Preparing for a Hurricane That May Blow Over
Physicians must be educated on proper documentation to meet ICD-10 code-set specificity and payer-coverage policies.
Guest commentary from Holly Louie, RN, CHBME, PCS, corporate compliance officer at Practice Management, Inc., in Boise, Idaho
The reimbursement impact of ICD-10 implementation on providers has the potential to be more severe than its proponents suggest. And while we're three years away from go-live on the new coding in October 2013 and 5010 transaction sets will not become mandatory until January 2012, that's not that far away when you consider the magnitude of the changes that have to occur and how it may disrupt your practice.
If implementation is not well-executed, the impact could be catastrophic to providers and their business partners. That's why the Healthcare Billing & Management Association (HBMA) is committed to supporting members and others in this effort, including the creation of an ICD-10 standing committee through 2013.
Representing more than 600 third-party medical billing firms, the non-profit association is collaborating with the public sector and industry stakeholders to develop an ICD-10 implementation structure and resources to help minimize the cost, uncertainly and complexity of the transition to the new diagnostic code set.
The HBMA ICD-10 committee is exploring the following hurdles and finding ways to clear them:
1) True electronic standard. We must have a true electronic standard with the new, requisite ANSI 5010 transition set. Payers must not be allowed to continue the practice of companion guides that permit the proliferation of thousands of different permutations of supposedly standardized transitions. Current health care reform addresses this issue, but whether it will survive the legislative process is unknown.
2) Freeze date. Instead of the annual updating of codes in the fall, CMS must freeze code sets October 2011 until everything is implemented in 2013. This will give practices time for coding retraining and process redesign.
3) Dual-code sets. Because some payers not subject to HIPAA may not convert to ICD-10, physicians will have to decide how to run two parallel systems, depending on the insurance company and the date of service. Systems not capable of that may require new programming or providers to purchase a new system. Variable implementation schedules are also anticipated. HBMA's standing committee suggests rather than taking a "big-bang" approach, practices should schedule several implementation phases with a readiness testing period between each before proceeding.
4) General Equivalency Mapping (GEMS). CMS developed GEMS to map ICD-9 codes to ICD-10 codes, a necessary step given the lack of one-to-one matches. Although the GEMS are available for anyone to use, commercial payers have indicated they will use a similar methodology to map their own crosswalks. The potential requirement for physicians to contend with innumerable, non-published mapping programs has not been addressed. HBMA proposes standardizing the mapping of ICD-9 to ICD-10 so providers know how they will be reimbursed.
Elephant in the room
The current coding system is antiquated and ICD-10 specifies more precisely what services are provided and equipment used. It speaks to quality measures and provides more specific reporting of adverse events so they can be truly measured and tracked and help identify false or fraudulent claims.
Several questions remain unanswered, however. If you don't code to that finest level of specificity, will you still get paid? Which of the mapped codes will be covered by payers? Will unspecified diagnoses still be reimbursed?
The answers to those questions are critical factors in educating physicians on proper documentation to meet the ICD-10 code-set specificity and payer-coverage policies. Potentially, every encounter will need to be coded based on payer-specific guidelines, rather than the authoritative coding conventions. Health records, whether paper or electronic, that include documentation prompts or templates, may require substantial modifications. Superbills that are one page now may require multiple pages to include the applicable ICD-10 codes.
Providers need to know how the transition to ICD-10 will impact their facility by talking to carriers and becoming members of their advisory committees. They must plan for cash flow disruption, if it occurs, during implementation. Providers should be on track in 2010 to do GAP analysis to determine if software programming changes are necessary to meet the new standards and if they can submit claims with all carriers.
Budgets need to be crafted for implementation. The Centers for Medicare & Medicaid Services (CMS) and others conservatively estimate that it will require more than two percent of revenue to convert to the new coding system. Others, such as the Medical Group Management Association, indicate CMS is underestimating the costs and time required to implement this complex new code set.
Physicians need to be involved at a level where they can plan for and minimize cash flow disruptions and avoid lost revenue over and above the cost of implementation.
The United States is among only a handful of countries that will use ICD-10 for not only statistical reporting purposes, but reimbursement. We will be the first country that uses multiple payers vs. a government single-payer system. Because this change is totally untested, there is no way to predict the outcome of implementation.
Providers need to prepare for a hurricane. It could just fizzle out or it might be the next Katrina. The question is: Are you willing to take the risk?
As a member of the Healthcare Billing & Management Association (HBMA), Ms. Louie is chair of the ICD-10 committee and the HBMA ethics & compliance committee.