Guest post by Michele Hibbert-Iacobacci, CMCO, CCS-P, vice president, information management and client services, Mitchell International.
The International Classification of Diseases – 10th Revision, Clinical Modification and Procedural Coding System’s (ICD-10-CM/PCS) implementation in the United States is being delayed yet again. According to the latest polls and surveys, there are many organizations (most who need to use it) that were ready to roll with the new classification on October 1st 2014. The change came about because the Senate approved a bill (H.R. 4302) on March 31, 2014, that delays the implementation of ICD-10-CM/PCS by at least one year and then a subsequent official announcement by CMS announced a forthcoming interim final rule that would set the new compliance date for October 1, 2015.
How will this new implementation date affect Property and Casualty payers and providers? For an industry that was not required to change, P&C was ready to go – mainly because of the dependency on payments and bill processing. The question was, “Will we see ICD-9 and/or ICD-10?”
Fortunately, from a processing perspective the P&C industry was prepared for most anything. Payers were creating processing systems and/or contracting with vendors who considered all possibilities including bills submitted with both codes and the submission of ICD-9 codes well after effective dates. These payers also considered the compliance environment as most are guided at the state level.
As difficult as it may be to be ready for the effective date of ICD-10 just to have it changed, most aspects are positive for property and casualty. Additional time for testing, communication to providers and overall education (external/internal) enhances the readiness for the new date. The negative is the cost – staff has been added and enhanced with testers, educators and coders for the initial date. Maintaining staffing levels for a longer period of time was not accounted for in most budgets. The cost will be higher to implement now and many companies did not plan on the additional timeline.
So how will this shake out moving forward? Providers will likely react by submitting ICD-10 codes to P&C payers before the implementation date of October 1, 2015. Payers will need to make decisions on how they will handle these claims since P&C is not guided by the same rules under HIPAA as the health side. Some payers may decide to turn these claims back to providers and others will translate to ICD-9 for payment. Compliance standards, whereby a state has implemented mandates on the use of code sets that need to be addressed and/or revisited, may also impact the way payers process ICD-10 codes prior to October 1, 2015.
On the first day of HIMSS 2014 in Orlando, I stepped into a bewildering echo chamber. “We’re doing population health,” repeated everyone, be they physicians at a hospital whose EHR system my company implemented, the IT directors of other hospitals looking to update their EHR system or competing EHR experts. Everyone was interested in buying it, and everyone was interested in selling it. On one particular walk of the floor a colleague quipped, “Will there be a prize for the one millionth person to say ‘population health?’”
Despite this obsessive buzz nobody seemed able to define what population health is. It’s the proverbial elephant described by touch rather than sight. Is it a concept of health or a study of the various factors that affect health? Is it a course of action for the treatment of the population in its entirety or individual patients only?
The Affordable Care Act, which cites population health as an essential component of its mandate, aims to expand access to the healthcare delivery system, improve the quality of care, enhance prevention, make healthcare providers responsible for outcomes, and promote disease prevention at the community level.
All of this is commendable, but, in the end, what is population health? What does it look like? Will we recognize it if we achieve it? A friend of mine on the payer side observes that vendors claim it’s everything and providers don’t know exactly what they want it to be. Put those together and the term becomes meaningless.
There are additional questions about population health that remain unanswered. Is it an outcome, as the ACA approach suggests, or is it a foundation built on big data, analytics, ACO tools, bundled payments, systems consolidations or something else? At every HIMSS booth, the answer to these questions was a resounding “Yes.”
With a flourish of congressional shenanigans lifted almost word for word from the teleplay of Netflix’s House of Cards, the HHS-mandated 2014 transition to use of the ICD-10 coding classification was brought to a screeching one year “delay.” We are left, once again, with “at least” another year of collecting healthcare information via ICD-9, an awful but omnipresent healthcare coding system. And more concerning, we are left with the impression that diligent and expensive work to comply with rules in a host of other areas, such as meaningful use of electronic health records, could become abruptly irrelevant. The result of the delay is that not only do we have a significant number of long-time objectors to the change to ICD-10, but they are also joined by a surge of rightfully angry and dubious ‘compliers’ who put in time and investment dollars to meet the deadline. But there are also some additional considerations given the amount of time that has passed as we prepare to make the trip.
Is this trip still worth the aggravation and expense?
The major underlying rationale of moving to ICD-10 remains laudable: to provide greater clarity to our understanding of healthcare practices through the use of better industry standard, diagnosis codes. With more granular, relevant and precise core codes at the foundation, medical quality and effectiveness studies utilizing these codes for analysis and program development were to have benefitted dramatically.
Given that our desire to advance healthcare value and improve outcomes through accountable care practices (‘fee-for-value’) we must acknowledge our dependence on much better information collection for analysis than is possible from ICD-9[1]. Significant questions remain however, as to whether the move to ICD-10, using codes predominantly still entrenched to support fee-for-service billing processes will get us where we want to go. While we can hope the enhanced and detailed nature of ICD-10 might yield greater insight into the real value of our activities, this remains a particularly frail hope in light of the way we use the codes as revenue cycle fuel.
Guest post by Michele Hibbert-Iacobacci, vice president, information management and client services, Mitchell International.
Employee morale is a constantly at the forefront of the healthcare industry because of on-the-job stress, do more-with-less mentalities and a consistent cost containment focus. With the introduction of ICD-10, employees who work in healthcare as medical coders will be expected to maintain productivity and produce quality coding. We are changing the communication language used between payers and providers and have an expectation that everyone speak the same language as of a specific date.
