Can Healthcare Sustain Another $6.8 Billion Dollar Loss?

by Phil C. Solomon on January 22, 2015

in ICD-10,Revenue Cycle Management

ICD-10 QuestionsThis the most insightful and informative article I’ve read so far about the ICD-10 transition. It answers the who, what, and why questions to give the reader a holistic view of the seemingly elusive conversion to ICD-10. We can only wait and see what will happen this year. It’s well worth reading. Phil C. Solomon

Ten Questions about ICD-10

Even though, there has been a substantial amount of information published regarding the implementation of ICD-10 over the last ten years, there are many misconceptions that continue to plague the physician community. Rumors run rampant; some are valid while others are completely unfounded. Frequently we hear the need for change in healthcare, yet resistance to change continues to stifle our ability to move forward. The unknown is a scary place. It is more comfortable to work with an established system that is flawed rather than implement a new, technologically advanced system. Reflecting back several years ago with the implementation of the 5010 HIPAA electronic transactions standard, many organizations were negatively affected because they were not prepared, yet after some adjustments, 5010 is successfully operating behind the scenes with little to no effort. Let’s review ten questions concerning ICD-10 in an attempt to dispel the myths.

Who developed ICD-10?

The World Health Organization (WHO) developed the ICD-10 Clinical Modification (CM) diagnosis coding system. The Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) develops and maintains the US version of ICD-10 CM. All modifications to ICD-10 are required to conform to WHO conventions. The physician community and healthcare industry had extensive input in the development of ICD-10 CM; in fact, much of the clinical detail was a result of the input received from physicians. So why all the resistance if the physicians gave much of the input?

What is the ICD-10 compliance date?

The looming question is “will there be another delay and if so when?” Currently, federal regulations require that ICD-10 codes be utilized for dates of service beginning October 1, 2015; thus, ICD-9 will expire on September 30, 2015. Once again, there has been much discussion regarding a delay of the implementation date. Last year’s delay was a political maneuver that was slipped in at the last minute to appease physicians because of the recurring Sustainable Growth Rate (SGR) issues. The delay surprised the Centers for Medicare and Medicaid Services (CMS), the American Academy of Professional Coders (AAPC), the American Health Information Management Association (AHIMA) and the entire healthcare community. Due to the multiple delays, it is understandable that the healthcare community has lost its confidence in the implementation taking place. As of the time this article is being written, it appears that legislation drafted by Representative Pete Sessions (R-TX) will include a two-year delay of ICD-10 for consideration by Congress.

According to CMS, it is estimated that the last delay cost the healthcare industry approximately $6.8 billion in lost investments, not including the cost associated with missed opportunities for better health data to improve quality of care and patient safety. A recent article in Modern Healthcare noted that “the proposal to delay implementation of ICD-10 diagnostic and procedure codes by an additional two years appears to be going nowhere in the current lame duck session of Congress.” It is recommended that we move forward until and unless we receive definitive information regarding a delay.

Why don’t we wait for ICD-11?

The projected date for the release of ICD-11 is 2017. The US version would then take another two years of revisions prior to release and implementation in 2019 at the earliest. In addition, ICD-11 builds on the concepts of ICD-10; therefore, it would be prudent to implement ICD-10 and become familiar with the new concepts and guidelines before upgrading to ICD-11. Greater diagnosis specificity is going to be necessary prior to 2019.

What is the impact on CPT codes?

The Current Procedural Terminology (CPT) codes will be unaffected by the implementation of ICD-10-CM.

How is ICD-10 implementation related to the Affordable Care Act (ACA)?

The implementation of ICD-10 is not part of the Patient Protection and ACA of 2009. ICD-10 is governed by HIPAA; therefore, it is not related.

Why should we change to ICD-10?

ICD-9-CM is obsolete and no longer able to reflect the many changes in healthcare, i.e., clinical knowledge and medical terminology advancements over the last 40 years. Today’s need for data is very different than it was 40 years ago. ICD-10 includes greater detail that will lead to better justification of medical necessity. Many interested parties anticipate that it will lead to fewer coding errors with fewer rejected claims because the system is more understandably structured and specified. It will be much easier to compare reported codes and check for consistency between diagnosis and procedure codes to identify illogical combinations of diagnoses and reduce opportunities for fraud. Hopefully there will be fewer gray areas.

What are the benefits of ICD-10 CM adoption?

Many physicians view the implementation of ICD-10 as onerous and expensive; there are many benefits that will offset this cost.

  • Improvements in patient outcomes and patient safety through better data for analysis and research
  • Improved ability to manage chronic diseases by better capturing patient populations
  • More accurate reflection of clinical complexity and severity illness in patients
  • Improved ability to identify high-risk patients who require more intensive resources
  • Improved ability to manage population health
  • Improved information sharing, which can enhance treatment accuracy and improve care coordination
  • Enhanced public health surveillance and improvement strategies
  • Improved ability to assess effectiveness and safety of new medical technology
  • Improved administrative efficiencies and lowered costs (e.g., fewer rejected and improper reimbursement claims, decreased demand for submission of medical record documentation) •• Justification of medical necessity
  • More accurate and fair reimbursement
  • More accurate representation of physician performance
  • Increased patient engagement (as a result of access to better data)
  • Validation for reported evaluation and management codes
  • Less misinterpretation by auditors, attorneys and other third parties

Can we just use the crosswalk from ICD-9 to ICD-10?

General Equivalence Maps (GEMs) to convert ICD-9 to ICD-10 should only be used as a guide for coding and not for the actual coding of claims. The code should be confirmed based on the clinical documentation presented. Many physicians find the volume of codes intimidating and the use of a crosswalk may seem to alleviate the stress of learning the whole new code set. Remember, 78 percent of the codes have a 1:1 relationship. This should dispel the fear about the number of ICD-10 CM codes. Laterality (right vs left) also accounts for almost 50 percent of the increase. The remaining 22 percent of codes will have a “one to many” relationship. These are the codes for which the crosswalk may not be applicable because they will need more clinical documentation in order to identify the appropriate ICD-10 CM code.

What about using external cause codes, signs/symptoms and unspecified codes?

As in ICD-9, the reporting of external cause codes has no mandatory requirement for reporting in ICD-10. It is only applicable under certain circumstances. Signs and symptoms, as well as unspecified codes, are also only reported under certain circumstances. It is important to report the code that represents the level of certainty known for that procedure or encounter. If the information is not known or available, then it is acceptable to report the appropriate unspecified code or the signs/symptoms. However, it is inappropriate to code unspecified or signs/symptoms if the information is available to the physician.

Where do we start ICD-10 training for our physicians?

According to AHIMA, the amount of training individual physicians will need is based upon the role they play within their practice. It is recommended that each practice perform an assessment to determine how their current documentation will compare to the documentation necessary to code ICD-10. Once this assessment is complete, the appropriate training for the organization can be determined. For instance, if a physician is doing their own coding, more extensive training will be required than for a physician who is documenting only and using the services of a coder. This assessment may alleviate the anxieties related to the implementation.

The key to a successful ICD-10 implementation is preparation. The time is now. Delaying practice assessment and training in hopes of a delay could potentially affect your cash flow for several months. It is better to be safe than sorry.

Author: Darlene Helmer, CMA, CPC, ACS-AN, CMPE, MBA
Vice President of Provider Education and Training, Anesthesia Business Consultants


References

http://www.AHIMA.org

http://bok.ahima.org/PdfView?oid=300625

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_036866.hcsp?dDocName=bok1_036866%20

http://www.modernhealthcare.com/article/20141208/blog/312059996&utm_source=AltURL&utm_medium=email&utm_campaign=mpdaily

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