Countdown To ICD-10

From patient accounting systems to sticky notes and “cheat sheets” posted in exam rooms, ICD-9 codes permeate the health care environment, translating the information in medical records to numbers on claim forms and ensuring that providers get paid for the care they give. But all those old codes have to be rooted out and replaced by October 1. ICD-10, the next-generation code set, is really coming this time, two decades after its original development and many years after its adoption world-wide for public health research and miscellaneous other purposes.

Ready or not, U.S. providers will be required to code their claims with the exponentially more complex ICD-10 codes, or not get paid by either government or private payers.

The Centers for Medicare and Medicaid Services will not be backing down from the deadline as it has before.

Unlike some changes, such as the 2012 migration to the HIPAA 5010 transaction standard, the ICD-10 switch goes far beyond the billing department to affect all the systems and people involved in patient care. “Industry-wide, we need to be looking at all policies and procedures to see which ones have ICD-9 codes attached to them,” says Melanie Endicott, director of HIM Practice Excellence for the American Health Information Management Association. “We recommend that people look at every single form they have. There are lots of areas where you might not expect them to be, like on a housekeeping record to flag the housekeeper what to expect in a certain room.”

Is the industry ready? It should be-it’s had years of warning, and a survey conducted last summer by the American Hospital Association showed 94 percent of its members were either very or moderately confident they’d be ready. But between deadline changes, general reluctance to deal with such a complicated issue, and other mandates like achieving meaningful use or getting ready for the Affordable Care Act, the ICD-10 switch-over is lagging.

Normally the Workgroup for Electronic Data Interchange, which advises the government on health data-sharing matters, is not a particularly alarmist bunch. But its most recent survey of ICD-10 readiness, released in December, is enough to inspire panic in the hardiest of health I.T. pros. According to the government’s ideal timetable, everyone-payers, providers and software vendors-should be done with their internal preparations by now and putting the finishing touches on a testing plan to make sure everything goes smoothly on switchover day. But instead:

* One fifth of vendors were halfway, or less than halfway, done with product development.

* Two fifths of vendors weren’t planning to be ready to test products before the end of 2013.

* One fifth of health plans had not completed their impact assessments.

* One third of health plans had not started internal testing by the end of 2013.

* Only half of providers had completed their impact assessments.

* Only half of providers expected to begin external testing before the end of June, even though CMS has set a “national testing week” in March (see sidebar).

“It is clear the industry continues to make slow progress, but not the amount of progress that is needed for a smooth transition,” said WEDI Chairman Jim Daley in his cover letter to CMS detailing the survey findings. To make the deadline, providers need to focus tightly on several areas:

1. Software. Robert Tennant, senior policy advisor with the Medical Group Management Association, recommends pressing software vendors on the gritty details of their ICD-10 plan: when the product upgrade will be available, how much it will cost, whether the vendor will offer training and whether there’s a transition plan. “Will they offer the ability to handle both codes sets, or will it be a flip of the switch and then you’re forced to do only ICD-10?”

Any system that uses ICD codes in any way should have an upgrade available for ICD-10, but in order to take advantage, providers may need to use the latest version of the system’s software. “If you’re a vendor, you can’t be developing four different software patches,” for older versions of the product, says Cecil Bohannon, health care IT and operations consultant with CTG Health Solutions. “If they have a big enough user base for an older version, they’ll do it, but they’ll charge for it. It makes more sense to change to the current version.” Organizations that are jumping more than one version also should be sure to budget for possible hardware upgrades.

2. Clinical documentation. MGMA is encouraging its members to document more thoroughly at the time of the patient encounter, with an eye to the details ICD-10 demands. “If a patient comes in with a sprained ankle and the clinician doesn’t document that it was the left ankle, the coder can’t guess at the laterality,” says Tennant. He suggests two ways providers can assess what training their clinicians need. One is to take adjudicated claims that have been paid with ICD-9 codes and have the coders code them in ICD-10. The other is to code current claims with both sets of codes. Either method will uncover areas where clinicians need to provide better documentation.

