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August 2015

Where We Are, Where We're Headed
By Torrey Barnhouse
For The Record
Vol. 27 No. 8 P. 36

As with life, ICD-10 is a journey and not a destination. My hat goes off to all the HIM professionals who have embarked on this trek toward more effective data capture that will enhance research for generations to come. We've endured many challenges along the way, but we've persisted and forged ahead. Here's a look back at several recent milestones and a look to where the profession is headed.

Paving the Way for Progress
HIM professionals breathed a collective sigh of relief as Congress voted on—and ultimately passed—HR 2, the Medicare Access and CHIP Reauthorization Act of 2015, in April. The act, which included no references to ICD-10 delays, essentially drew a more definitive line in the sand in terms of an October 1, 2015, implementation deadline.

The passage of HR 2 has had a significant positive effect on the health care industry as a whole. For starters, it disproves the notion that the industry will skip ICD-10 and move to ICD-11. It also provides HIM professionals with the additional boost of confidence they need to make the next few months successful. In addition, the most recent American Hospital Association (AHA) fact sheet reports that 93% of hospitals "indicate they are moderately to very confident they will be able to report under ICD-10 by October 2015."

HIM professionals should feel proud of the grassroots efforts that made passage of HR 2 possible. For example, AHIMA and the Coalition for ICD-10 mobilized resources and spread the word about the importance of the transition to ICD-10. It couldn't have come at a better time. The April 2014 delay put a damper on ICD-10 progress, but the passage of HR 2 has led to cautious optimism.

However, HIM professionals and ICD-10 backers must continue to advocate for ICD-10. The journey didn't end with HR 2.

Three Bills Cloud the Picture
The legislative saga continued in late April when Rep. Ted Poe proposed HR 2126, which would prohibit Health and Human Services (HHS) from replacing ICD-9 with ICD-10. The good news is that according to govtrack.us, the bill has little chance of being enacted. Rumors of a proposed dual coding period, whereby providers could run ICD-9 and ID-10 codes simultaneously, also circulated but were quickly dismissed by the American Hospital Association and others as "unworkable." However, the rumors proved to be true a few months later.

In July, Reps. Marsha Blackburn and Tom Price proposed HR 3018 that would allow providers to submit codes in both ICD-9 and ICD-10 for a period of six months. This approach, which incorporates dual coding, is designed to give physicians flexibility in addressing systems and reporting issues; however, many HIM professionals feel that a dual-coding approach would jeopardize data quality and cause even more confusion and errors.

In May, Rep. Diane Black proposed HR 2247, which calls for an ICD-10 transition period, but no delay and no dual coding of claims. It proposes "comprehensive, end-to-end testing" by HHS after which the agency would be required to open testing to all providers and suppliers. Thirty days following the completion of universal end-to-end testing, HHS would be required to submit a certification to Congress on whether the ICD-10 standard is "fully functioning." In addition, HR 2247 provides for an 18-month transition period during which no claim submitted to Medicare could be denied solely because of unspecified or inaccurate ICD-10 codes.

Time will tell if and when these new bills advance through the legislature. AHIMA has spoken out against them for a variety of reasons. In particular, it points out that the January end-to-end testing revealed that only 3% of claim denials were caused by ICD-10 coding errors. Ironically, an additional 3% of claims were denied due to ICD-9 coding errors. The April testing found claims denials decreased to 2% for ICD-10 and less than 1% for ICD-9. Providers, suppliers, billing companies, and clearinghouses conducted final testing July 20-24.

Surveys Say … What?
Ongoing and conflicting surveys on industry readiness only serve to confuse the situation, sending lobbyists and ICD-10 opponents straight to Capitol Hill.

The February 2015 ICD-10 survey conducted by the Workgroup for Electronic Data Interchange (WEDI) found that the April 2014 delay had a negative impact on some readiness activities and that many organizations did not take full advantage of the additional time. Instead, organizations most likely reprioritized and tackled other challenges such as meaningful use and EHR implementations. For these organizations, a keen focus on ICD-10 during the next few months should allow them to make great strides toward the October 1 finish line.

