Updated on: March 16, 2016

What Should You Do Next? Payer and Provider Experts Address ICD-10 Limbo

Original story posted on: March 9, 2012

Rather than focusing on the question of what the Centers for Medicare & Medicaid Services (CMS) will do and when will it do it, providers, vendors, and payers should consider another question: “What should we be doing to position ourselves so that we can hit the ground running when CMS makes its announcement about the implementation date?”


That’s a piece of the advice Dennis Winkler, Technical Program Director of Program Management and ICD-10, Blue Cross Blue Shield (BCBS) of Michigan, offered during the March 8 ICDUniversity webcast entitled Adrift in a Sea of Uncertainty—The Potential ICD-10 Delay: What to do Next? Lyman Sornberger, Executive Director, Revenue Cycle Management, Cleveland Clinic Health System, also shared details about his facility’s plan to proceed in the coming months of uncertainty.

Industry Reaction

The Department of Health & Human Services’ (HHS) Feb. 16 announcement that it would delay implementation of ICD-10 left the healthcare industry, initially, in a state of shock quickly followed by uncertainty and a slew of unanswered questions. How long will the delay be? When will CMS announce its decision? Should we continue or halt our transition process toward ICD-10?

Although the future of ICD-10 is still uncertain, Winkler did provide some “news” from a colleague he identifies as a “reliable third-party source” who was present at a meeting with CMS staff about the Medicaid program’s plans for switching to ICD-10.

At the present time, CMS is not looking at a separate implementation date for diagnosis and procedure codes. It is considering two primary alternatives: a one-year delay or no delay at all. The agency expects to announce its decision in April, and Winkler likely speaks for many in the industry when he says, “Over the next weeks we hope to hear more from CMS.”

Federal Facts to Consider


Even though the compliance date is currently in limbo, implementation of ICD-10 is still the law, and a law can’t be changed without going through the federal rule-making process, which may range from 90 days (the interim rule-making process) to 180 days (the full rule-making process).

Winkler and Sornberger believe that HHS will likely take 180 days to make that decision, and here’s one reason why. “CMS uses the interim rule-making process (90 days) only when its decision will be uncontested,” Winkler explains, and this is certainly not that kind of decision.

The most obvious example of a group that may contest CMS’s decision is, of course, the American Medical Association, which has a very powerful lobbying presence in Congress where it is challenging the “administrative and financial burdens” of implementation. Once CMS issues a proposed rule, many from both sides of the fence will weigh in on the risks and benefits, and it will take the agency time to sort through the comments.

In his remarks, Winkler covered several scenarios—no delay, one-year delay, and two-year delay—and the likelihood of one over the other based on the rulemaking process and the effective date of the federal government’s fiscal year, which is October 1.



Effects of Delay


Sornberger noted that, since HHS’s announcement, there have been numerous surveys and polls conducted throughout the healthcare industry soliciting opinions on the effects of a delay. In general, the healthcare industry believes that a delay will be detrimental for many reasons with financial losses clearly at the top of the list.

How much money might a one-year delay cost providers and payers? In an attempt to answer that question, Sornberger summarized the results of a survey conducted by Edifecs (a technology company for regulatory compliance and data exchange).

“With both payers and providers investing heavily for the ICD-10 switchover, cost was a chief concern,” he said. “When asked about the impact of a one-year delay, nearly half of poll respondents said it would increase costs 11–25 percent, and another 37 percent said their costs would be up to 50 percent. Edifecs estimates the cost of a one-year delay to be between 25–30 percent increased expense. Based on existing overall cost estimates for ICD-10 from multiple sources, officials estimate a year-long delay in ICD-10 could therefore cost the industry anywhere from $475 million to more than $4 billion.”

At Cleveland Clinic, another concern, says Sornberger, is that “a delay of ICD-10 implementation will derail current progress.” On top of that, there is a concern about losing staff and having to repeat training. For example, he says, “We’ve already started coder training so even a year delay would mean putting them back into training later.” The Clinic would have to pay for the training again as well as endure the lost productivity of coders who are attending training or trying to learn on the job.

Each facility’s revenue and resource loss will be different depending upon how far along it is in the transition. Finance directors and staff must analyze their operations, determine their losses if there is a delay, and incorporate those into their budget.

Making a Decision


Equally important to consider, and perhaps most difficult, is to determine whether you will slow down your implementation plans to wait and see what CMS will do—not a choice recommended by webcast presenters. The temptation is that a slow-down would free-up staff time and finances that could be used for other priorities and health reform initiatives.

However, there’s a dark side to such thinking, Winkler says. “If CMS comes back in August and reports that the implementation date stays unchanged, can you recover from the slow-down? If the answer is ‘no,’ then you’d be ill-advised to follow that track. You must think through all of the possibilities, so you can respond to high-level questions about the alternatives.”

Both BCBS and Cleveland Clinic have analyzed the alternatives and have decided to stay on track. If CMS delays implementation, they plan to take advantage of the extra time.

“No matter what you do in the next six months—or until CMS makes a decision, you must focus on risk management,” advises Winkler. “None of us knows what will happen next, but even considering taking a hiatus from the work that has to be done to implement ICD-10, may be too risky.”



Between Now and Then


During its period of forward movement, Cleveland Clinic is addressing what Sornberger calls “several areas of opportunity,” including a clinical documentation improvement (CDI) program and increased coder productivity. A primary part of the CDI program is getting nurses to work with physicians to clarify their documentation thus providing more details that can improve code assignments.

“From the time of the original mandate, we’ve agreed to focus on improved clinical care,” Sornberger said. “We believe that the new system gives our facility an opportunity to provide better clinical care [and better coding and reimbursement] through more granular clinical information.”

As he explains, “Since the nurse is already querying the doctor, it’s a perfect opportunity to introduce the requirements of I-10 and ask more questions about specificity. This has become a part of the normal workflow process.”

In its initial analysis, Cleveland Clinic determined that coder productivity would decline 50 percent and in the upcoming months that risk will be addressed. Computer-assisted coding (CAC) is currently being implemented in the ambulatory area and should be in place within the next year. Remote coding also is being considered.

Parting Shots

The message coming from Sornberger and Winkler is clear: Stay on track during this uncertain period, conduct a risk assessment, and keep up your momentum.

Winkler says, “If you choose to slow down and there’s no delay, you’ll have to make up for whatever was lost in the last six months. You’re not going to have any relief.”

On the other hand, making a decision to go forward will give you more time to discover and resolve the impacts of the new system for you and your providers. From the start, Sornberger wanted Cleveland Clinic to be an early adopter of ICD-10 and its payer, BCBS, agreed.

“Our intent is to be able to transmit I-9 and I-10 simultaneously, and BCBS would process our claims,” he said. “We would see the results from both a provider and payer perspective, and use that data to improve the processes.”

In general, Sornberger advises looking for the “silver lining” and acting on them.


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.