We’re seeing a lot of pushback against ICD-10 implementation, with the American Medical Association’s “vigorous opposition” at the extreme. Gloom and doom types equate to potential IT disaster to Y2K. Ever since watching T. Bedirhan Üstün, M.D. — curator of the International Classification of Diseases, the master coding set from which ICD-10 is derived – present at the American Health Information Managers (AHIMA) annual meeting last October, a question’s been gnawing at me:
If flipping the switch on ICD-10 come Oct. 1, 2013 will be such a disaster as groups like the AMA claim it will be, then why didn’t it bring down the European and Asian health systems that implemented their own flavors of ICD-10 years ago?
The reporter in me – especially when hearing people couch ICD-10 in terms like “unfunded mandate” and “sky-is-falling” hyperbole – suspects it’s all about politics. During the course of debate in these times, it seems as if people on both the left and right resort to browbeating rhetoric faster than I’ve ever seen in my life. And why not? Reciting the catchphrase du jour requires far less reasoning than a well-constructed, original thought.
“Political rhetoric is exaggerating the ICD-10 issue” is just my hypothesis. Are there any actual IT reasons transcending the theoretical that might concern us about ICD-10? On what basis should the pragmatic, budget-driven CIO planning for ICD-10 involve more than just the usual software upgrade hassle? I’ve posed this question to several experts. Everyone gave me vague theories about what could possibly happen, without actually committing to an actual opinion based on facts.
That is, until I ran into Lonnie Johnson, COO of Zotec Partners, whose company provides business management, coding and revenue cycle analytics services for health care providers, with an emphasis on radiology, anesthesiology and pathology.
His company also created its own medical billing clearinghouse for its physician customers, and conducted extensive, government-mandated HIPAA 5010 testing for electronic transactions with a bevy of payers large and small in advance of this week’s implementation deadline. HIPAA 5010 is a precursor to ICD-10, in that it paves the way for ICD-10 coded claims and reimbursements to flow between hospitals and payers because it adds more data fields to accommodate the more documentation-intensive coding language. The previous standard, 4010, couldn’t do that.
In short: As HIPAA 5010 implementation goes, so goes ICD-10, albeit on a much smaller scale because 5010’s confined mainly to billing and revenue-cycle management software and won’t run the whole gamut of clinical information systems that ICD-10 will.
Johnson’s got a ground-level view of how ICD-10 implementation might work, having tested 5010. Even though Zotec ironed out the HIPAA 5010 bugs with many payers and confirmed its various transactions worked, he’s still worried about bumps in the road as payers update, tweak and troubleshoot their systems for 5010 compliance. He’s not an analyst, consultant, industry observer or agenda-driven association rep; instead, cold, hard business reasons drive his interest in 5010 and ICD-10.
He sees potential difficulties for ICD-10 implementation, more in the United States than the rest of the world, because of our health system’s scale. He suggests that, because other countries have many fewer payers – in some cases, a single payer – flipping the switch from ICD-9 to ICD-10 was probably more straightforward. The U.S. health care system’s mishmash of public, private and mixed insurance carriers poses a much more complex implementation puzzle.
“Here, we’ve got multiple payers, with multiple levels of understanding — and intricacy of systems that are nonstandard for the most part,” Johnson said. “So the ability for all the payers that we deal with to [implement] ICD-10 consistently – that’s where the challenge comes in.”
Large payers were on the ball with HIPAA 5010 compliance, Johnson said, and conducted more robust testing than smaller commercial plans. The latter still worry him – will technical glitches negatively affect his customers’ revenue streams? He’s already advising his customers to plan on disruptions. ICD-10, because it affects more systems for health care providers than 5010, could be more glitch-ridden. That makes sense. Actual IT reasons to worry about.
Note: Johnson’s neither opposing ICD-10 nor predicting gloom and doom. Not at all. It’s just another business problem to solve, right after payers finally nail down HIPAA 5010 compliance. But if gloom and doom happen to come next year with ICD-10, it’s important to create contingency plans, judging on how HIPAA 5010 went. I’m betting Zotec will.
Don Fluckinger is a features writer for SearchHealthIT.com. This post appeared on its community site, Health IT Exchange.