Experts caution coders not to try to bypass documentation improvement by overuse of “not-specified” codes, a category that should be employed only if the minutely detailed ICD-10 code set really doesn’t have an applicable code. “I don’t worry about that with the larger hospitals that have well managed HIM departments, but it may be a problem in smaller shops where Doc Jones has his nephew coding the claims,” says Bohannon.

Slacking off on the details, or using “not-specified” codes to get through the transition period, may ultimately result in claims being paid at a lower rate or rejected outright, says Dennis Winkler, director of technical program management for Blue Cross Blue Shield of Michigan. “If providers take that approach, it would be bad for the industry.”

3. Trained coders. Coders will be less productive during the transition-possibly up to 50 percent less. That gives providers a stark choice: beef up their coding staffs or risk a catastrophic slowdown in billing. “We hope there will be enough coders,” says AHIMA’s Melanie Endicott. She says many organizations have hired backup coders on a contract basis to supplement their staff during the training and testing period, and some contracting companies are already running out. “If you haven’t secured them by now, you won’t be able to find them,” she says.

AHIMA is encouraging providers to hire new graduates of HIM programs. While they’re normally not as appealing due to their inexperience and relative slowness, they’ve just spent months or years getting a thorough grounding in ICD-10. That gives them an edge over their more experienced colleagues whose brains are ingrained with ICD-9. “They know more than your current staff,” Endicott says. “This is the time for them to shine.”

Computer-assisted coding may help, but it requires an investment in hardware and software, plus a learning curve of up to a year, Endicott says. “Software can help with some procedures that have no variation, or situations that only involve one code, but for the most part you’ll still need a human to validate the codes.”

Endicott recommends having coders use both ICD-9 and ICD-10 on at least a selection of charts, to get the hang of how they’re related. The dual-coded charts can also be used during any testing with payers or clearinghouses. “I think dual coding is the way to go if you have the time, but it will hit your productivity and you need to be prepared,” she says. Some institutions are dual-coding all their charts, while others devote a few hours a week to the effort.

4. Testing. There’s a lot of debate over what should be tested and with whom, since testing is expensive and time-consuming, and all parties are short of time and money. On the other hand, the disastrous debut of Healthcare.gov shows the folly of launching a major systemic change without enough testing. “If each part is thoroughly tested and perfect, then all parts should function as a whole when they’re hooked up, but I’m not sure that’s ever really happened,” says WEDI’s Daley.

Both format and content must be tested. Format is fairly straightforward: If a claim contains valid ICD-10 codes, it should get from the provider to the payer without incident. That’s the focus of the National ICD-10 Testing Week taking place in March.

Content is another story, and the one that will determine whether claims actually get paid, and at what level. Blue Cross Blue Shield of Michigan is trying to meet with all its providers, to test an agreed-upon group of DRGs. Providers recode old claims with the new codes and send them to Blue Cross, which assigns them a new DRG. If the reimbursement changes in unexpected ways, Blue Cross works with the provider to determine the cause. “Our strategy was to come up with a cost-effective way to test and make it available to a lot more providers,” Winkler says.

HIMSS and WEDI conducted a pilot test in 2012 and 2013 to see how accurately providers would be likely to code in ICD-10. It used de-identified, real medical records as “medical test cases,” which were collected, vetted and developed by ICD-10 National Pilot Program’s Testing Scenarios and Coding Work Group. AHIMA-approved ICD-10 trainers from various organizations coded the test cases in ICD-10 to produce the “answer key.” The cases were sent to 200 participating providers who coded them and then compared them against the answer key to measure their accuracy. The accuracy varied wildly depending on the type of case, but averaged 63 percent.

The program was designed by the Lott Group, a consulting firm specializing in health care testing, and the company has expanded it nationally (see box for links). All providers can participate, with fees based on number of records they want to test. “We dual-code the records for the providers across multiple expert coders, then we send them to the payer with the right answer,” says CEO Mark Lott. “After the testing is complete, providers can see who needs additional training and what concepts are difficult for everybody.” The test structure can also help identify problems with underlying clinical documentation.

