Updated on: March 16, 2016

Industry Makes Progress, but Far from the Home Stretch

Original story posted on: February 26, 2014

Guarded hope that the transition to ICD-10 is progressing and confidence that the Centers for Medicare & Medicaid Services will not delay the implementation and enforcement date of October 1, 2014 prevailed during yesterday’s broadcast of Talk-Ten-Tuesday from the 2014 HIMSS conference.

Proof of that cautious optimism came from AHIMA’s Meryl Bloomrosen, vice president for thought leadership, practice excellence and public policy. Bloomrosen summarized the key points of her recent testimony to the National Committee for Vital Health Statistics (NCVHS) on industry readiness. Although many providers, clearinghouses, and payers, as well as CMS, are well on their way to being ready for implementation on Oct. 1, some non-hospital providers, small physician practices, and hospitals are behind and facing important challenges.


Those who are not ready, and even those who think they are ready, should be aware of the risks and develop strategies to mitigate them, said Bloomrosen. Those risk include the following: 

  • Underestimating the scope of work required to get ready
  • Probable productivity impact
  • Staff shortages
  • Inadequate medical-record documentation
  • Insufficient training and education
  • Decreased clinician and coder productivity
  • Increased coding error rate
  • Noncompliance with reimbursement requirements
  • Potential coding backlogs and claim denials
  • Lower quality ratings
  • Other costly administrative burdens.

“CDI strategies also are keys to the risk-mitigation approach,” she says. “Spending time and effort to resolve clinical documentation issues is important and considering the tools and techniques like EHR templates may help facilitate data and documentation capture to support specificity.”

Mark Hendricks from Precyse added that CDI program preparation and risk mitigation were common themes from the HIMSS audience at the session he presented.

“Organizations are looking for CDI programs to better their data for clinical purposes and to get them ready for the new payment methods (pay for performance etc.) and challenges, two-midnight rule, and computer-assisted coding [CAC],” he said.

Although CDI is high on the must-do list for ICD-10, Betty Gomez from Zirmed notes that clearinghouses “can do a lot beyond CDI and coding” for those undergoing the ICD-10 transition, and many opportunities and software are available from them that can be leveraged.

“We sit in a good place—between payers, physicians, patients. We can help payers understand issues that providers will have, and we help providers understand what payers are doing.”

An example of just how helpful Zirmed could be came up during the Talk-Ten-Tuesday roundtable at the end of the program. One listener, who works for a billing company that’s ready to test, indicated that it was a beta site for Medicaid. Its clearinghouse told them that it wouldn’t test with any submitter that didn’t have 3,000 claims.

In response, Gomez said, “We have been ready to test since December 2013, and I don’t have any providers sending me claims. I am begging physicians to send me claims, so we won’t turn you down. When payers allow it, we will do it.”

Will Slow but Steady Win the Race?

“Thank goodness people are waking up, and there is finally a lot of activity surrounding ICD-10” said Stanley Nachimson of Nachimson Advisors. “They are getting interested in CDI, which is a key to implementation. Once CDI is in place, the rest is mechanical. Key documentation allows correct codes to be selected.”

Nachimson called the ICD-10 testing being conducted next week as “one small step for ICD-10,” and Mark Lott from the Lott QA Group calls it “limited because providers get no 835 out of the process.” To get to the Medicare administrative contractor (MAC), providers must go through the clearinghouse, which means no direct testing. Lott advises providers to “not stack up 50 or 100 records” for next week’s testing.

Nachimson also agrees with Lott’s comment that providers need to know, “Am I going to get paid, and how much? How long will it take me to get paid? Do we have the right documentation? Do I need to send additional information? Is this code covered?”

Lott says that he doesn’t have high expectations for testing week. “Most providers are not ready so there will be handholding and physical manipulation to get them to the clearinghouse and then to payer. It’s a 5010 test as far as I’m concerned. The main testing will be [CMS’s] end-to-end testing [in July] to find out about the payments.”

However, CMS only plans to work with a small sample of claims, so Nachimson urges providers to “find someone who will do EET for them.”

Flip a Coin

John Wollman, executive vice president of innovation for HighPoint Solutions, Inc., also agrees with Lott as far as provider readiness, citing two major realities previously mentioned:

  • Organizations have just begun trading partner testing.
  • CMS will not conduct end-to-end testing until mid-summer.

“I don’t think we’re anywhere near the home stretch and nothing I am hearing at HIMSS makes me think otherwise,” he says.

“Everyone needs to be ready to test with each other, adjudicate and ensure payment,” he said. “Most people are focusing on remediation and reimbursement, but operational impacts are not being thought out yet. Until you hone your operations around ICD-10, managing code tests properly, make sure the technology is working, and people are fully trained you’re not on the home stretch,” he said.

On the other hand, “People will never be 100 percent ready even though we are farther along than we have ever been,” added Samir Mehta, business development executive, Dell. “They know testing won’t be at level they expected, but it’s a start. It gives smaller groups an opportunity.”

In fact, he says, many attendees are looking for tools and trying to identify the best way to put testing programs in place. “Provider and payer organizations that I work with are starting to figure out ways to engage with other organizations and get physicians onboard and into a testing program,” he says.


Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Janis Oppelt

Janis keeps the wheel of words rolling for Panacea®'s publishing division. Her roles include researching, writing, and editing newsletters, special reports, and articles for RACMonitor.com and ICD10Monitor.com; coordinating the compliance question of the week; and contributing to the annual book-update process. She has 20 years of experience in topics related to Medicare regulations and compliance.