Sitting in the audience at the June 10 National Committee on Vital Health Statistics (NCVHS) quarterly Subcommittee on Standards meeting, I listened attentively to the wide range of presentations on the effect the ICD-10 delay has had (and will have) on the healthcare industry. As I listened to testimony, I was struck by the opposing opinions.
Starting off the discussion was Rhonda Buckholtz, vice president of ICD-10 education and training for the AAPC, speaking on what the delay means for medical coders and billers. Surveying its membership, the AAPC found that 50 percent of respondents decided to slow down their timelines because of the delay (which was unfortunate, since 70 percent of them were ready to test). What will it take to make sure another delay won’t happen again? Buckholtz set the mantra for the rest of the speakers: make sure the vendors are ready, engage in positive messaging, convince opposition groups thatICD-10 is necessary, conduct end-to-end testing, and build up credibility regarding the Oct. 1, 2015 implementation date. AAPC also asked for a code set freeze of ICD-10-CM. For more on Buckholtz’s presentation, go online to http://ncvhs.hhs.gov/140610p45.pdf.
Next up was Jim Daley, chairman of the Workgroup for Electronic Data Interchange (WEDI) and director of IT risk and compliance for Blue Cross Blue Shield of South Carolina, who briefed the committee on the WEDI Emergency ICD-10 Summit. The most important takeaways from his testimony were the outcomes from that meeting, which fell into three categories. First was communication and collaboration, including building credibility around a new test date, communicating Medicare and Medicaid readiness, conveying a more positive message, focusing provider education on clinical documentation improvement (CDI), re-energizing the RECs, expanding communication and messaging, and targeting outreach to non-covered entities. Second was testing and tracking, with encouragement to expand Medicare and Medicaid testing and quickly disseminate results; to encourage an effective private sector testing process; to consider conducting or supporting limited pilots; to establish clear milestones and metrics; to track readiness and share transparency; and to support the PMS accreditation program. Finally, there were several other considerations, with the suggestion that providers assess financial impacts of the delay, identify contingency measures, and support WEDI’s outreach efforts. Daley’s full presentation can be found online at http://ncvhs.hhs.gov/140610p36.pdf.
The Centers for Medicare & Medicaid Services (CMS) was well-represented at the meeting by Denesecia Green, ICD-10 program lead for the agency; John Evangelist, director of the Business Applications Management Group in the Office of Information Services; Diane Kovach, director of the Medicare Provider Billing Group; and Godwin Odia, lead of the State Medicaid Programs ICD-10 Implementation Centers. Green noted the number of weekly calls she is having with various stakeholders (including Cooperative Exchange members) to update what’s going on at CMS and to solicit ideas. She wanted everyone to know that the decision not to go ahead with end-to-ending was not a cancellation, just a postponement. The agency fully expects to set testing dates once the final rule (and date) has been released. Odia briefed everyone on the work his team is doing on targeted state Medicaid agencies’ (SMAs’) implementation assistance. As was already pointed out, there were costs related to staffing and funding that contributed to the delay. He noted that postponement had cascading impacts to internal ICD-10 projects and to external stakeholders. This was especially true in the loss of trained project personnel through reassignment or attrition, with a cost estimate of up to $14.5 million. That being said, SMAs are not halting their ICD-10 project activity, but rather conducting targeted SMA implementation assistance, focusing on territories and optimizing implementation, including by working with worker’s compensation programs. Odia’s full presentation can be found online at http://ncvhs.hhs.gov/140610p44.pdf.
Holly Louie, chair of the Healthcare Billing and Management Association (HBMA) ICD-10 Committee, focused on the opportunities the delay is offering to the industry. “We have the opportunity, over the next 18 months, to robustly test all of the documentation, coding methodologies, practice management systems, interfaces and adjudication systems affected by this change,” she said. “In other words, we can have 18 months of end-to-end testing.”
An HBMA member survey showed only a 62 percent success rate for the CMS testing conducted in March. This was different from CMS’s findings indicating an 89 percent success rate. HBMA also recommended addressing the credibility issue, asking payers to publish and then freeze their coverage policies, conducting nothing less than full end-to-end testing now (not in 2015), and that CMS reach out to other organizations and industry stakeholders to solicit help (and, as with meaningful use, to offer financial incentives). Louie’s full testimony can be found online at http://ncvhs.hhs.gov/140610p37.pdf.
Sue Bowman, senior director of coding policy and compliance for the American Health Information Management Association (AHIMA), spoke on the delay’s effect on training.
“Further delay would necessitate that much of that training and setup investment be repeated, greatly increasing the overall costs of systems conversion,” she said. “Significant costs will also be incurred to maintain ICD-10 coding skills for staff who have already received training.”
Bowman was the first to address the issue of why it is important to convert from ICD-9.
