion and ask that it provide 30 coders, and the vendor must be ready to supply them. “It’s all staff, the need to secure full-time equivalent coders,” she adds.

Improving physician documentation to minimize the need for coders to ask physicians for more information is another major wish, one that’s typically dependent on a robust physician clinical documentation improvement program, Schulte says. Better documentation means quicker completion of each chart, and faster billing processes with cleaner claims. The company offers physician clinical documentation improvement and coder gap analysis and education programs for its clients.

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