Some 32 years after work began on developing the International Classification of Diseases 10th Revision of diagnostic and procedural codes, most providers, many with fingers crossed, jumped off the ICD-10 pier at midnight Thursday.
And by most accounts, the first 12 hours have gone off without a hitch.
“I think, by and large, at least the people we’ve worked with, they have done so much preparation that they’re eager,” said Ed Hock, managing director and ICD-10 guru with the Advisory Board, a healthcare consultant. “I’ve yet to hear any horror stories.”
Health information technology cognoscenti predict most providers of size—large hospitals and health systems, large physician groups and large health plans—will swim right along in a sea of far more numerous, complex and very specific new codes.
If larger organizations experience cramps, they likely appear later as kinks in their cash flows caused by delays in reimbursements.
And after three government-induced delays totaling four years, most providers should have been ready.
The organizations most likely to have trouble, however, are smaller providers and health plans, which for several reasons lagged in implementing IT upgrades and training to handle the more robust ICD-10 codes.
Relative calm has defined the early atmosphere among several insurers. Debra Cotter, the ICD-10 project director at Highmark in Pittsburgh, said her company has been performing quality checks since midnight.
“All is going well,” Cotter said. “We have seen our first claims submitted in ICD-10, and we have finalized a couple claims already. So we’re excited to see the years and years and years of work actually in practice.”
Highmark, a Blue Cross and Blue Shield plan with 5.3 million members, has prepared for the switch to ICD-10 since 2010 and has conducted routine testing of claims with providers for more than a year. Due to Highmark’s large size—it processed more than 114 million healthcare claims last year—Cotter said it had to start thinking about ICD-10 early on.
But the new code set does not mean ICD-9 will be immediately buried in its grave. ICD-10 codes are required for all dates of service on or after Oct. 1, 2015. For people who saw their doctor or were admitted to a hospital more recently, like Sept. 30, those claims will still have the ICD-9 language.
Cotter said Highmark will be ready to juggle both coding systems at the same time. “We believe the industry is really ready and embracing the fact that ICD-10 is finally here,” she said.
Dr. J. Mario Molina, CEO of Molina Healthcare in Long Beach, Calif., a publicly traded insurer that mostly offers Medicaid managed-care plans, said claims operations at Molina have been status quo so far. Molina’s business processes have been ready for ICD-10 for more than a year.
At Security Health Plan, a smaller 230,000-member payer owned by Marshfield Clinic in Wisconsin, the immediate impact of ICD-10 won’t be felt until later Thursday night and next week. Security will receive its first claims files this evening for any services that were provided today, said Sara Foemmel, Security’s claims operations director.
Few hiccups are expected. “We’ve tested a tremendous amount with all of the providers,” Foemmel said.
The same holds true at Blue Cross and Blue Shield of Louisiana. But insurers can’t rule out potential delays in payment if codes aren’t submitted properly.
The American Medical Association, numerous state medical societies, and other physician groups had fought the conversion for years, almost to the bitter end. The AMA didn’t throw in the towel until July, cutting a deal with the CMS in which physicians were given one year’s worth of wiggle room via a pledge by the agency not to bounce Medicare claims incorrectly coded.
According to Stanley Nachimson, the principal of Nachimson Advisors, a health IT consultancy, the ICD-10 brinksmanship has consequences. “A lot of docs are panicking at the last minute,” he said.
Nachimson said the first problems probably won’t surface until Monday or Tuesday, when the nation’s first round of rejected ICD-10 claims are processed.
“There was only a very small percentage of providers doing any testing” of their revenue-cycle software and processes leading up to Thursday’s start date, so, for many of these providers, moving the claim even that far is a big unknown, he added.
After that, he said, another round of glitches could come from the payers—Medicare, Medicaid and commercial—which implemented their own software applications to handle the new codes.
The CMS insists its claims-processing contractors are ready.
“We’ve tested and retested our systems in anticipation of this day, and we’re ready to accept properly coded ICD-10 claims,” Sean Cavanaugh, deputy administrator and director of the Center for Medicare and Medicaid Services, said in a blog post Thursday morning welcoming providers to ICD-10.
“ICD-10 will help move the nation’s healthcare system to better, smarter care.”
But, according to Cavanaugh, even the CMS won’t know for sure how well the transition to ICD-10 is going for a while.
“Most providers batch their claims and submit them every few days,” he said.
