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There were no reports of major collisions on the I-10 Thursday, Oct. 1. Computer systems failed to crash and everything was pretty much business as usual for America’s healthcare system on a day some once thought might lead to a year of calamity. It didn’t happen. 

Remarkable for its absence of drama, it was the day when, like flipping on a light switch, the United States went from using its 30-year-old ICD-9 codes to the much-vaunted ICD-10 coding version. There were no blackouts. The event was momentous, yet underwhelming.

As benign as the transition turned out to be, however, the lead-up to the on-again, off-again transition had grabbed America’s attention in mainstream news media. Angst was everywhere.  

Leading up to that day, Sue Bowman, the American Health Information Management Association’s (AHIMA’s) senior director of coding policy and compliance, was quite concerned that there might be another delay – and it was a concern that was quite well-founded. In previous years, the American Medical Association (AMA) had been ferocious in its unrelenting fight to delay the adoption of ICD-10. 

Another Delay

“My main concern was that implementation might be delayed again,” Bowman told ICD10monitor. “Other concerns were the potential adverse impact the multiple delays might have on readiness.” 

Bowman was also aware that many organizations were well-prepared, and had been for some time, but she was concerned about the potential for loss of momentum. 

“(Delays) had caused some providers to fall behind who previously had been on track, because they had stopped preparation activities in light of the delay,” Bowman said. “And also, some providers that had been lagging behind and should have theoretically been helped by the delay didn’t use the extra time to catch up, because they were skeptical (that) the transition would never happen.”  

Early Worries

The processing of new ICD-10 claims was an obvious concern for many; after all, reimbursement was on the line and end-to-end testing of claims had been spotty throughout the country.

“My primary concern was that providers were not going to have processes in place to assure that clean claims would go out the door right the first time under ICD-10,” said Maria Bounos with Wolters Kluwer. “Without having strong processes in place, there is a risk of rising accounts receivable, and, ultimately, unpaid claims.” 

Holly Louie, the president of the Healthcare Billing and Management Association, a trade organization of third-party medical billers, shared the same concerns. 

“Claims disruptions,” Louie said tersely. “The biggest concern was the profound lack of commercial payer testing.”

Echoing that at the time was Laurie Johnson, director of health information management (HIM) consulting services for Panacea Healthcare Association. 

“My concern primarily was (whether) claims would be paid on a timely basis,” Johnson said. “I was relieved to see that the payment issue was a non-event. The payers and clearinghouses were able to process claims immediately.” 

Emerging Issues Surface

As the implementation progressed and gained speed, some unexpected issues began to surface. Also, as expected, coder productivity did decline, but according to industry sources, things improved shortly after the transition. 

“There were some payment policy translation errors whereby, for example, some codes were missing from payment policies, resulting in inappropriate claims rejections or denials,” Bowman recalled. “In most cases, these problems were resolved pretty quickly.”

Bowman noted that some providers had reported issues with certain electronic health record (EHR) coding tools, and that some ICD-10 code look-up tools embedded in EHR systems were designed improperly or sub-optimally, resulting in coding errors.  

“But the few issues that surfaced right after (the) transition were minor or limited in nature or scope, resolved quickly, and/or did not lead to widespread disruption,” she added.  

Think Local

Johnson, who began her career as a coder, was quick to notice some problems that arose more quickly than others. She was one of the first healthcare professionals to report on ICD-10 issues regarding national and local coverage determinations (NCDs and LCDs) and their impact on claims. 

“NCDs and LCDs were not translated accurately, which resulted in claims being returned to provider (RTP) or denied by all Medicare Administrative Contractors (MACs),” Johnson said. “Many organizations worked tirelessly to get their claims appropriately paid in a timely manner.” 

Johnson believes that many healthcare professionals were disappointed with the response from the Centers for Medicare & Medicaid Services (CMS).

“For the first few months, they (CMS) were updating the NCDs and LCDs and reprocessing,” Johnson recalled. “By February 2016, CMS put the updates in the regular process, and providers were waiting for payment for services that had already been provided.”

