An Epiphany…of Sorts

What’s Happening?

Everyone working on ICD-10 preparedness in any capacity fits into one of two groups:

  • Group 1 includes those who have thought “I will be so glad when this is done and ICD-10 is all there is!”
  • Group 2 includes those who have not thought this.

Typically, the group in which you find yourself is a direct function of how long you’ve been working on this stuff!

Yet for those in Group 1 – whether you are a provider, a payer, a clearinghouse or a business associate – the distant light of hope shines on Oct. 1, 2013, when ICD-10 becomes law.

Ready or not, here we come – and we will comply!

What Is It?

But there is one small problem … one tiny problem … one teensy-weensy problem … one microscopic, mere wisp of a problem (drum roll):

In case you haven’t heard, not everyone is converting to ICD-10.

Two groups of payers in the industry are unique because they pay claims for which neither the patient nor the patient’s family are financially responsible. Those two payer groups are workers’ compensation plans and motor vehicle liability plans.

Under the former, an employer (or their insurance) is liable for the cost of medical care, and under the latter, an “at-fault” driver (or their insurance) is liable for the cost of vehicle-related damages. And since, in the former case, neither the patient nor their family is liable, our incomparably wise Congress and CMS decided that those patients don’t have the right to privacy afforded by the HIPAA Privacy and Security Rules. Likewise, those insurers can ask for pretty much anything they want, because the HIPAA Transaction Rule doesn’t apply to them either.

Presently there are roughly 500 authorized exceptions to the HIPAA Transaction Rule. That is, CMS has permitted 500 or so variations from the so-called Transaction Rule “standard.” And the biggest exception of all was covered in the original law (drum roll No. 2):

If you are not ultimately responsible for the cost of your medical care,

you have no rights, under HIPAA, related to that care.

What Does It Do?

This part is easy: since the HIPAA Transaction Rule (and its requirement for 5010 and ICD-10) does not apply to workers’ compensation and motor vehicle liability plans, those payers have no real incentive to switch from ICD-9. After all, their historical statistics are in ICD-9; it costs $0.12 to $0.43 per member (estimated) to convert to ICD-10; and honestly, converting from ICD-9 to ICD-10 is expected to be a total pain in the derriere, which only will be exacerbated by the adoption of ICD-11 around the start of the next decade!

If I’m the big boss of California Workers’ Comp or XYZ Car Insurance, I challenge you to give me just one good business reason to go through the ICD-10 conversion hassle. Alas: it can’t be done. We may all think it’s a great idea, but if we look at it objectively, perhaps we’ve decided it’s a good idea only because we have no choice.

What Does it Mean?

Whether you are a covered entity (provider, clearinghouse or payer) or a business associate (vendor, consultant, whatever), this nonsensical situation means only one thing (drum roll No. 3):

You probably will never be fully rid of ICD-9.

Here’s the proverbial bottom line, friends:

You must maintain both systems – coding, billing and collections – because

you have no idea what will be on the next claim that comes in.

Yes, this is a sticky situation, but it’s the plain truth, and it will only get worse. Just imagine: in less than 10 years you may need an encoder that can use ICD-9, ICD-10 or ICD-11 – and you may need to use any of them for any date of service!

Oh my…

Suddenly I have a severe headache. I think I’ll go take a half-dozen aspirin and a double shot of something strong.

Until next time…

About the Author

Billy K. Richburg, M.S., FHFMA is HFMA-Certified in Accounting and Finance, Patient Accounting and Managed Care. Bill has held positions including CEO, COO, CFO, and CIO in hospitals ranging from 75 beds to over 300 beds. Bill is a Board Member of the Lone Star Chapter, HFMA, and is Director of Government Programs for the Revenue Cycle Technologies business segment of MedAssets, Inc. His office is in Plano, Texas.

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