“Significant ongoing costs are being incurred because of the failure to replace the ICD-9-CM code set,” she said. Bowman further noted that continued use of the out-of-date and imprecise ICD-9-CM code set will result in costs associated with inaccurate decisions or conclusions (including those pertaining to healthcare delivery, reimbursement, research, or performance) based on faulty or imprecise data; administrative inefficiencies due to reliance on manual processes; coding errors related to code ambiguity and outdated terminology; and worsening imprecision in the ICD-9-CM code set due to the inability of the code structure to adequately accommodate requested modifications, exacerbated by the partial code freeze that has been in effect since 2011. Her recommendations centered on what CMS can do to communicate with stakeholders, Congress, and the White House on the importance of ICD-10; training, education and technical assistance, including the development of customized resources, to help at-risk constituencies; and the notion that all stakeholders stay the course and continue end-to-end testing. Bowman’s full testimony can be found online at http://ncvhs.hhs.gov/140610p38.pdf.
John Powers, chief administrative information officer at Beth Israel Medical Center (BIDMC) in Boston said that the delay caused his ICD-10 team to lose momentum and postpone further work until 2015, but he also found that “the positive aspects of the March 31, 2014 delay outweighed the negative.” By this he meant that BIDMC could defer some recurring costs and devote more time to improving clinical documentation so that it can become compatible with ICD-10. But it was the cost of implementation ($2.4 million to date) and recurring costs ($3.3 million annually) for coding staff, software upgrades, and maintenance, training, and education that caused him to question the ROI of ICD-10.
“At least from my viewpoint, ICD-10 has few supporters amongst practicing physicians,” Powers said. “BIDMC has over 2,500 physicians on staff, and I have yet to encounter one that believes ICD-10 will benefit them or their patients.”
Powers recommended to the committee that ICD-10 be promoted for disease classification, with less emphasis on reimbursement issues. His full testimony can be found online at http://ncvhs.hhs.gov/140610p39.pdf.
In keeping the emphasis on the provider community, Nancy Spector, director for electronic medical systems for the American Medical Association (AMA), spoke next. She reiterated the AMA’s policy position to stop the implementation of ICD-10. The AMA is concerned by ICD-10 implementation costs, financial risks to practices during transition, industry preparedness, and divergence from important initiatives such as meaningful use and PQRS. Spector recommend providing financial compensation to physician practices for implementing ICD-10 by the compliance deadline. This could be done either through partial coverage of costs or tax credits, or by decreasing penalties in other programs. Other recommendations included developing industrywide contingency plans for ICD-10 issues during the transition period and for CMS to establish more flexible guidelines on its Medicare advance payment policy. All payers, including Medicare, should reinstate end-to-end testing as soon as possible and widely publicize the results of testing in a timely manner, she added. Spector’s full presentation can be found online at http://ncvhs.hhs.gov/140610p40.pdf.
Rounding out the testimony was Sid Hebert, ICD-10 program director for Humana Inc., speaking on behalf of the America’s Health Insurance Plans (AHIP). His message: Full steam ahead!
“The health insurance industry remains committed to the implementation of ICD-10, which will allow practitioners to identify and report conditions and condition management in more specific ways that will lead to more effective measurements of quality and outcomes,” he said, citing the amount of money that has been spent to date getting ready for ICD-10 and the two delays, which have caused additional expenses for the industry.
Hebert spoke on not relying solely on CMS to ensure industry readiness in 2015, but instead how all healthcare stakeholders can collaborate with CMS to ensure a smooth transition. This collaboration is dependent on five things, he suggested: a focus on provider concerns and readiness; vendor readiness; ongoing support for implementers; a realistic implementation approach; and testing. Hebert’s full testimony can be found online at http://ncvhs.hhs.gov/140610p41.pdf.
Testimony seemed to be all over the place regarding the implementation of ICD-10. There were those organizations that don’t see the ROI of ICD-10, and those that see significant ongoing costs being incurred because of the failure to replace out-of-date and imprecise ICD-9-CM codes. There are those who have to be convinced to move forward, and those who are moving forward regardless. I heard those who testified that this delay wasted dollars and time, and those who testified that the delay was a relief.
While there were disagreements, many of the speakers were on the same page when it came to solutions. There must be end-to-end testing, and testing must accurately represent a live claim environment. Many speakers cited credibility issues resulting from the delay. The industry needs certainty (or as much certainty as can be provided) that the Oct. 1, 2015 date is real, otherwise stakeholders will not move forward.
We need to establish realistic and enforceable interim milestones while continuing to focus on clinical documentation improvement initiatives.
And finally, provider and vendor readiness must be addressed. I just hope we’re not testifying about the same matters before NCVHS this time next year!
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Tim McMullen is executive director of the Healthcare Administrative Technology Association (HATA).
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This article was contributed to by Chris Bruns, product manager, Medinformatix, email@example.com; Eric Crist, CEO, PracticeAdmin, firstname.lastname@example.org; Buddy Claborn, CEO, HealthPac, BDC@healthpac.net; Ana Croxton, VP, EDI products and services, NextGen, email@example.com; Patrick Hall, EVP business services, e-MDs, firstname.lastname@example.org; and edited by Sherri Dumford, president, Three Bridges Consulting.