October 6, 2014

The Tortoise and the Hare Approach to ICD-10

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The recent Workgroup for Electronic Data Interchange (WEDI) survey results confirm what everyone watching this race to ICD-10 already knows. The proactive and mostly larger groups, facilities, and practices are proceeding full steam ahead for the Oct. 1, 2015 implementation date.

The rest of the world is either taking a wait-and-see approach or moving forward slowly, if at all. Vendors and payors seem to be making progress also, although there are still significant variations among them. Ironically, these findings are very similar to what the industry reported two years ago, and again last year. So why haven’t the ICD-10 delays resulted in everyone being “ready?” Why do some continue to procrastinate? Why does the readiness divide between those leading the race and those lagging far behind remain?

 

It can be challenging to delve deeper into the root causes. Payers and vendors point to providers as the delaying factor. Providers say their vendors aren’t ready, or that they cannot participate in any meaningful testing with payors. The answer is never that simple. The truth is that revenue cycle, coding, billing, claims processing, and payer adjudication all represent a continuum with multiple steps, each of which must function perfectly for a successful outcome. There are a lot of moving parts – and therefore disconnects – and problems are fairly common along the continuum.

The introduction of ICD-10 into this process is not a simple task. Full cooperation and collaboration among all parties is an absolute necessity for success.

More importantly, there are many other variables significantly impacting the industry (and therefore readiness) that are either out of the control of the industry or issues for which control is vested only in a small segment of the industry. These are not new issues. They have been widely discussed, and recommendations for mitigation have been made for years. Unfortunately, those recommendations often seem to fall on deaf ears. So what are these stumbling blocks, impediments, and barriers? Why have some successfully overcome them while others either cannot or have not?

Fool me once, shame on you. Fool me twice, shame on me. Fool me three times? Not happening. The implementation delays going on during the past two years have made many providers justifiably skeptical. Statements of certainty that it “will really happen this time” are simply not credible. The expectation that additional delays will be coming in 2015 make the laissez-faire attitude logical to many. Spending more time, money, and resources for something that may never happen is simply not a financial option. Equally obvious is the fact that smaller practices and entities typically have fewer resources and must exercise great care in protecting them.

The myriad regulatory requirements associated with the same implementation schedules also constitute an issue that has been raised by many for years. Every single one cost money, time, programming, and resources, stretching already-tight budgets. A look at the proposed physician fee schedule for 2015, and presumably the OPPS and hospital rules, reveals even more requirements that will further strain providers. Meaningful Use, PQRS, increasing payment for quality measures, implementation of various penalties, increasing contractor audits and subsequent appeals, the Centers for Medicare & Medicaid (CMS) utilization and addition of HCPC II codes with descriptions that directly contradict or conflict with the comparable CPT codes – all of these add significant costs for practices.

And don’t forget, reimbursement is decreasing while those costs keep climbing. Over and above the various federal issues identified, the prevalence of commercial payer remittance advices with RARC and CARC codes that do not accurately report the adjudication determination adds to these ever-increasing costs without offering noticeable return for practices.

So can the tortoises catch the hares? Maybe. What needs to occur, industry-wide, to make that happen? For one thing, an implementation date that is set in stone. Once that is a certainty, forward progress can and must happen, even if it means delaying implementation of other federally mandated requirements. Give the whole industry adequate time to allocate resources in a sequential manner, don’t pile on all at once. Allay fears of payment disruptions.

Widespread, meaningful, end-to-end testing must rapidly commence and time to remediate identified issues must be granted. Eliminate idiosyncratic payer communications and enforce current requirements for standardized code sets.

The message should be identical no matter who sends it. Stop the blaming. Everyone has a part to play and every part relies upon those who come before and affects those who come after. Work together, not in isolation. Be aware of financial realities. Remember that what is easily doable in people, programming, time, and money for some is a nonstarter for others.

Let’s make the time remaining a team event, not a race to the finish.

Holly Louie, RN, CHBME

Holly is the Compliance Officer for Practice Management Inc., a multi-specialty billing company in Boise, Idaho.  Holly is the 2016 President of the Healthcare Billing and Management Association (HBMA) and previously chaired the ICD-10 Committee.  Holly is also a national healthcare consultant and testifying expert on matters related to physician coding, billing and regulatory compliance.  She has previously held compliance officer positions in local and international billing companies. Holly is a member of the ICD10monitor editor board and is a popular guest on Talk Ten Tuesdays.

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