Getting ICD-10 right will have a direct effect on providers' bottom line, but "the real impact comes…from coding accurately to properly reflect the severity and condition of the patient…That is so much of what value-based arrangements are based on these days," says one health plan executive.
After years of delays, the healthcare industry is finally making the transition to ICD-10 on Thursday. I've spoken recently with executives at four health plans about the long-awaited, long-dreaded shift to the new coding protocol. Here are the top five things they want providers to know:
1.There is Still Time to Prepare
Stacie Watson |
Although the go-live date for ICD-10 is October 1, provider organizations that have not already trained staff and updated their computer systems sufficiently can use the grace period that is built into every payer contract to get up to speed before filing claims, says Stacie Watson, head of the ICD-10 program management office at Hartford, CT-based insurer Aetna.
ICD-10: A Checklist for Implementation Readiness
Most payer contracts define "timely filing" as being anywhere from 90 to 120 days, Watson says, meaning that providers can hold claims for three to four months as they enhance their readiness.
"CMS requires transactions to be coded in ICD-10 as of October 1, 2015. Because CMS requires that, we and most payers will require it. If a provider is not ready, they are likely to send in a claim and have it rejected. That said, it is still possible after October 1 to get systems updated and make sure coders are ready," she says.
Because of the ongoing nature of ICD-10, it is worthwhile for providers who don't feel they are completely ready to invest in more training and education, agrees Jack C. Randolph, president of Paramount, the health plan affiliate of ProMedica, a Toledo, OH-based integrated delivery network.
"It is late in the game, but there are a lot of training scenarios available through professional associations, and providers can still bolster their training activities," Randolph says.
"This isn't going to be like Y2K where it is just an issue on day one. It's not like on October 1, we are going to see if something happens and if it doesn't, then everything is fine… Physicians are going to need to code this way two months from now, three months from now, six months from now."
2. Correct Coding Can Prevent an Increase in Denials
While some hospital leaders may be concerned about experiencing an uptick in their denial rates due to ICD-10, Aetna's Watson does not expect that to be the case.
"We didn't see any evidence of that in any of the testing we did. We did internal testing where we compared outcomes from claims coded in 9 to those coded in 10. Then we did external testing, and it doesn't appear that just by the nature of ICD-10 coding that we will see an impact on denials."
Paramount's Randolph says higher denial rates should not occur as long as coding is being done correctly. "To the extent that providers are not coding correctly or are using old ICD-9 codes, there could be denials. But, if they are coding accurately with ICD-10 codes, there won't be any particular reason for a higher level of denials on the part of payers."
Jack C. Randolph |
3. Documentation Must Support Code Selection
Along with having the right code, providers will also need to make sure they are providing detailed documentation in order to prevent a denial, says Holly Perzy, MD, executive director at MetroHealth Select, the health plan division of Cleveland-based MetroHealth System.
"Not having something coded correctly is an important factor [in denials], but physicians also need to be making sure the documentation supports the way it is coded," says Perzy, who also serves as MetroHealth's vice president of care delivery and practices medicine about 30% of the time.
CMS: No ICD-10 Audit Claims for Specificity in Year One
Holly Perzy, MD |
"I can write a generic note, but when I code it, it has to be much more specific, and the documentation, obviously, has to support the code that has been chosen, which isn't new, but the extent of the depth and breadth of the knowledge required by ICD-10 is greater."
As providers and payers work through the documentation challenges created by the transition to ICD-10, it will be important for both sides to communicate well with each other by setting up "enhanced communication lines and pathways," Perzy adds.
"A lot of providers feel that once the patient is gone, they are done with that. But, there are going to be questions about the coding and documentation that only the physicians can answer. My tip to the physician staff is to be patient and be open because you are going to be questioned," she says.
"On the payer side, you should be respectful of the fact that in order to get those answers, you are interrupting the physician. Be patient and set up communication channels so maybe you are not going directly to the physician but to an administrative person instead."
4. Don't Be Overly Afraid of Change
One of the biggest challenges for healthcare organizations is to overcome the fear of change that is surrounding the transition to ICD-10, says Inderpal Chhabra, MD, a medical director at CareConnect, the health plan division of North Shore-LIJ Health System, (soon to be renamed Northwell Health) based in Great Neck, NY. Chhabra, who is also the president of Lefferts Medical Associates, is leading the ICD-10 efforts at North Shore LIJ.
"No one likes change, and no one likes the idea of ICD-10. For the past many years, the provider community has been bombarded with negative perceptions about ICD-10 because of all the additional codes or the weird examples of codes that people are giving. That is what they are exposed to," Chhabra says.
Inderpal Chhabra, MD |
"We have been through this recently when people were asked to implement computers in their offices. It was the same doomsday scenario where everyone was saying, 'The sky is falling,' or 'The hospital is trying to control us.' If I ask those same colleagues now about going back to a paper system, everyone would say 'No.' This is the same exact thing."
Instead of dreading the change, Chhabra suggests that providers look at the positive side of ICD-10: the added patient information that will be collected and can help physicians provide better care.
"We get a much clearer picture of what is going on with the patient... We see patients with tiny little nuances every day and the current codes don't really capture the full condition of the patient. And on the health plan side, the data points that payers are looking for are in those details, which can be captured now in ICD-10."
5. It's Not Just an IT Conversion
While shifting to ICD-10 requires a new approach to capturing data, provider organizations should not think of it as merely a systems upgrade, says Paramount's Randolph.
"I think the biggest thing is that they shouldn't view this as an IT change. It isn't just about making a technology system change," he says.
"They really need to look at it as an entire business process change and look at all the facets of it from that standpoint with regard to how they operate. The IT change is probably the least significant of the issues, although it is important."
Additionally, getting ICD-10 right will have a direct effect on providers' bottom line, Randolph says, as the healthcare industry continues its evolution toward reimbursement structures built on value instead of volume.
"The real impact comes not as much on the payment for an individual claim, but from coding accurately to properly reflect the severity and condition of the patient that the provider and system is caring for," he says. "That is so much of what value-based arrangements are based on these days."
HealthLeaders Media Webcast: How Health Systems Prep for ICD-10—Physician Alignment, Support and Technology, will be broadcast on Tuesday, October 20, 2015, from 1:00 to 2:00 p.m. ET. Hear from the University of Mississippi Medical Center's chief health information officer as he describes how to overcome the obstacles of implementing ICD-10.