Shifting MS-DRGs

Johnson also said there were some errors in the translation of codes from ICD-9-CM and ICD-10-CM/PCS in the MS-DRG methodology. She explained that some codes that did not impact MS-DRGs under ICD-9-CM now were impacting ICD-10 MS-DRGs, as well as the opposite. 

“Organizations were struggling with the question of ‘should we code to match what the DRG was under ICD-9-CM, or do we code correctly and get what we get under the ICD-10 version?’” Johnson said. “Some organizations (saw) an increase in payment with the transition to ICD-10, while others, because of their specialties, (suffered) some reimbursement losses.”

Johnson believes, however, that there is good news on the horizon.

“CMS has been listening to the information that has been provided about where there were potential errors and have fixed them for fiscal year 2017, but I am sure that there are more errors to be fixed for 2018,” Johnson added.

The reported errors and omissions of the NCDs and LCDs during the immediate aftermath of implementation certainly caught the attention of Louie, whose organization has urged the elimination of LCDs. Louie wrote and spoke extensively on both the NCD and LCD issues on ICD10monitor and Talk-Ten-Tuesdays.

“The LCD issues are still in progress, and the NCDs were finally updated July 2016,” Louie said, noting that it is “still a work in process because claims were not automatically reprocessed.”  

“We have to resubmit,” she said. “Those errors had a trickle-down effect to other payers.”

What a Difference a Year Makes

Delayed in 2013 by CMS, ICD-10 was delayed a second time in March 2014. In a deft congressional slight-of-hand, the U.S. Senate passed H.R. 4302 to extend the sustainable growth rate (SGR) while at the same time delaying the implementation of ICD-10 for at least one year. The vote was 64-35, as reported by ICD10monitor.

Also widely reported was the fact that the provision for extending the ICD-10 delay was tucked into the House bill as a temporary measure that the industry has come call the “doc fix.” Nonetheless, in a Rose Garden signing ceremony on Tuesday, April 2, 2014, President Barack Obama signed into law the Protecting Access to Medicare Act of 2014. ICD-10 would be delayed until Oct. 1, 2015.

But did the one-year delay really make a difference, in terms of the implementation?

“(The delay) may have eased the anxiety and apprehension some providers experienced as the ICD-10 implementation date approached,” Bowman said. “I think it may have also helped to send a clear message to the industry that there would be no more delays, and therefore motivated providers to step up their preparation efforts and get ready.” 

The delay might have affected some providers more than others, as it turned out. 

Bounos said that larger facilities and health systems with more than 500 bed were prepared for the 2014 implementation date, one year earlier. The extra year, from 2014 to 2015, she thought, helped the smaller facilities prepare for the coding switch. 

“A lot more time was focused on education and dual-coding, which helped the organizations that approached the transition with this method,” Johnson said. “I think that the additional year did help providers and payers feel confident about the transition.” 

Louie also feels that the one-year extension was beneficial for providers and payers alike.

“I do think it was very helpful in most situations, and likely minimized far more issues that may have occurred,” Louie said.

But still, in responding to anecdotal comments about what she said are “numerous studies indicating EHR coding is inaccurate and provider pick lists lead to errors,” she said she is reserving judgment. 

“I don’t think we are done with the resolution of all the issues still lurking beneath the surface,” Louie said. “Only time will tell.”

Wait, That’s Not All

One would think that there will be plenty of time before the United States is faced with transitioning to ICD-11. But is there? The World Health Organization has stated that the introduction of version 11 has been set for 2018. Estimates are that adoption of ICD-11 in this country will require four to six years of clinical modification for the new codes to be ready to implement. It took America more than 30 years to get to ICD-10.

“We should have ICD-11-CM by 2022-2024,” Johnson said in estimating the preparation time. “Let’s hope that we don’t wait another 35 years to change code sets, and that we adopt ICD-11 when it is feasible and we are not too ingrained in ICD-10.”

Johnson hopes the ICD-10 implementation experience will provide some confidence that the industry can change code sets without bringing the revenue cycle to its knees. 

But, again, time will tell.

So, far though, no ICD-10 disasters, as had been earlier predicted.


Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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