Was the fear and trepidation surrounding ICD-10 overstated or is the early success around a lack of denials only temporary for providers?
It took 23 years for ICD-10 to come to the U.S. healthcare system, from its publication by the World Health Organization in 1992 to its mandatory implementation date last year, with multiple delays, a good amount of pushback from high-level doctor groups, and lots of stress for physicians crammed in between.
Just like Y2K, ICD-10's impending deadline came with a lot of trepidation and hype. A survey of more than 300 physician practices, released by the Workgroup for Electronic Data Interchange in the summer of 2015 found that less than half said they were ready for the change. While it's been only six months, experts say just like Y2K the trepidation and hype were just that. The fear of denials, lost revenue, and work flow is nowhere to be seen.
"For the most part, it has been successful. By that, I mean we really haven't seen many decreases in revenue, which everyone predicted. The AMA was predicting as much as a 25 percent hit for private practice. We have not seen that," says Scott Griffin, vice president of consulting services for Culbert Healthcare, a Woburn, Mass.-based consultancy.
A Physicians Practice survey revealed that 47.3 percent of readers say they are having no problems with the ICD-10 transition and claims are being rejected at the usual rate (see related sidebar). Another survey, from Navicure, a claims management company based in Duluth, Ga., found that 60 percent of practices said they have not seen an impact on monthly revenue.
Moreover, Mike Denison, senior director of regulatory compliance programs with Change Healthcare (formerly, Emdeon), a clearinghouse firm from Brentwood, Tenn. that processes ICD-10 claims for payers and providers, says there has been barely any variance in denials. "Overall, the rejection rates from both a clearinghouse and payer perspective were very close to baseline. From a payment and denial perspective, when you compare Q3 2015 to Q4 2015, we see very little variance in the average paid amount from a claim as well as the average denial percentage. If you look at commercial Blue Cross Blue Shield payers, for example … there was a less than 1 percent variance," says Denison, who notes the problems are similarly quiet coming from Medicare as well.
For Joshua Bock, a Mesa, Ariz.-based chiropractor and managing partner of a 24-doc practice, ICD-10 was a matter of preparation. He had to reassure the other doctors at the practice that ICD-10 was not a mystical creature each time it got postponed. In early 2015, the practice began preparing for the transition. They educated themselves with ICD-10 books, conversion charts, and invested in software that converted the codes from ICD-10 for them automatically.
"It's been a piece of cake. We haven't had any issues. From a billing and coding perspective, we've had no rejected claims and no issues at the clearinghouse [due to ICD-10]," Bock says. There are some ongoing issues, but most have been minimal. One, he says, is that treating patients with a bilateral problem is tricky with the coding set.
Robert Tennant, the director of health IT policy with the Medical Group Management Association (MGMA), says there are a few reasons why things have gone well so far. He says the additional time - due to previous delays - the industry received was beneficial. Furthermore, the joint announcement in July from CMS and the AMA, where providers would have a window of coding flexibility for one year in ICD-10, was an indicator that there would be no more delays. "Because that happened in July, it [gave providers] sufficient time to do any last-minute changes … to make sure your software was ready, and you lined up your ducks in terms of clearinghouse work," he says.
Another crucial reason for the early ICD-10 success, Tennant says, are what he calls "relaxed edits," from payers like Humana and UnitedHealthcare. If a provider codes ICD-10 within the same family of codes, those payers have said they won't reject that claim during processing. In the announcement with AMA, CMS offered flexibility as well, although because it has to do with auditing of claims, rather the processing of them, it's not as big of a help, he says.
This positivity, while not unfounded, may still be fleeting. For one thing, denials could creep up once those "relaxed edits" go away. Kristen White, director of operations for coding and compliance at Physician Chart Auditors, a coding educational firm that is a part of Lake Forest, Ill.-based Stericycle, seems to think they will and says physicians can get into bad habits if they don't learn to code to the degree of specificity payers want.
White says from what she has seen, in terms of documentation, there isn't a big difference between ICD-9 and ICD-10. There are a lot of unspecified codes out there and a lack of specificity, she adds. Both of these things, she says, could have a major effect on a practice's reimbursement.
Culbert Healthcare's Griffin says he has already begun to see ominous signs from payers. "We're seeing more requests by payers for additional information. This is a usual trigger leading up to a denial or a rejection," he says.
Not everyone buys into the idea that this shift will lead to more rejections though. Tennant says it's not in the payers' best interest to have wide-scale disruption. Denison at Change Healthcare says there may be "pockets of issues" that will occur, but not a big wave of denials.
SIX MONTHS AND BEYOND
One thing everyone can agree on is that the work is not over when it comes to ICD-10. As life after ICD-10 nears the six-month mark, practices will have to continue to monitor their claims, especially rejections and denials, says Griffin. Tennant says a practice should be conducting internal audits on the 30 most commonly used codes or clinical scenarios from its largest payers, especially if the practice is already having problems getting paid. "Look at the codes that have been successfully adjudicated … and see what level of documentation and granularity was submitted," he says.
Another ICD-10 area practices should continue working on is education, experts advise. White says "wait and see" is not the smartest move and practices should constantly reeducate themselves. Griffin says education should go from the classroom lectures that may have occurred before or during the early days of ICD-10 to more one-on-one lessons. "Every provider learns at a different pace," he notes.
For those physicians that feel like they have ICD-10 down pat, such as Bock, their future plans are more detailed. He plans on using the coding set to keep a close eye on insurance carriers. He is concerned that they could possibly place limitations on policy holders because they have more data to understand a patient's condition, saying it wouldn't be fair to his patients since they pay for those benefits. Overall, he looks at his ICD-10 experience as a positive one and advises physicians to adapt to this new world.
"Sometimes we fear change, but if you really look at most common conditions in your practice and you look at what ICD-10 allows you to do, I think you would find you can be more precise with causation and with prescription of condition - via location or symptom. It allows you to more clearly communicate the types of conditions you are treating," says Bock.
Gabriel Pernais the managing editor for Physicians Practice. He can be reached at firstname.lastname@example.org.
This article was originally published in the April 2016 issue of Physicians Practice.