As I write this on the eve of April Fools’ Day, I can’t help but wonder if the events that transpired over the last week, resulting in the passing of H.R. 4302, “The Protecting Access to Medicare Act of 2014,” really happened.
With the influx of arriving emails about the details of the sustainable growth rate (SGR) patch, reality has set in, and it is time to dig through it all and get to work. Is this déjà vu? Yes – the healthcare industry has been handed yet another one-year extension of the ICD-10 compliance date. In fact, just one short sentence added to the bill in the 11th hour sealed the deal for an Oct. 1, 2015 compliance date…or did it?
Before reading too much in between the lines, let’s examine the specific language of the legislation:
SEC. 212. DELAY IN TRANSITION FROM ICD–9 TO ICD–10 CODE SETS.
The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal Regulations.
The language seems to leave some room for interpretation. Exactly how long will the delay be? Could it actually extend beyond Oct. 1, 2015? If not set as the standard, could stakeholders voluntarily begin using ICD-10 prior to Oct. 1, 2015? This wording is vague and leaves much up in the air, similar perhaps to the yet-to-be-named group that asked for it to be added.
As an industry, we must ask ourselves: Is the extension of the compliance date the worst-case scenario? Stakeholders throughout the industry, including hospitals, health systems, vendors, health plans, clearinghouses, and more have worked diligently to ready themselves for an Oct. 1, 2014 compliance date, and for some, the pressure has been mounting. Competing initiatives, strained resources, and budget concerns abound, and contingency planning has become the new focus. So how does an industry that has already invested billions, if not trillions, of dollars and many resource hours move forward?
Why Might More Time Be Beneficial?
From the beginning (whenever that is for you), ICD-10 has been a project that has forced us as an industry to evaluate how things are done today so we can understand how to move forward with ICD-10 tomorrow. This evaluation has touched people, processes, and technology, and has provided many pearls of wisdom and opportunities for improvement. These improvement opportunities have impacted the entire revenue cycle. The obvious areas of coding and documentation have been impacted, and scheduling an appointment and verifying insurance for the posting of payments and utilization of claims adjustment reason codes (CARCs) has been scrutinized. There is now a clear understanding that real blind spots and potholes exist in our ICD-9 revenue cycle. Without first patching those bumps in the road, the move to ICD-10 would not be viable.
Understanding your current denial ecosystem is critical for forward movement, not just for ICD-10 but also for overall payment reform. Where is your staff spending time and effort on denials and claim re-submissions? Which contracted payors have the highest denial rates and why? Which denials are coding-related? Establishing a baseline and a tolerance threshold for ICD-9 is critical before setting the bar for ICD-10, along with inviting the right people to the table. Is there an active feedback loop inclusive of your staff working denials and your contracting staff? With the extra time, you can create countermeasures to maintain your current denial ecosystem and put in place a construct promoting positive payor relations and accurate data to influence future contracting.
What about Coding and Documentation?
The obvious benefits from an extension of the deadline are related to coding and documentation. While a majority of coders either have been trained or are in the middle of training, an extension will not be detrimental unless they lose the opportunity to use their new skill set. This is the foundation of a solid argument to continue the momentum forward, with perhaps a slight shift in the focus. Significant investment has been made in coding education and training – as well as physician and other documenter training – and this investment was not in vain.
Consider coding for a diabetic patient today, in the world of ICD-9. In general, more than 80 percent of ambulatory visits with diabetic patients are recorded as 250.00, representing a healthy, non-complicated diabetic patient. Documentation may provide a clinical impression reflecting whether the diabetes is controlled or not, but linkage to complications or disease manifestations is often not present. In both ICD-9 and ICD-10, linking clinical manifestations to the disease process tells a more accurate patient story, and by virtue of teaching the cause and effect of “due to” linkage, we have more robust documentation with which to code, regardless of the ICD version. Capturing added specificity has many benefits for both ICD-9 and ICD-10, including:
Better physician profiles for patient care
Improved RAF scores
More specific and sometimes more complex reporting of services
Decreases in denied/rejected claims and the time needed to work them
While diabetes is a common example used to define documentation improvement, there are several diseases, conditions, and procedures ripe for targeted documentation improvement as well, regardless of the standard code set. Many of these improvement opportunities resonate closely with the quality metrics healthcare stakeholders are diligently tracking today to avoid payment penalties, to leverage risk-based contracting models, and to substantiate value-based care.
Understanding your coded and clinical data has never been more important. The convergence of meaningful use, accountable care organizations, value-based payment initiatives, and ICD-10 often has been referred to as the “perfect storm” by the industry. The added benefit of a one-year ICD-10 extension provides an opportunity to dig into your coded and clinical data and feel confident that, as an enterprise or sole provider, you have one source of truth for your reported data and you are accurately depicting each patient’s story. The public reporting of quality measures and outcomes is no longer a distant bleep on the horizon, but rather a model for consumer-driven healthcare.
Time to Collaborate and Communicate as an Industry
A key step in the adoption of ICD-10 has required payors, vendors, and health plans to work together closely to execute testing strategies and to share lessons learned. There is incredible value in working with each other, and the benefit of another year should permit the industry to slow the testing pace to a workable cadence. It should come as no surprise that as the Oct. 1, 2014 date was only a season away, testing environments were not nearly robust enough, mapping was not perfect, communication was not always transparent, and volume-based demands were hampering the production of meaningful test results.
The addition of one year allows the above-mentioned stakeholders an opportunity to continue the joint effort to reduce the overall costs of healthcare – administrative, medical, and technological costs. By working together, we have an opportunity to be fully transparent regarding progress and to communicate lessons learned more globally. The ICD-10 investments already made will be for naught if we don’t collaborate.
Take a Breath and Push On
While there are many mixed emotions on the passing of yet another delay, now is not the time to put your ICD-10 project on the shelf and dust it off at this time next year. ICD-10 and payment reform in general are not easy tasks, as evidenced by our elected officials’ inability to agree on a sustainable and permanent SGR fix. Significant time, funds, and resources have been expended to move to a new standard code set, and along the way valuable lessons have been learned.
While ICD-10 may not change how patient care is delivered, it has made the industry as a whole keenly aware of how complicated our healthcare system is. At the end of the day, we are all patients consuming healthcare services, and we all benefit from greater specificity in documentation and the ensuing comprehensiveness a more specific code set imparts to our clinical information.
Take a breath and push on.
About the Author
Penny Osmon Bahr is the director of healthcare solutions for Avastone Health Solutions. Penny has more than 18 years of healthcare experience with a strong background in Medicare compliance, coding and billing, HIPAA privacy and security, quality measurement and health information management. She currently provides strategic guidance and solutions on revenue cycle, ICD-10, risk assessment and health information technology for health care clients throughout Wisconsin and the Midwest. Penny is a Wisconsin ICD-10 (WICD-10) partnership steering team member and sits on the HIMSS national ICD-10 task force. She also is a member of the Medical Group Management Association.
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