July 9, 2013

Potholes in the ICD-10 Testing Road

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ICD-10 testing has been a major topic of conversation recently, and understandably so. As a matter of timeline, all healthcare providers should be well into their implementation plans by now, but some areas of the industry may be experiencing more difficulties than others.

Senior Policy Advisor for Government Affairs of the Medical Group Management Association (MGMA) Robert Tennant presented findings of a recent research project to the National Center for Vital and Health Statistics Subcommittee on Standards in mid-June. The 1,195 respondents to the MGMA research survey described a bleak picture of their path down the road to ICD-10 implementation and testing.

When asked when their major health plan partners would be ready to perform ICD-10 testing, 71.2 percent of respondents said they had not heard from those partners. Some 60 percent also said they had not heard from their clearinghouses about when they plan to start ICD-10 testing. Those are some pretty hefty percentages.

The percentage of respondents that have not heard from their clearinghouses paints an even bleaker picture, however, when combined with the fact that more than 78 percent of the survey respondents said they use a clearinghouse for between 80 to 100 percent of the insurance claims they process. If the clearinghouses and the payers are not informing data trading partners about the expected date by which to submit test claims, it’s easy to see why the MGMA would be concerned about the potholes in the road ahead.

To complicate matters even more, many of the existing practice management systems and electronic health records in use in medical practices around the country will need to be upgraded or replaced to handle ICD-10-CM transactions. The respondents to the survey indicated that approximately 5 percent of their systems have been or will need to be replaced, and about 70 percent of the systems will need to be upgraded to accommodate such transactions. These upgrades and replacements will cost on average around $10,000 per provider, using a full-time equivalent (FTE) in the practice. The survey also showed that about half of respondents with upgrade/replacement needs do not have a specific date from their vendors regarding when they plan to finish implementing these upgrades and changes. It seems fairly obvious that it’s hard to test a system if you don’t have the new system in place yet!

Robert Tennant’s statements to the subcommittee also reflected concern over a recent statement by Palmetto GBA, a Medicare Administrative Contractor (MAC) that indicated that “Medicare does not plan to pursue testing of Medicare fee-for-service claims directly with providers for ICD-10 at this time.” A statement such as this seems to send the incorrect message that testing is not vitally important. Yet the Centers for Medicare & Medicaid Services’ (CMS’) own implementation handbooks for various organizations and payers provide clear instructions on the need for end-to-end testing. \MGMA was quick to point out how these mixed messages are creating uncertainty within the industry.

Yet MGMA offered some excellent recommendations to the U.S. Department of Health and Human Services (HHS) in the form of ways the department can support the industry during this transition. Specifically, MGMA called for a reversal of the policy not to test with external trading partners and called for the need to fully engage with the HIMSS-WEDI National Testing Pilot. In addition to these pointed recommendations, they also called for a ramp-up of education and the provision of resources directed to all stakeholders, with an emphasis on vendors and small, rural and safety-net providers who could see a large negative impact from any lack of a solid ICD-10 implementation and testing plan.

Based on the results of their research, MGMA also called for a focus on the role of the clearinghouse, given the large numbers of claims that are processed through these partners. Specifically, MGMA suggested leveraging the use of the Regional Extension Centers (RECs) to help reach smaller practices and the expansion of the REC mandate to include medical specialties other than primary care.

These recommendations place a clear focus on the need to use all available resources and involve all major players to ensure that the industry moves quickly to prepare for this impending change.

About the Author

Maria T. Bounos, RN, MPM, CPC-H, is the practice lead for coding and reimbursement software solutions for Wolters Kluwer.  Maria began her career at Wolters Kluwer as a product manager, responsible for product development, maintenance, enhancements and business development and now solely focuses on business development.  She has more than twenty years of experience in healthcare including nursing, coding, healthcare consulting, and software solutions.

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Maria Bounos, RN, MPH, CPC-H

Maria T. Bounos, RN, MPM, CPC-H, is the practice lead for coding and reimbursement software solutions for Wolters Kluwer.  Maria began her career at Wolters Kluwer as a product manager, responsible for product development, maintenance, enhancements and business development and now solely focuses on business development.  She has more than twenty years of experience in healthcare including nursing, coding, healthcare consulting, and software solutions.