Although difficult to attempt in a short time frame, this language change has been coming for many years and we should be ready by October 1, 2015. While the industry has been given more time to prepare, this transformation will still have an effect on the medical coding professional from a morale perspective, let’s face it – do coders know ICD-9 or what? Most have ICD-9 memorized so change will be a very new condition for the medical coder to deal with.
Steps to mitigate morale issues should be reviewed and/or introduced to minimize pushback and employee attrition. Skilled coding professionals are needed in the industry, they are valuable and the ICD-10 language barrier is one that requires specific steps to maintain medical coder involvement.
Having worked as a coder for many years, I can attest to the following as ways of boosting morale:
Guest post by Michele Hibbert-Iacobacci, vice president of information management and client services, Mitchell International.
Seamlessly integrate ICD-10? How is that possible? Realistically, yes, ICD-10 is new and the United States will start to utilize the new code set effective October 1, 2014.
Is ICD-10 really new, though? Not really, and frankly many entities are so ready they are looking forward to ICD-11, which has a “who knows when” implementation timeframe.
Seamless integration of anything takes preparation. The best part of ICD-10 is that covered entities have started and stopped implementations twice prior to the impending October 1, 2014 effective date. In fact, we almost had a third postponement with proposed federal legislation called the “Costly Codes Act,” which today has a two percent chance of making it to committee and zero percent chance of passing. This bill has more than 35 sponsors, so it’s amazing that we are seven months from implementation and this type of delay is still being contemplated.
It’s likely the sponsors are not aware of where ICD-10 has been and where it is going. The 2014 implementation date was postponed because of providers not being ready for the program. A third postponement would be devastating to the entities that have prepared for all three implementation dates.
As most healthcare professionals know, an important step in the improvement of healthcare quality and cost will take place in October 2014, just under a year from now. This important step is the transition from ICD-9 to ICD-10 – with this new code set, the largest financial system change will take place since the Prospective Payment System (PPS) in 1983.
This change has to take place for several reasons including that with a maximum of 13,000 codes, ICD-9 is not specific enough for detailed diagnoses and the current codes do not reflect new services and technology in CMS payment systems. With more than 171,000 codes, ICD-10 will provide much more detailed clinical pictures and data, improving accuracy in all aspects of patient care. New data available through ICD-10 will help determine public health needs and identify trends, as well as helping to spot bioterrorism and epidemics.
The transition will not only impact healthcare organizations, but also physicians, for whom it will be particularly beneficial. Physicians will be able to determine the severity of illnesses more clearly, and, therefore, quantify the level of care more accurately. The codes will also create an electronic trail of documentation, which can help physicians receive proper payment and ensure their reputation remains in good standing.
With the importance and significance of this transition, it is crucial that ample preparations are made. However, there are many organizations that have not yet embarked on the road to preparedness and many concerns exist throughout the industry. For example, according to a survey conducted by the MGMA-ACPME of 1,200 office-based practices surveyed, approximately 70 percent of respondents were very concerned about expected loss of clinician productivity and the same percentage was very concerned about changes to clinical documentation. 71 percent surveyed responded that, in order to accommodate ICD-10, their EHR systems either were upgraded or still need to be upgraded, will need to be replaced, or they are unsure which. Only 0.6 percent had tested their EHRs for ICD-10 compliance.
Guest post by Jonathan A. Handler, MD, FACEP and chief medical information officer for M*Modal.
The U.S. Government officially recognizes that filling out paperwork is expensive. The most costly paperwork requires us to measure and report information – like our yearly income. If you have ever filled out a government form, you may have noticed that it provides an estimated cost to complete.
For example, the simplest “EZ” income tax form will cost each taxpayer an average of four hours and $40 (http://goo.gl/C6ra — page 41). This is a result of the Paperwork Reduction Act, which requires the government to reduce the paperwork burden on the public and publish the estimated cost of completing each form. However, the Paperwork Reduction Act may have a loophole, because it seems to be limited to government documents.
The government creates a tremendous documentation burden on healthcare providers that appears to fall outside the scope of the Act. In 2014, new government requirements will increase that workload dramatically even as reimbursement drops. Since we do not have consensus on how to address these changes without sacrificing patient care, I believe a key trend in 2014 will be “Managing the Cost of Measuring Care.”
Clinicians are already at the breaking point in the time they spend on documentation and care measurement. This year, regulations demand more than ever. The move to ICD-10 significantly increases the cost of choosing the right billing code because ICD-10 is more complex and about eight times bigger than ICD-9. Stage 2 of the government’s meaningful use program requires clinicians to record more patient information in structured form, to report clinical quality measures, to perform medication reconciliation, and much more. The Two-Midnight rule requires physicians to anticipate when an admitted patient will need to stay in the hospital longer than “two midnights” and justify that in writing.
The casualty claim arena involves evaluating and payment of claims for claimants who have suffered from an auto accident or workers’ compensation injury. This side of the health payment continuum has been omitted from the Health Insurance Portability and Accountability Act (HIPAA) as a covered entity.
This means that casualty claim insurers are not required to abide by the standards set forth in HIPAA and that these standards only apply to the health payer. Omitting the ICD-10 in casualty claims from standards does have merit, but when it comes to standardization, all health claims should be adjudicated and paid in the same manner. Why should a provider charge differently and be paid differently when the payer of the claim is not on the health side? This is a question many casualty payers ask and not being part of the standardization only raises the question more.
There is no option for submission of claims by the covered entity to not be compliant by October 1, 2014 with the International Classification of Diseases, 10 Revision (ICD-10). Why is it a good idea to omit the casualty payer from these standards if the majority of health payments are made using this new standard? In addition, if providers are covered entities, then why would the casualty payer not speak the same code language? It’s almost like trying to communicate in a foreign country without the benefit of knowing the language.
