December 17, 2015

Malaise to Melioration: The ICD-10 Journey Continues

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In some quarters of healthcare, 2015 was the year of the big malaise. Although former President Jimmy Carter never actually uttered the word in his July 1979 speech about a “crisis of confidence,” his comments ultimately become known as the “malaise speech.”

 

There’s no doubt that a palatable sense of malaise hung over much of the healthcare industry during the last year, much like the frustration at the gas pump in ‘79 as a result of a decline in oil production in the wake of the Iranian revolution. Would ICD-10 become adopted after a decade of fits and starts? Would Congress intervene and order another 12-month extension?

Going into 2015, those were the burning questions. Just the year before, behind-the-scenes negotiations between then-Speaker of the House John Boehner (R-Ohio) and former Senate Majority Leader Harry Reid (D-Nev.) resulted in a last-minute rider to the sustainable growth rate (SGR) bill that delayed the implementation date of ICD-10 until no earlier than Oct. 1, 2015.

But much changed in 2015, and advocates for adoption of ICD-10, most notably the American Health Information Management Association (AHIMA), started making their voices heard. And yet, all through the first quarter of the year, everyone still seemed to be watching for a repeat of the one-year SGR delay.

Even testimony by AHIMA’s Sue Bowman, the Association’s senior director of coding policy and compliance, before the House Energy and Commerce Committee’s Subcommittee on Health didn’t completely assuage everyone.

On March 24, we reported that Congress was expected to work out details on legislation to repeal the SGR. Bipartisan leaders from the U.S. House of Representatives Ways and Means and Energy and Commerce committees had introduced H.R. 1470 the previous week. Yet this time, there would be no rider.

As there was no language in the draft legislation that would postpone the adoption of ICD-10, stakeholders greeted the news with a note of cautious optimism.

President Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) on April 26 in the Rose Garden, and ICD-10 came into far clearer focus on the horizon.

Yet there still persisted a feeling of uncertainty among many providers, which prompted us to ask veteran ICD-10 observer Stanley Nachimson why. Nachimson told us in an interview that since ICD-10 has been delayed multiple times, there emerged reluctance by some to commit funding for implementation. 

“While larger hospitals may be able to absorb some of the losses from (the) delay, smaller ones may not have that luxury,” Nachimson told us. “There is also the concern about loss of productivity for coders and the question as to when to send them for training and commit time to practice ICD-10.” 

Perhaps adding to this uncertainty was an announcement by AHIMA to its members that it would continue to monitor upcoming legislation for any ICD-10 delay language.

Dozens of health information management (HIM) professionals had told ICD10monitor that their facilities were reluctant to move forward until they knew for sure there wouldn't be another delay.

“We will never be 100 percent certain of no delay until we arrive at Oct. 1,” Nachimson told us, adding that “I give the chances of a delay now at 5 percent or less.”

So, what was the tipping point? What combination of events presaged the arrival of ICD-10 on Oct. 1?

“The announcing of the relatively successful Medicare end-to-end testing results was a major step forward, along with the testing results from other health plans that showed little payment disruption expected,” Nachimson said recently, adding that he sensed a tipping point in the ICD-10 journey during the late summer.

On the other hand, Bowman told ICD10monitor in an email that even before the hearing, AHIMA sensed growing support for transitioning to ICD-10 without further delay, due in large part to the Association’s ICD-10 advocacy campaign, which involved grassroots outreach to members of Congress coupled with the support of other sectors of the healthcare industry also contacting their legislators. Bowman also credited the success of the Centers for Medicare & Medicaid Services (CMS) end-to-end testing.

So, what were some of the milestones along the way to ICD-10 becoming implemented?

“Obviously, the biggest milestone is the actual transition to ICD-10 on Oct. 1,” Bowman said. “If you’re thinking of the entire year (including post-implementation), I would say a major milestone is the success of the transition – with few problems and none of the dire consequences that had been predicted by some.”

AAPC Vice President of Strategic Development Rhonda Buckholtz told ICD10monitor that the major milestones all produced the same result.

“We succeeded,” Buckholtz said. “The coders learned the codes, providers began to improve documentation, vendors had their systems ready, and the payors paid.”

But what are some of the challenges facing the industry in 2016?

Buckholtz sees three challenges facing coders next year, including the need for continued growth in learning the new code set, increasing their skill levels, and gaining a better understanding of chronic conditions for the highest level of code assignment. Finally, Buckholtz said there is a need for continuing education of clinical documentation improvement efforts among providers.

One more challenge facing coders will be the thawing of the code freeze in 2016.

“(There will be a) much larger number of new codes and other code modifications on Oct. 1, 2016,” Bowman said, noting that many code proposals could not be implemented during the code freeze and have been waiting to go into effect.

“Looking ahead to the first quarter, I believe that the challenges for coders will be productivity and feeling comfortable with ICD-10-PCS for the inpatient coders,” said Laurie Johnson, director of HIM consulting for Panacea Healthcare Solutions, the parent company of ICD10monitor. “For the clinical documentation specialists, the major challenges will be understanding when a query should be issued for documentation concerns.”

Johnson offered one example in particular: “A physician writes ‘history of atrial fibrillation.’ Can the coder or CDS interpret this diagnosis as chronic atrial fibrillation?” she asked. “There is no specific guidance regarding this specific issue, but it represents where the hesitation is for query writing as well as code assignment.”

“My only advice is to continue to learn about the code sets,” Johnson added. “We did not learn everything about ICD-9-CM in 1979 and we will continue to learn about ICD-10-CM/PCS in the coming years.”

For the industry as a whole, Nachimson doesn’t foresee any major issues at this time.

“2016 should be used by providers as a year to improve documentation and reduce the use of ‘unspecified’ or ‘other’ codes,” he said.

As for provider revenue?

“Directly, very little (impact),” Nachimson said. “However, quality measures (in part based on ICD-10) will be having a bigger impact on provider revenue in 2016 and beyond.” 

Bowman said that revenue being impacted by ICD-10 would vary.

“Different healthcare organizations will experience different impacts, depending on their coding accuracy, quality of medical record documentation, and patient population,” Bowman said. “Physicians’ revenue will continue to be driven by CPT® codes rather than ICD codes.” 

With Christmas only a few days away, Buckholtz summed up her feelings about ICD-10 in an article we published on Dec. 1.

“After spending the last five years working to bring ICD-10 implementation to the industry, I can tell you that when Oct. 1 arrived, I was reminded of the Grinch. ‘It came without ribbons, it came without tags; it came without packages, boxes, or bags,’” she wrote.

“ICD-10 came without fanfare, without parades, it came without flaming water skis, and sucking of someone into jet engines, but most importantly, it came without shutdowns and physicians got paid,” Buckholtz concluded. “Maybe the industry needed this plan, working together, holding some hands. It did feel like Christmas when it went off just like we planned.”

Chuck Buck

Chuck Buck is the publisher of ICD10monitor and is the executive producer and program host of Talk Ten Tuesdays.

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