Even after submission, Medicare claims take several days to be processed, and Medicare—by law—must wait two weeks before issuing payment. Medicaid claims can take up to 30 days to be submitted and processed by states.
Robert Tennant, policy director of Health Information Technology at the Medical Group Management Association, said his organization would survey its members in a few weeks on their experiences.
While many have said the ICD-10 conversion would be another Y2K, where Americans braced themselves for a technological meltdown at the turn of the century that never happened, this might have a more recent reference point.
“Remember the exchange site?” said Russ Branzell, president and CEO of the College of Healthcare Information Management Executives, a professional association of chief information officers, recalling the disastrous launch of Obamacare’s enrollment website, Healthcare.gov. “It’s not that it didn’t work in concept, it was in volume. You may or may not know the issue is there until there are tens of thousands or maybe hundreds of thousands of claims not getting through.”
For Monique Fayad, CEO of ICDLogic in Harrison, N.Y., business is booming. Her nearly 3-year-old company developed a Web-based clinical documentation guide for physicians.
“I think that people have literally woken up in the last couple of days,” Fayad said. On Wednesday, ICD-10’s eve, “The traffic to our website and the downloads to our demos increased 10 times the average for the quarter.”
Repeated delays of the ICD-10 launch have been a nightmare for Fayad. “For three years we’ve been waiting for this. It’s been so long and drawn out,” she said. Now, it’s like Valentine’s Day at a chocolate shop.
Doctors, hospitals and insurers are bracing for possible disruptions on Oct. 1 when the U.S. health-care system switches to a massive new set of codes for describing illnesses and injuries.
Under the new system, cardiologists will have not one but 845 codes for angioplasty. Dermatologists will need to specify which of eight kinds of acne a patient has. Gastroenterologists who don’t know what’s causing a patient’s stomachache will be asked to specify where the pain is and what other symptoms are present—gas? eructation (belching)?—since there is a separate code for each.
In all, the number of diagnostic codes doctors must use to get paid is expanding from 14,000 to 70,000 in the latest version of the International Classification of Diseases, or ICD-10. A separate set of ICD-10 procedure codes for hospitals is also expanding, from 4,000 to 72,000.
Hospitals and physician practices have spent billions of dollars on training programs, boot camps, apps, flashcards and practice drills to prepare for the conversion, which has been postponed three times since the original date in 2011.
Some coding experts warn that claims denials could double as providers and payers get used to the new, more specific codes.
Others are more sanguine. “We’re hoping it will be like Y2K,” when the switch to 2000 dates was expected to crash computers world-wide, says Robert Wergin, president of the American Academy of Family Physicians. “Everybody will worry, and the claims will go through fine.”
The real upshot won’t be apparent immediately. “Any problems that crop up will be far more evident on Oct. 15 than Oct. 1, because it takes that long to process claims,” says William Rogers, an emergency physician who is the Center for Medicare and Medicaid Service’s ombudsman for ICD-10 conversion.
ICD codes are an international system for recording diseases, injuries and other conditions set by the World Health Organization; federal agencies developed the far more elaborate version for the U.S. To get paid, doctors submit such diagnosis codes along with separate procedure codes that describe the service performed. Private and government insurers scrutinize the ICD codes to judge whether the service was medically necessary.
The new coding system is needed, many health-care experts say, because modern medicine has outgrown the old one, adopted in the U.S. in 1979. The ICD-9 doesn’t differentiate between Type 1 and Type 2 diabetes, for example, or distinguish Ebola from “other diseases spread by viruses.”
ICD-10 will help researchers better identify public-health problems, manage diseases and evaluate outcomes, proponents say. Over time, it will create a much more detailed body of data about patients’ health—conveying a wealth of information in a single seven-digit code—and pave the way for changes in reimbursement as the nation moves toward value-based payment plans.
“A clinician whose practice is filled with diabetic patients with multiple complications ought to get paid more for keeping them healthy than a clinician treating mostly cheerleaders,” says Dr. Rogers. “ICD-10 will give us the precision to do that.”
The multitude of codes for external causes of injuries have gotten most of the attention to date. Hurt in a prison swimming pool? That’s Y92.146. Crushed by a human stampede while resting or sleeping? That’s W52.04. But insurers and Medicare officials say that, in most cases, they won’t require doctors to include such external-cause information for billing, although it is useful for research purposes.
