June 29, 2015

ICD-10 Readiness: Examining the Role of Technology in Preparing Physician Practices

By Bill Reid

It looks small – a coding change – but its impact will be far-reaching. Because ICD-10 readiness involves communication between parties, everyone has to change together. To make this change easier for everyone, the industry needs to ensure that the right tools are in the hands of the people who begin the process – the providers who begin the referral workflows – in order to ensure that the codes are done right the first time, with crosswalks to previously used codes preserving clinical continuity. Such tools allow for complexity to be managed and for operational consistency across trading partners. 

Perhaps the most salient parallel to the current ICD-10 readiness process is when electronic data interchange (EDI) was introduced for payment standards under HIPAA. There was some “forgiveness” built into the systems during that transition – no one was allowed a hard failure, but everyone was pushed toward correct coding and usage. As a result, today it is standard practice to use a 270/271 transaction format to verify eligibility, or to use an 837 for a claim. All entities worked together under the pressure of a deadline to improve the overall way of doing business, enduring a short-term pain for longer-term gain.

As with any significant industry change, the ICD-10 transition should be anticipated and approached with significant planning and detailed execution. This means that clinicians and those actually working with trading partners will need extensive training regarding new codes, guidelines, and policies. More importantly, stakeholders also must adequately transition their existing ICD-9 code sets to the tenth edition in ways that support financial neutrality, ensuring diligent testing and consistency between trading partners. The dynamics between health systems and independent providers must support this – or both institutions will lose.

To meet this mandate, health systems are working relentlessly on ICD-10 initiatives, having spent millions on computer-assisted coding (CAC) and clinical documentation improvement (CDI) software and training to ensure readiness. But a recent WEDI report shows that many physician practices have made only modest progress in the past year. Physicians must be directly engaged now in order to understand current readiness, ensure that training is happening, determine points of interaction, automate manual or non-standard processes, audit codes and documentation, and engage in testing for electronic interfaces. Otherwise, hospitals risk unsuccessful transitions if physician offices in their communities aren’t ready. And ready they aren’t; WEDI and other entities have conducted industry surveys showing that fewer than 30 percent of physicians have received training for ICD-10 and have the appropriate software installed – and fewer than 10 percent of clinics have begun testing.

These physician practice delays are due to many reasons, including resource constraints, optimism that the deadline will shift once again, and a misperception that the impact of not transitioning will be less significant than many are predicting. Regardless of the reason, community physician offices that are ill-prepared for the transition not only will put their own practices at risk, but those of the health systems with which they do business. To this end, CMS predicts denials could increase 100-200 percent in the first year after implementation.

How can health systems pull their financially strained, less informed, independent healthcare brethren along with them successfully, so as not to lose time and money from independent practices’ inefficiencies and delays associated with ICD-10?

It’s an important and urgent question when one considers the stakes. The risks for the hospital and community physicians, and the relationship between the two, are not just a single point of vulnerability. There are multiple types of risk, including risks to clinical neutrality, which means maintaining the same characteristics for patient care and achieving the same medical necessity outcomes so that the ICD-10 transition doesn’t cause a change in care; risks to financial integrity, which means ensuring that claim payments remain approximately the same irrespective of ICD-9 or ICD-10 codes being used for a diagnosis and resulting treatment; and finally, risks to operational stability – ICD-10 will have far-reaching impacts on organizations’ structures, including people, processes, and technologies, and transition plans need to accommodate the requirements of each.

As a shorter means to an end, health systems and independent practices may create crosswalks that convert their most frequently used ICD-9 codes to ICD-10 equivalents. New cost-effective, cloud-based community care business management tools that coordinate not only referrals and orders for patients, but also ensure that episodes are coded accurately, can be very attractive ICD-10 solutions for providers and health systems. These electronic bridges help automate and simplify the first mile of the patient access experience and make it as easy as possible for community physicians to send in accurate orders and referrals, with the correct codes being used from the start of that workflow.

Imagine the following scenario: a patient at a physician office has a headache and needs to be scheduled for a CT scan. While the patient is still at the office, the staff can enter the dashboard of the electronic solution through a simple Web interface and schedule a new order. First, the provider will be prompted to include information related to the diagnosis and the procedure. The provider selects the diagnosis from the dropdown menu and it auto-populates the reason for the visit and appropriate IDC-9, ICD-10, and CPT codes. Then the provider enters the patient data, which shows everything the provider knows about the patient, including insurance information. The provider sends the order and can monitor the order status in their dashboard. The hospital automatically receives the order, along with all necessary information, including the correct ICD-10 code, and can begin processing it.

Agile technologies like this exist in today’s markets, and they are designed to be intuitive for providers to use, making experiences better and eliminating complexity and time when collaborating with health systems and other trading partners. These solutions can make the lives of both providers and health systems easier by saving them time and money that would be lost by scrubbing and changing codes during each transaction, improving efficiencies and providing overall peace of mind regarding ICD-10 transactions.

About the Author

Bill Reid is the senior vice president of product management and partners at SCI Solutions, where he oversees partnership development and delivery of the company’s product offerings.

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