There is currently a plethora of information ranging from mild panic to sheer hysteria over the upcoming ICD-9 to ICD-10 transition mandated for October 1, 2015. Countless webinars, whitepapers, consultants and educational information are being pitched in an effort to capitalize on the uncertainty surrounding such a monumental change in the US healthcare system. The truth is the transition isn’t as “doomsday scenario” as some are making it out to be, but it does have several moving parts and possible significant side-effects that need to be taken into consideration.
What is ICD-10?
If you don’t know already, ICD-10 is the 10th iteration of the World Health Organization’s International Classification of Diseases. The US has been using ICD-9 for decades, but many feel that ICD-9 is just not complete enough anymore. Thus, the Centers for Medicare and Medicaid Services decided to adopt the much broader ICD-10 code set for identifying patient’s conditions. ICD-10-CM has roughly 68,000 codes – about 4 times the number of codes ICD-9-CM. Not only are there more codes, but the codes are completely different. For example, allergic rhinitis is 477.9 in ICD-9 and J30.9 in ICD-10.
The Real Challenge
For decades the US healthcare system has revolved around ICD-9 codes. Everything from labs, insurance companies, worker’s comp, and doctor’s offices use ICD-9 on a daily basis to identify a medical condition. The amount of knowledge, both human and digital, based on ICD-9 is incredibly substantial – and it is all about to be wiped clean and started from scratch. This is the primary challenge of the ICD-10 transition. It isn’t whether your software supports the ICD-10 code set – it is that the entire industry is going to have to reset all of its working knowledge that it has gained from decades of experience. This reality is the primary cause for concern, because while you may successfully prepare for the transition, you will be affected by things outside of your control, such as third party glitches and mass industry confusion. The transition is further complicated by the fact that CMS has decided this is a hard-cutover which means, unlike the ANSI 5010 transition, there is no “transition period” where you can use both ICD-9 and ICD-10 to ramp up your transition. The entire industry will be switching on the same day, resulting in a recipe for chaos likely lasting throughout October 2015.
How to Survive
So what can you do to ensure you are ready for ICD-10? There are a few things – some relate to the third party products you use and some relate to things you can do internally to be better prepared for the things you won’t have control over.
The Software You Use
If you utilize software that uses diagnosis codes, these are the things you should be on the lookout for from your vendor to ensure that the software will be ready to support ICD-10:
The software should allow entry of ICD-10 codes - ICD-10 codes can be longer than ICD-9 and have a different format. Some software hardcode the formatting for ICD-9 and will require an update to even have ICD-10 codes in the system.
You should be able to designate a code as ICD-9 or ICD-10 - You can’t get rid of your ICD-9 codes just yet. They will be required on all information prior to the October 1, 2015 transition date. Your system needs to hold both codes and allow switching between the sets depending on the date of service you are working with.
The software should support up to twelve diagnosis codes - Because of new healthcare legislation and the fact that ICD-10 is much more specific than ICD-9, insurance companies want more than the standard four diagnosis codes per claim that has been used for years. The system should not only allow for the twelve codes at the claim level, but should also allow each line item to have four pointers to provide maximum flexibility.
CMS-1500 form should be updated prior to April 1, 2014 - Even though the transition date to ICD-10 is October 1, 2015, CMS has mandated that the updated CMS-1500 form that accepts twelve diagnosis codes must be used for all claims after April 1, 2014. It is important to note that, while the new form is required, CMS will only accept ICD-9 codes until the ICD-10 effective date of October 1, 2015.
Verify that third party interfaces have been updated - Clearinghouses, insurance companies, and labs, in particular, are changing their systems to accept ICD-10 as well and your vendor should acknowledge that ICD-10 is supported, not only internally, but also when communicating with third party systems.
Organizational Preparation
While it is important that your software support ICD-10 by the transition date, this does not mean you are “ready” for the actual transition. The key to being prepared is understanding the scope of this transition. The entire healthcare “engine” will be changing to new versions of software and data all on the same day. This means that you can be prepared, do everything right, and still have a disruption in cash flow because of problems with payers. One need only look to the ANSI 5010 transition fiasco in 2012 for an example of chaos resulting from industry standard changes. For months providers faced significant delays in payments due to system glitches and confusion due to new edits implemented for ANSI 5010. The switch to ICD-10 is arguably a bigger deal – remember that ANSI 5010 had a transition period, while ICD-10 will not. Also, and this is daunting to think about, but all of the insurance edits and medical necessity data has been rebuilt from the ground up. All the stability gained by years of ICD-9 use is out the window as this completely new code set goes into effect. My prediction is that there will be great delays in payment from the major payers for at least 60 days. This is compounded by the fact that the payers’ support teams will be overwhelmed and, in many cases, unreachable to assist in questions that will get your claims paid in a timely manner.
So what can you do? Here are a few of my recommendations:
Stockpile working capital – Begin October 2015 with money in the bank to provide a cushion in the case of significant payment delays. Plan for the worst by anticipating that payers may take 60 – 90 days to get things straight.
Don’t count your money until it is in the bank – Don’t look at an audit trail with a 100% acceptance rate and think everything is fine. Wait until the remittance comes back – remember that checks for medical necessity don’t happen until the adjudication of the claim happens, so all those “accepted” claims could still result in non-payment.
Know the “timely filing limit” of your payers – Most insurance companies have a timely filing limit where you don’t get paid if the claim isn’t accepted by a specific time limit after the date of service. Some payers have very short windows of only a couple of months after the date of service to get your claim accepted and processed. If the claim is submitted after that time, it will be declined and you will have to write off the entire visit. Know the payers with the shortest timely filing periods and make sure those claims are addressed first when troubleshooting filing problems. Keep in mind that many payers require the claim to be accepted, not just submitted. This is very important during the ICD-10 transition because claims kicked out for failing a payer’s edit have not been “accepted” and therefore haven’t made it to the payer as far as that payer is concerned.
Make sure your staff is educated – Challenge your staff to begin researching and learning about ICD-10 now. Start looking at codes used in your specialty to see how they translate to ICD-10. Begin with the most common codes and work down the list to the more obscure. Remember that you can only control what you have control of – try to limit the internal chaos so you and your staff have more energy to overcome the external chaos.
Conclusion
As you can see, the transition to ICD-10 is a very large undertaking, and while it is important that all your software support it, the biggest challenges lie outside of the technical domain. An entire industry has to relearn classifying patient conditions and the intricacies coding a visit to get it paid by the insurance companies. In addition, everyone is transitioning at the exact same time with no transition period. CMS has stated there will be no more extensions to the deadline, so the only thing you can do is prepare for the possibility that this transition will be as cumbersome as those in the recent past.
References
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Updates
12/15/2014 - Post was revised to reflect the delay from October 1, 2014 to October 1, 2015.