Clinicians will need to document enough detail about patients’ conditions to support the new codes, including what side of the body is affected, how severe the problem is and whether it has occurred before.
ICD-10 also offers different codes for ailments depending on myriad circumstances, such as whether respiratory diseases are due to tobacco use and whether obesity is due to consuming excess calories or some other reason. In many cases, doctors readily know such information; in other cases, it could require more discussion and longer visits.
Medicare officials say they won’t deny claims solely for lack of specificity for the first 12 months, as long as providers supply the correct general category of illness. But that doesn’t apply to hospital procedure codes, and most commercial insurers aren’t offering such a grace period.
To what extent insurers will require doctors to use the most specific codes, or use them to adjust reimbursement rates, isn’t clear. “In the first few months, the goal is simply to get the ICD-10 codes into the system and make sure providers are using them,” says Clare Krusing, a spokeswoman for the America’s Health Insurance Plans.
Cost estimates for the ICD-conversion vary widely. Dueling studies have estimated the cost from less than $10,000 to more than $225,000 for small practices. Some large hospitals systems say they have spent millions on training and other preparations.
“This affects literally every single system in a hospital, except maybe the cafeteria,” says Ed Hock, managing director of revenue cycle solutions for the Advisory Board Co., a consulting firm that has warned its hospital clients to expect their accounts-receivable days to increase by three to five, on average. “That can mean millions of dollars in cash flow.”
ICD-10 codes will affect Medicare payments for some conditions because the added specificity moves them to a different severity tier, which changes how they are reimbursed. For example, in ICD-9, there is only one code for hepatic encephalopathy, a severe brain disorder that can occur with liver failure, which is considered a major complication. ICD-10 asks whether the patient is in a coma and if not, the condition is downgraded to a regular complication and the hospital is paid, on average, $2,800 less, according to an analysis by the Advisory Board.
But ICD-10 does give providers and health plans a chance to increase payments by recording patients’ conditions in more detail. In Medicare Advantage and other plans that receive per-member, per-month fees to provide care, payments are adjusted to reflect the severity of patient illnesses, so the more secondary diagnoses providers record, the more they may be paid.
“Hospitals leave millions of dollars on the table today through incomplete documentation or coding errors,” says Mr. Hock. “There’s a revenue opportunity in doing this right.”
Some patients will be affected, too. Those getting regular tests or infusions at outpatient centers will need to bring new orders bearing ICD-10 codes starting Oct. 1, says Kevin Lenahan, chief financial officer at Atlantic Health Systems, which owns five hospitals in New Jersey.
Atlantic plans to have personnel armed with ICD-10 code books stationed at every registration desk that day. “We won’t turn patients away. We’ll either call their doctor, covert the code for them or, in the worst case, we’ll put the bills on hold until we get the right information,” says Mr. Lenahan.
Insurers will have to work with both ICD-9 and ICD-10 codes for months or years until all the claims for tests, treatments and doctor visits before Oct. 1 are cleared. “If someone had a service in August that doesn’t get billed until December, that will still have an ICD-9 code,” says Debra Cotter, director of ICD-10 implementation for Pittsburgh-based Highmark Inc. Insurers generally give patients two years to submit out-of-network claims. “If someone has stashed a bill in a shoebox, it might be a year or more before they realize they’re owed some money,” Ms. Cotter says.
Even the threat of a government shutdown will not stop the Oct. 1 switch to ICD-10, the Centers for Medicare & Medicaid Services says.
“In the event of a shutdown we will continue – and I want to be clear on this — to pay claims,” CMS Principal Deputy Administrator Patrick H. Conway, MD, told media during a telephone conference call on Thursday.
“We will continue to implement the ICD-10 transition. We do planning at any time when there’s the potential of a government shutdown [and] we will continue to pay claims. We will continue to be operational and we will make the transition to ICD-10.”
William Rogers, MD, CMS’s ICD-10 ombudsman, added that “the MACs will still be operating. They’ll still be accepting claims and claims will still be paid, and we are sure of that.”
If government is kept operational by a continuing resolution, Conway says nothing would change.
“We would continue to process claims, the MACs would continue to pay claims and we would execute the ICD-10 transition,” he says. “In terms of staffing we have the flexibility to ensure that core operations are operational and in effect and we say our payment systems are a core piece of the Medicare system that will continue to be fully operational.”
This is not CMS’s first experience with a government shutdown, so Rogers says they aren’t starting from scratch.
