IT shops grapple with new healthcare codes for hurled turtles, fiery water skis

Starting Oct. 1, number of descriptive medical codes jumps from 14,000 to 68,000

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The AMA has called for delays in ICD-10's implementation to ensure healthcare providers are ready for the changeover.

"Burdens on physician practices need to be reduced - not created - as we work to get the best value possible for the health care dollar and the nation undertakes significant payment and delivery reforms," Wah said in an email reply to Computerworld.

The AMA is not alone. Brennan said there are many healthcare-industry lobbying groups who see ICD-10 as an unfunded mandate.

The delays, Brennan said, were "a blessing for healthcare providers and healthcare plans in Massachusetts who needed more time to upgrade their claims management systems."

Not everyone agrees. St. Francis Hospital's Christian said the delays have meant he's had to keep IT teams in place that he'd prefer to move on to other technology projects.

"Every time we delay it, we create anxiety. We have IT folks who've been in constant process mode ensuring this is ready to go for years," said Christian, who is also chairman of the College of Healthcare Information Management Executives (CHIME).

"I think we need to pull the Band Aid off and get it over with," Christian added.

Delaying ICD-10's rollout has been costly. The CMS estimated the added costs to healthcare and insurance providers range from 10% to 30% or $1.2 billion to $6.8 billion overall.

"We believe it is important to require implementation of ICD-10 as soon as the law permits because it will allow the industry to begin reaping the benefits of ICD-10 as soon as possible," CMS stated in a report released in August 2014.

The American Health Information Management Association (AHIMA) is also urging Congress to stick to the current deadline.

"The industry has already seen two delays in implementation, and each delay has cost the industry billions of dollars, as well as the untold costs of lost benefits from implementing a more effective code set has shown that the estimated costs, time, and resources required by physician offices to convert to ICD-10 are lower than initially estimated," AHIMA stated in a press release.

ICD-10 graphic American Health Information Management Association

A survey of 454 healthcare decision makers last year revealed the systems they're most concerned ICD-10 will affect.

The first round of Medicare end-to-end testing for ICD-10 coding will take place the week of Jan. 26. Last March, in a pilot test conducted by the CMS, 2,600 participating providers, suppliers, billing companies and clearinghouses (about 5% of all claim submitters in the U.S.) submitted 127,000 claims. The CMS said 89% of the test claims using the new ICD-10 coding were accepted.

ICD-10 benefits

ICD-10's granularity, according to the Centers for Medicare & Medicaid Services (CMS), will improve data capture and analytics of public health surveillance and reporting, national quality reporting, research and data analysis, and provide detailed data to inform health care delivery and health policy decisions.

The new standard also will improve quality measurement and reporting capabilities,  tracking of illnesses and will reflect greater accuracy of reimbursement for medical services.

"ICD-10 codes can be used for data mining to determine how we're doing on specific disease processes," Christian said. "If we get good clear documentation and it's coded with specific data, we can extract that and use analytics on it. You can't use free text data a lot because you can't really understand what the inferences are based on how something's said."

A report released last year by health care consulting firm Nachimson Advisors for the AMA estimated the cost of implementing ICD-10 would range from as little as $56,639 for a small physician practice to as much as $8 million for a large practice.

The AHIMA, however, recently offered a far lower estimate than Nachimson Advisors'. AHIMA said ICD-10 implementation for a small physician practice (three physicians or fewer) should cost from $1,960 to $5,900.

While the rollout of EMRs has been gradual, taking place over three phases (including its own set of delays) and many years, ICD-10 will simply turn on like a light switch. That means, on Sept. 30, providers and payers will be using ICD-9, and on the next day, they'll be using ICD-10.

"That's the thing that makes ICD-10 so terrifying - the one-day cutover," McDermitt said.

At the same time, medical billing filed prior to Oct. 1, will need to continue to be processed with ICD-9 systems after that time.

Between now and Oct. 1, hospital billing systems must be recoded and payer systems must be upgraded to recognize the new ICD-10-compliant claims as readable electronic data interchanges (EDI). Failure of systems to read the claims means hospital billing systems won't receive claim acknowledgements.

It's a complex exchange of data between providers and payers, and ICD-10's medical terminology and coding is completely different from ICD-9.

"It's completely independent of ICD-9. It's like going between two languages, like Spanish and Italian that both share a native root language - Latin - but ICD-10 has a different clinical interpretation of clinical concepts," McDermitt said.

Because ICD-10 is independent from its predecessor, old claim adjudication systems, many based on Cobol, have to be mapped to the new database systems so that data isn't lost in the changeover.

For example, health insurance giant Humana created more than 15,000 maps to run in production so all of its businesses can run in ICD-9 and ICD-10 in parallel for dual processing during the changeover, according to McDermitt.

The risk of not property rolling out ICD-10 is huge and involves the potential loss of billions of dollars.

For example, if a healthcare provider fails to include a medical procedure received by a patient, the provider risks losing revenue, and if a provider's claims system doesn't interface properly with a payer's, it will delay accounts receivables.

So not only do medical backoffices have to recode systems, but finance and operations must as well, Brennan said.

A survey of 454 healthcare employees conducted last year revealed that most are concerned about how IDC-10 will affect accounting and billing (42%), electronic health records (37%), analytics (35%) and the exchange of health information with other facilities (31%).

Of the 454 responses, 32% were from those with management and supervisory roles, 24% were directors and 16% were executives, while clinicians and other titles made up the remaining percentage.

The survey was conducted last June by the American Health Information Management Association, the eHealth Initiative and Edifecs.

Brennan said ICD-10 testing doesn't need to be arduous. Testing with a massive number of real claims is less important than testing with a small number of high impact test claims using rapid cycle times.

"Probably the most valuable lesson we learned, and a real value for all the [test participants], was understanding what they didn't need to do," Brennan said. "If anything, the participants in our program are going into this year with a much more focused and hardened infrastructure for doing what ICD testing remains before October."

Copyright © 2015 IDG Communications, Inc.

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