April 17, 2015

Detours Slow ICD-10 Preparedness

By Holly Louie, RN, BSN

Like the vast majority of revenue cycle companies and many physician practices, our readiness plan for 2015 was well-established early.

More detailed employee education in the first quarter, intensive focus on client needs, more end-to-end testing in the second quarter, intensive dual coding all year, retesting systems for all 2015 programming changes, pushing trading partners and vendors that have not yet announced readiness or testing dates, reviewing contingency plans, and more.

Even though we have been preparing for ICD-10 for several years, it’s still a long list necessary to be sure we are as ready as possible. Everything was right on schedule until February. And then it hit: the detour, stop, and “road out” signs. Suddenly, all our plans had to be put aside to manage the mess so many of us still are dealing with right now. It’s simply not possible to manage the urgent problems and continue preparing for ICD-10 as planned.

What created the mess? Multiple commercial payors and Medicare Part C contractors did not get the 2015 CPT® codes loaded in their systems, so every claim with a new CPT in 2015 was incorrectly denied. Some have still not corrected the problem. One payor had the audacity to indicate that it may not be corrected by June! Some Medicare Part C contractors are processing the new Centers for Medicare & Medicaid Services (CMS) modifiers that replace modifier -59 for certain claims, yet others will not. One Part C contractor asked us to send proof that CMS had established the new modifiers. An inadvertent data entry error for one code combination in the CCI edits created the need to either hold all claims for the first quarter or have them all be denied if submitted as is. A commercial edit program used by numerous payors had programming errors that caused high volumes of claims to incorrectly deny. In general, these types of errors are rectified quarterly, not immediately, and that’s a very long time to wait for payment for legitimate services that were correctly coded.

In addition to the significant negative impact on cash flow, the ripple effect is enormous. Patients don’t understand why the claim was denied and call for information. In addition, patients call inquiring about bills for the services that were held pending corrections. Some patients call reporting that their beneficiary notice indicates that the coding is in error, and that they are concerned the physician is doing something wrong. The number of calls often is far higher than normal, and each one takes more time away from normal business operations. 

All of the incorrect denials require work that is not typical and should not be necessary. There are phone calls to be made, letters to be written, follow-up to be done. Each and every case involves efforts far above and beyond that of the normal course of business work. More importantly, the volume is so staggering for some practices that overtime is necessary. For large practices and companies, that can be shared work. For small physician groups and practices, there are no staffs to share the load. Do you lose all those dollars? Do you incur rapidly escalating costs at the same time your cash flow has stopped or fallen precipitously? 

It is my personal opinion that these problems are 100 percent preventable and completely inexcusable. Annual changes for CPT, as in ICD-9 and soon ICD-10, are predictable. In addition to the onus placed on the physicians and their representatives, there is no recourse or penalty for the payors who fail to abide by the rules.

We, as an industry of stakeholders, must understand that each and every one of these avoidable errors diverts time, people, money, and resources away from ICD-10 preparations. These errors place enormous strain and stress on already overburdened physicians. If CPT changes, an infinitesimal shift compared to that presented by implementation of the ICD-10 codes, annually result in such significant disruptions to physician cash flow for such long periods of time, can we really expect that these same payors will implement ICD-10 without any problem? I think not. 

In closing, many of the resources that businesses and physicians had dedicated to ICD-10 readiness in 2015 now have been diverted to resolve the problems that threaten their survival. We can do much, much better. 

About the Author

Holly Louie is the president-elect of the Healthcare Billing and Management Association (HBMA) and chairs the ICD-10 committee.  The committee developed definitions for readiness and end-to-end testing for successful ICD-10 implementation. 

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