Technology and culture

Most large providers are in the thick of ICD-10 planning. MariJo Rugh, vice president of application services at University of Colorado Health, Loveland, Colo., has her hands full on both technological and cultural fronts as the organization prepares for ICD-10. On the tech side, an Epic EHR implementation has only recently been completed in all of UC Health’s five hospitals. With physicians now documenting electronically, Rugh’s team is working on creating templates to impose ICD-10-consistent structure on the data they enter. She expects to start dual-coding every chart by April, and start testing with payers.

“Our priority systems are the ones that are now sending or receiving ICD-9 codes,” Rugh says. The Epic EHR is the first priority, followed by lab and cardiology systems. Some ancillaries won’t be ICD-10 ready by the deadline, and Rugh plans to handle those with interfaces that let the systems continue to receive ICD-9 codes until they are upgraded.

Rugh has been looking at the possibility of adopting computer-assisted coding software, but won’t get started until the new budget year begins in July, so she won’t be relying on it for the October deadline. “We think we can do it more effectively if we’ve ramped up our human coders first,” she says. The university’s affiliated physicians’ group has been pursuing computer- assisted coding already, and Rugh hopes to benefit from their experience.

ICD-10, meaningful use

At JPS Health Network, the publicly funded provider for Fort Worth, Texas, CIO Melinda Costin has spent almost $2 million on software, hardware and data storage to help cope with the ICD-10 switch, including a computer-assisted coding product from 3M. The investment was more than Costin expected, but probably less than it would have cost to hire and train enough coders, even if the HIM department could have found people to hire. “Budgeting and acquisition of the software tools and associated hardware is the first thing to be focused on, if you aren’t already,” she says.

JPS has an Epic EHR, and is on the verge of qualifying for HIMSS Analytics Stage 7, once it implements full medication barcoding. Finding every cranny of the system that will be affected by the coding change has been challenging. The organization plans to be ready to do dual coding by April, and has gotten commitments from all its payers on testing readiness dates. Costin says the tests will focus on a sample of records that have been dual coded, and will entail just making sure the claims will go through the payer’s system correctly. JPS won’t address whether the claims will be paid and at what level.

While payment is the fundamental survival issue for providers, Costin says she has stopped worrying about it, at least for now. “The HIM department said I was looking at the wrong thing,” she says. “As long as we know we’re coding to the level of effort we’re putting in and capturing the true level of care, we’ll get paid for the work we do.” To that end, JPS instituted a major clinical documentation improvement effort among its clinicians. Costin doesn’t want them to worry about the intricacies of ICD-10 per se, but to capture all the care details that will help JPS’s coders. “To think physicians are going to take the brunt of the responsibility is not going to happen,” she says.

While the combination of ICD-10 and meaningful use Stage 2 seems overwhelming, Costin says they actually complement each other, since both demand better documentation. “We’re a teaching hospital, and for the young kids we’re training, good documentation is maybe not at the top of their list,” Costin says. “We’ve been concerned about copy-and-paste; we can’t have that as we go to Stage 2, since we’re providing information back to the patient.

“We’re going to have to be much more in sync between what the doctor is documenting and what we’re billing for,” she says. “The documentation has much more significance than it ever did before.”

National Testing Week

To help providers prepare for the ICD-10 transition, CMS has created a “national testing week” March 3-7, 2014, for providers and clearinghouses to test their ability to transmit clean ICD-10-based claims to government payers. Registration is required. CMS says participants can expect the following:

* Test claims with ICD-10 codes must be submitted with current dates of service (i.e., Oct. 1, 2013 through March 3, 2014), since testing does not support future dated claims.

* Test claims will receive the 277CA or 999 acknowledgement as appropriate, to confirm that the claim was accepted or rejected in the system.

* Testing will not confirm claim payment or produce remittance advice.

* MACs and CEDI will be staffed to handle increased call volume during this week.

More information is at www.ngscedi.com/ICD/ICD10.htm.

Additional ICD-10 Resources

CMS: http://www.cms.gov/Medicare/ Coding/ICD10/index.html

AHIMA: http://www.ahima.org/education/onlineed/Programs/ICD10

MGMA: http://www.mgma.com/5010icd10/

WEDI: http://wedi.org/workgroups/icd-10

Lott QA Group National Testing Platform: http://www.nationaltestingprogram.com/

HIMSS: http://www.himss.org/icd10nationalpilotprogram

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