It's unclear whether the respondents who participated in an August 2014 survey are the same ones who participated in the February survey. If there are two different sets of participants, the results may not be comparable, leading readers to draw false conclusions. Other notable statistics from the February 2015 WEDI survey include the following:

• The February survey featured more than twice the respondents of the August 2014 survey. The significant increase in the number of respondents indicates that the issue is now "top of mind" for many executives. This bodes well for HIM professionals working hard within their organizations to help make the ICD-10 transition successful.

• Approximately 33% of providers responded that they had completed their impact assessments, a notable decrease from the August 2014 survey in which slightly more than 50% of providers indicated they had completed the assessment. The data may be indicative of the fact that today's assessments are far more intensive than those completed a year or more ago. As providers examine documentation and perform other gap analyses, they may realize that the assessments they thought they could complete in one or two weeks now take a month or more.

• Only 25% of providers have begun external testing. In addition, approximately 25% of providers said they won't test until the second or third quarter of 2015. By this time, the majority of providers and suppliers should have conducted testing. Multiple rounds of testing are ideal to ensure process bottlenecks are remediated. Also, providers should test with as many payers and clearinghouses as possible.

The results of WEDI's final ICD-10 survey are expected to be released sometime this month. In the meantime, other organizations, including the AHA, NueMD, Navicure, and Qualitest, have weighed in on the matter. All of the recent surveys lead to similar findings: Hospitals are the most prepared for ICD-10 while physician practices are the least equipped to meet the October 1, 2015, deadline.

How to Spend the Last Few Months
At many facilities, coder refresher and specialty training continue to be top priorities. Organizations—particularly early adopters—are providing focused ICD-10-PCS training and having coders perform dual coding with existing clinical documentation.

Hospitals are using the remaining time before the deadline to streamline processes, lower denial rates, increase revenue integrity, and mitigate productivity loss. The following are other ongoing national trends:

• Professional development investments. Organizations realize they must invest in their coding staff in order to better address more complex and higher acuity ICD-10 cases as well as to capitalize on the specificity inherent in the new coding system. As a result, education budgets have been extended as organizations remain diligent in finding new strategies to enhance coder knowledge. Even in ICD-9, coder training is an essential element of all HIM budgets.

• Increased collaboration between vendors and providers. The experience deficit of coders and ICD-10 code auditors has led many organizations to deepen relationships with outsourced coding vendors. Requests for total outsourcing (rather than staff augmentation) are on the rise, particularly in organizations without an established remote coding program. According to a Black Book report, 47% of hospitals have added contract coders in 2015 to support dual coding programs and maintain daily discharged not final billed levels. Organizations also are taking the time to secure multiple coding vendors in the event that additional staffing needs arise.

• A move toward offshore coding. With the dawn of value-based purchasing, the HIM industry has become far more quality driven than ever. HIM directors realize that quality coding can be performed efficiently and effectively offshore. Accurate coding is paramount regardless of where it occurs. This trend will continue upon ICD-10's arrival as organizations search for cost-effective ways to enhance quality.

In addition, the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association announced on July 6 that they would embark on a joint venture "to make sure physicians and other providers are ready ahead of the transition to ICD-10 that will happen on October 1." Together, they plan to provide webinars, on-site training, educational articles, and national provider calls each with the intention of making sure that everyone is ready for the transition. In its announcement, CMS also made the following four promises:

• identify an ICD-10 ombudsman;

• ensure that Medicare will not deny claims based solely on the specificity of an ICD-10 diagnosis code as long as the physician uses a valid code from the right family of codes;

• suspend penalties for the Physician Quality Reporting System, value-based payment modifier, or meaningful use stage 2 programs due to unspecified codes; and

• make advance payments available if the Medicare system encounters problems processing ICD-10 claims.

Looking Ahead
From a bird's-eye view, vendors, providers, and payers all have been working diligently on ICD-10 readiness throughout 2015. Coding vendors, in particular, continue to invest heavily in ICD-10 preparations in order to accommodate clients that need support as competing initiatives mount.

The HIM industry has made monumental strides toward ICD-10 implementation. It's worked hard to raise awareness within its various organizations, educating physicians and others about the importance of the new code set and its ability to enhance data quality. Amid ongoing objections and attempted legislative derailments, hopes are high as it appears the industry is back on track and headed full-steam ahead toward October 1.

— Torrey Barnhouse is founder and president of TrustHCS, a firm dedicated to serving the coding auditing, ICD-10 preparation, clinical documentation, and revenue integrity needs of health care organizations.