MGMA is "extremely concerned" that Medicare has announced it will not be conducting ICD-10 end-to-end testing with external trading partners, including physician practices, says the group's CEO.
This article originally appeared in Managed Care Contracting & Reimbursement Advisor, October 2013.
CMS is moving forward with the switch to ICD-10 whether you're ready or not, and it won't test the system before putting your revenue at risk. That decision to go forward without testing how the new process works for physicians is being criticized as hasty and risky.
CMS recently posted a statement on its website saying, "Medicare does not plan to pursue testing of Medicare fee-for-service (FFS) claims directly with providers for ICD-10 at this time. The Centers for Medicare & Medicaid Services (CMS) feels confident that the current level of testing that is done each quarter for any changes to the Medicare claims processing systems is effective to ensure that claims will be processed properly and that ICD-10 diagnosis codes will be accepted and claims will be processed correctly."
See Also: Failing to Prep for ICD-10 Will Cost You
The CMS decision could have disastrous results, says Robert Tennant, MA, senior policy advisor at MGMA.
"The entire industry is going be vectoring toward October 2014 with no guarantee that physician services are going to be paid," he says. "The potential for catastrophic backlogs of Medicare claims is extremely high."
Medical Group Management Association President and CEO Susan L. Turney, MD, MS, FACMPE, FACP, wrote recently to HHS Secretary Kathleen Sebelius to protest the decision. The group is "extremely concerned with the Medicare announcement that it will not be conducting ICD-10 end-to-end testing with external trading partners, including physician practices," she wrote. "We strongly urge that you immediately reverse this policy and expedite Medicare ICD-10 end-to-end testing. This action would decrease the potential of a catastrophic back-log of Medicare claims following the Oct. 1, 2014 compliance date. Failure to do so could result in significant cash flow disruption for physicians and their practices, and serious access to care issues for Medicare patients."
Turney went on to say, "This deviation from the traditional Medicare testing policy and inconsistent messaging have sharply increased the apprehension that physician practices already feel regarding the implementation of ICD-10."
CMS officials have expressed surprise that anyone even expected ICD-10 to be tested with physicians before implementation, Tennant says. At the same time, however, CMS is requiring that state Medicaid agencies test the system with providers.
"The reason why this is important is that 5010 was a technical issue. If you had the right format for the claim, chances were you going to get paid," he explains. "With ICD-10, two types of testing are required. There's the technical question of whether you are able to insert the ICD-10 code on the claim. But then there's the question of whether they will pay the claim with that code."
The payer may accept a given claim because the technical parameters are met-i.e., the code is a valid and properly entered ICD-10 code. But there is no guarantee that the claim will be paid at the rate the provider expects, Tennant notes. Testing would help spot those problems early enough to avoid a financial hit for the physician.
"We have to know if, on the technical side, CMS is able to accept Medicare claims with ICD-10 codes, and if the code submitted by the provider is appropriate and will be reimbursed by CMS," he says. "It is critical that CMS be out front and lead the industry. If they choose not to test, what message does that send to the large commercial health plans?"
Industry pressure could convince CMS to reverse its decision and do some end-to-end testing prior to the regulatory deadline, says Kari Hutchison, RN, senior advisor at Impact Advisors, a healthcare information technology consulting firm in Naperville, Ill.
"Essentially, CMS is saying their file format, readjusted for 5010, is able to accept seven characters in an alphanumeric structure and they completed this testing along with that previous effort, so they are ready to go," she says. "They are saying it is up to the health systems, hospitals, and physician practices to ensure they can send the data in that format and they are ready to accept it."
Many payers and clearinghouses are looking for early adopters of ICD-10 who can test now, Hutchison notes. If organizations are late to the game, they may not be able to test with all their payers due to the volume these payers would be receiving. So if organizations want to test end-to-end, they should get started early, she says.
"To be fair, almost every healthcare provider in the country would want to test with CMS," she notes. "The management of that volume of test claims would almost become unmanageable, and if they were to select only a few to test with, how would they make that selection?"
One solution could be a time deadline for testing with providers that are ready prior to a certain date, or randomly selected different types of providers, she says. Hutchison points out, however, that while some testing might provide peace of mind for industry providers, it would not allay all fears about the ICD-10 transition. Testing with CMS may not be the best trial since every practice is set up differently and uses a different EHR vendor, interface, and file format, she says.
Still, healthcare providers are beginning to update their systems and perform their own testing. "This is a huge undertaking. They plan to test with every payer and every downstream system in an end-to-end format. CMS's announcement has gone significantly against the grain of this type of project approach," Hutchison says. "CMS is one of the largest payers for many organizations and independent practices across the country. If providers are performing testing with all their payers, there would be some significant discomfort with the fact that these organizations are unable to do end-to-end testing with a huge portion of their income."
Additionally, organizations around the country also want to ensure CMS is able to turn claims around quickly and provide the same level and speed of reimbursement they expect, she says.
"Organizations and providers alike are already worried about internal productivity and getting timely clean claims out the door with few denials," Hutchison says. "The unknown of a major payer being potentially unable to read/process a claim due to insufficient testing I'm sure weighs heavily."