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Hey, that post leaves me feeling foolish. Kudos to you!
First of all, coding will not be sloppy and inaccurate, unless you are hiring substandard coders. Of course “Docs” don’t see the point, but coders DO. ICD-9 is non-specific, out-of-date, unable to be updated properly, and inadequate. ICD-10 has much, much more detail, particularly in regards to severity of illness! Yes, I can see that affecting patient care and provider effectiveness, mostly for patients with multiple providers or patients in need of transfer. You don’t use ICD-9 to gauge the health of your patients because current Dx codes are not useful or helpful in relaying information to medical personnel…but ICD-10 codes are. Instead of having to flip through pages of dictation, possibly wondering what another provider meant, or being frustrated by lack of documentation, wouldn’t it be helpful to have a list of ICD-10 codes that, literally, tell you in detail what diagnoses the patient has/had?
“I don’t see any contribution to your effectiveness or patient care. Do you?”
Just what I was thinking!
My feeling is that the coding will be so sloppy and inaccurate that it will be of nowhere near reasearch quality.
The real problem with ICD-10 is that the CPT code must be associated with the correct diagnoses to be paid. I am sure there are already algorithms that accomplish this. With modern HIT the increase in codes can easily be handled, and data bases can be purchased for moderate investments. No one is going to be looking up codes in an AMA manual. Even if some practitioners are not coomputerized with EMRs ICD/CPT matches will be available on DVDs and/or USB and HDDs. The challenge will be lack of interoperability, however supposedly ONCHIT standards for interoperabiliiyt should take care of that? Wanna bet?
Umm…. It should work the other way around. First you diagnose then you order a procedure. If you order a CPT and then start hunting for some diagnosis that will pay for it, we are approaching fraud. HIT does not and should not do that automatically. There are programs that identify lack of “medical necessity” after the fact, but I am not aware of anything that will diagnose patients based on CPTs ordered.
The problem here is that docs must pick the ICDs, and where there were a handful of ICD-9 to remember, there will now be hundreds of ICD-10.
I am sure payers will be more than happy to deny everything in site. Remember that most contracts will still be formulated based on ICD-9.
My suggestion would be to have a very nice cash reserve on October 1st 2013.
Most contracts are written to specify how much is paid for each CPT code. Surely the insurers aren’t going to come up with new contracts for each provider with a different payment for each of the 64,000 or so new ICD-10 codes. I’m unclear as to how this will affect payment, as we’ll still be operating with contracts that pay per CPT code only.
Yes, but medical necessity is defined by ICD-9 to your CPT. The crosswalk to ICD-10 is not deterministic enough, so I expect denials to abound. Perhaps not so much in primary care where the CPT list is mostly E&M.
Thanks for the reply. But back to my original question: whom is this change supposed to benefit?
Or maybe payers can obtain better visibility into your practice. For example, I noticed that practically everything has initial encounter, subsequent encounter and sequela. They should be able to fine tune payments, most likely.
I don’t see any contribution to your effectiveness or patient care. Do you?
James has it correct above. Because ICD codes drive reimbursement in the United States, our experience will be dramatically different than the rest of the world where its primary mission is diagnostic categorization.
But even in places like Canada, it did slow down the process. It didn’t break it, but they still struggle compared to pre-ICD-10 days in chart completion.
I predict that at first the struggles will mostly be with mistakes on both sides of the transaction. Once we have acclimated to ICD-10 (say 12-16 months) the payers will begin to figure out how to game against the providers, and with ICD-10 the game board gets much larger.
GM once said we finance and we also happen to sell cars. Cars were just means for GM to finance.
Diagnosis code are also means to finance physician costs that rest have to pay for. We will understand that better after we spend time on money on ICD 10 upgrade.
“If flipping the switch on ICD-10 come Oct. 1, 2013 will be such a disaster as groups like the AMA claim it will be, then why didn’t it bring down the European and Asian health systems that implemented their own flavors of ICD-10 years ago?”
Short answer: We use ICD-9 as the backbone of our payment systems. Others, by and large, do not do so.
I haven’t seen a clear explanation of the benefits of switching to ICD-10, to whom they will accrue, and who will pick up the bill.