“We do think service around core customer service and provider service functions are critical, so we would prioritize those, whether it be ICD-10 or other areas,” he says. “Our goal is to have a smooth transition to ICD-10 both from a payment perspective and from the service around that payment.”
Rogers says it’s not clear if his office of the ombudsman would be considered a vital service during a government shutdown.
“We just don’t know,” he says. “It really is the different legal issues that have to be considered about what emergency operations and what aren’t. So, honestly we don’t know at this point. People who aren’t in this room are deciding what we can do and can’t do in case of a shutdown in terms of staffing here at CMS.”
On other issues related to ICD-10, Conway says it will take “a couple weeks before we have a full picture” of the transition.
“First off, very few providers file a claim on the day of the office visit, lab, or surgery. Most provider batch their claims and submit them every few days,” he says. “Generally speaking Medicare claims take a couple of days to process and can take approximately two weeks. The Medicaid claims can take up to 30 days to be submitted and processed. For this reason we expect to have more detailed information after a full billing cycle is complete.”
“We recognize that this is a significant transition and we have set up processes and operations to monitor the transition in real time assess our systems and investigate and address issues as they come in through the ICD-10 coordination centers.”
Conway says that providers having problems with claims submissions should first contact their billing vendor or clearinghouse. If problems persist, they can contact their Medicare administrative contractor, or the ICD-10 ombudsman at CMS.
Although physicians’ associations have expressed dread at the looming transition, Rogers says he believes the switch to ICD-10 will be relatively smooth.
“Most smaller practices just use a Superbill,” he says. “It requires an expansion of the number of diagnoses on the Superbill but they can easily crosswalk their ICD-9-based Superbill to an ICD-10 Superbill. Once they’ve done that it’s business as usual in the office. I expect that small practices should have little or no expense involved.”
While the CMS says Medicare contractors are ready to switch their claims processing to ICD-10 coding on Oct. 1, about half of state workers’ compensation claims payment systems are taking a pass.
According to the Workgroup for Electronic Data Interchange, a not-for-profit healthcare industry trade group that promotes computerization in healthcare, only 21 states have adopted the Oct. 1, 2015 deadline for switching over their workers’ comp systems to processing physician and hospital inpatient and outpatient claims to ICD-10. Another four states have pending ICD-10 regulations for workers’ compensation claims.
Meanwhile, WEDI also released a list of websites for state Medicaid programs where providers can check for ICD-10 updates. State Medicaid programs must switch to ICD-10.
WEDI isn’t tracking their progress. “I don’t know what I don’t know with Medicaid,” Jopp said. “I’d hate to speculate where states are.”
On Thursday, the CMS reported 87% of the organizations passed its third round of end-to-end testing of Medicare claims. It pronounced provider claims processors are ready for Oct. 1.
Just five weeks out from the October 1 ICD-10 deadline, the Department of Health and Human Services’ Medicare Learning Network (MLN) will hold a National Provider Call on August 27 to provide last-minute coding guidance and tips, as well as updates from the Centers for Medicare and Medicaid Services.
Topics addressed on the “Countdown to ICD-10” call will include: how to get answers to coding questions, claims that span the implementation date, results from acknowledgement and end-to-end testing weeks, and where to find additional provider resources.
Speakers and subject matter experts scheduled for the call are Sue Bowman, senior director of coding policy and compliance at the American Health Information Management Association (AHIMA), and Nelly Leon-Chisen, director of coding and classification at the American Hospital Association.
Medical coders, physicians, physician office staff, nurses and other non-physician practitioners, provider billing and health records staff, and all Medicare providers are encouraged to listen in.
However, time is quickly running out for ICD-10 procrastinators. An eHealth Initiative survey of 271 providers, conducted in conjunction with AHIMA and released in June, revealed a preparedness gap between larger and smaller provider organizations.
“It’s very concerning that about 14 percent of physician practices and almost 12 percent of the small organization category have not completed any of the steps to prepare for ICD-10,” said AHIMA’s Bowman.
Space for the MLN ICD-10 call may be limited, so those interested are asked to register as soon as possible. Online registration is available here.
A poll of 1,670 providers conducted by SERMO shows a majority of providers, 71%, said they are not ready for the Oct.1 ICD-10 implementation deadline, compared with 29% who said they are ready.
The poll also shows that just 17% of the 487 providers surveyed said they plan to hire additional staff to help with ICD-10 implementation and management.