ICD-10 Testing: Medical Practices Lagging

“He who hesitates is lost.”

The origin of that centuries old proverb is open to conjecture, but its accuracy is unquestioned. In other words, spend too much time deliberating on implementing one strategy and you lose the chance to do anything.

And according to results of a recent survey by the American Health Information Management Association and eHealth Initiative, physician practices may be pushing the envelope a bit too far in testing the proverb’s veracity.

For example, the survey found that only 41% of physician practices have trained staff on using ICD-10 compared with 85% of hospitals.

Those results are not surprising to Pam Klugman, co-founder and chief products officer for Clear Vision Information Systems. She points out that, “The more complex an organization is, the more familiar they are with planning things. And as a result, they’re more aware of what it takes to change direction on a bigger ship than on a small dingy.”

So, where does that leave smaller physician practices?

Historic Undertaking

ICD-10 implementation is quite possibly the biggest healthcare information transformation in modern history. The switch from ICD-9, which has been postponed several times and is now scheduled to start on Oct. 1, 2015, involves moving from a system with fewer than 20,000 codes to one with more than 150,000 codes. That’s huge.

So what are physician practices waiting for? Klugman says she’s confident that “most organizations are doing as much as they can to become compliant, and that everyone is doing something.” But she also understands why in many cases testing is lagging.

“The two biggest factors, in my opinion, are uncertainty and cost,” she explains. “They’ve gone through this two years in a row. And they’ve spent a lot of money getting ready two years in a row. So to test again, and to spend again, they’re willing to wait and see if this is really going to happen on Oct. 1.”

That casual attitude could be a detriment if practices did nothing the prior two years to prepare for the transition. But Klugman believes most healthcare entities did at least some measure of preparation. As such, when Oct. 1 arrives, they can simply dust off what they’ve previously done and proceed from there.

Guarded Leeway

To help providers get ready for ICD-10, and perhaps to ease many concerns, the Centers for Medicare and Medicaid Services recently announced that, while “diagnosis coding to the correct level of specificity is the goal for all claims,” it will not deny a claim for 12 months after ICD-10 implementation if it is not to the highest level of specificity.

That doesn’t mean CMS is going to reimburse for mistakes. Klugman said providers must use the correct ICD-10 codes in order to get paid, even if it's just the family code. (see correction below)

"And that’s exactly in line with what CMS did in the initial years of risk adjustment for the Medicare managed care organizations," she said, "because it would risk adjust family codes, and then slowly, as HIPAA became the law of the land, you had to have the higher level of specificity.”

The potential negative impact here, Klugman says, is if the provider community interprets CMS’s flexibility as a means for extending the time that they have to fully implement to the highest level of specificity.

“It’s like an on ramp to the freeway,” she says of the CMS grace period. “You want to get onto the on ramp and get into the flow of traffic as fast as you can. You don’t want to just plod along.”

And plodding along, she points out, could have financial ramifications.

“A family code may not reimburse as high as a higher level of specificity, or tied to a higher procedure code in terms of time,” she says. “Providers have to consider the impact to their reimbursement.”

In addition, Klugman points out that the grace period only pertains to CMS.

“What about other payers who say hey, you have to be to the highest level of specificity,” she says. “They may also need those higher codes to meet the local and national coverage determination requirements aside from Medicare.”

Action to Take

Klugman says that medical practices that have yet to begin testing, or have done little testing, need to, at the very least, begin training their staff.

“They need to go to the CMS website on ICD-10,” she says. “There’s a lot of training material there. If they don’t have the money to bring somebody in to help them do it, there’s a lot of self-help information.

Gina Stassi, vice president of marketing and business development for Clear Vision, adds an important consideration.

“Don’t think that the implementation ends Oct. 1,” she says. “It’s very important for any practice to be vigilant in October, November, and December with any vendor partner. Make sure that with all their transactions, anything that has ICD-10, has gone through the way it is expected to.”

*Correction: An earlier version of this article incorrectly stated that claims would be paid if they had the correct ICD-9 coding. The article has been updated to corect the error.