The latest extension of the ICD-10 deadline buys radiology—and all of healthcare—at least one more year to prepare for its transition to the most radical change in medical billing in decades.
As healthcare was scrambling to comply with the Oct. 1, 2014 deadline, Congress approved a bill on March 31 that will delay implementation of the new set of diagnosis and procedure codes under ICD-10 until at least Oct. 1, 2015. This is the second time the deadline has been pushed back since ICD-10 was adopted by the U.S. Department of Health and Human Services in January 2009.
The ICD-10 provision was included in the “Protecting Access to Medicare Act of 2014,” the so-called “doc-fix bill” that also suspends Medicare’s sustainable growth rate (SGR) formula that would have cut the physician reimbursement rate this year by nearly 24 percent. Congress faced a March 31 deadline to pass the legislation that averts the payment cut and further delays Medicare cuts to physicians until April 1, 2015.
The diagnostic coding system was implemented by the World Health Organization (WHO) in 1993 to replace ICD-9, developed by the WHO in the 1970s. The U.S. is one of the few countries that have not yet adopted ICD-10. The looming conversion is mandated by Congress under the auspices of the U.S. Department of Health and Human Services and administered by the Centers for Medicare & Medicaid Services (CMS).
In lauding passage of the “doc-fix” bill, the American College of Radiology (ACR) supported its various provisions, including the plan to “delay implementation of controversial ICD-10 provider payment codes as ACR works to prepare radiology providers for the transition to this new system.”
The American Health Information Management Association (AHIMA) opposed the ICD-10 extension but said in a statement the organization will work to clarify questions raised by the delay and continue to work with government officials to implement ICD-10.
CMS has estimated that another one-year delay of ICD-10 would likely cost the industry an additional $1 billion to $6.6 billion on top of the costs already incurred from the previous one-year delay.
Some coders who have invested considerable time and energy preparing for the October 2014 deadline disagreed with the extension, but urged healthcare organizations to take full advantage of the extra year to get fully prepared for the new set of ICD-10 diagnosis and procedure codes—five times larger than ICD-9.
“Nevertheless, I anticipate that organizations that were already actively preparing will continue to do so, although they might slow down their timetables,” said Melody Mulaik, president of Coding Strategies, Atlanta, which offers ICD-10 training and consulting support to specialty physician practices. “Those entities that had not begun preparing will delay their preparations by yet another year and will most likely be in the same position next year.”
Radiology leaders are urging healthcare professionals to take full advantage of the much-needed extra year of preparation. Before the extension was granted, ACR Chief Executive Officer William T. Thorwarth Jr., M.D., expressed concern about healthcare organizations not prepared for the October 2014 transition, saying, “This is not something you can tune up for in the final six to eight weeks.”
Payers, providers and claims clearinghouses who have been working together to test various facets of the new system are likely to continue the process, especially considering CMS estimates that providers can expect ICD-10 testing to take up to 19 months.
“While that will be up to each individual payer, it is a reasonable expectation that payers and entities will use the additional time to perform more end-to-end testing to ensure a successful implementation,” Mulaik said.
Format testing ensures that the bill gets through to the payer, without being returned for having invalid codes. Content testing—which determines whether the claim gets paid and at what level—is more expensive, complicated and time-consuming. It usually involves taking a paid claim that has been coded in ICD-9, seeing if it can be recoded in ICD-10 using the existing documentation, and sending it to the payer.
If the new version is denied or sent back for a revision, or results in changed reimbursement (even though CMS and other payers have promised that the change will be revenue neutral), providers and payers have a chance to adjust their procedures and software accordingly.
“End-to-end” testing is a combination of format and content testing. While CMS had not originally planned to do official end-to-end testing, problems with Healthcare.gov and requests from provider groups persuaded CMS to rethink its position.
When ICD-10 is finally implemented, the reimbursement process will be considerably more time-consuming for all involved. Referring physicians will need to provide more detailed information, radiologists will need to use greater detail in their reports, coders will have to master the new system and all providers should brace for a payment slowdown of unpredictable magnitude and duration.
And although the new deadline is more than a year away, experts suggest focusing on finances well before October 2015 arrives. Radiology coding expert Renée Engle recommends practices secure a line of credit large enough to see them through a minimum of 30 days of expenses, though she says some consultants are recommending 90 to 180 days. Her company, Management Services Network, Locust Grove, Ga., handles billing for radiology practices in 27 states.
“My biggest concern is that ICD-10 has never been implemented in our current environment,” Engle says, noting that while it’s been an international coding standard for years and is widely used for research and planning, other countries don’t use it to determine payment. “We’re talking about thousands of carriers across the country implementing a new system.”
To that end, the American Academy of Professional Coders (AAPC) acknowledged that the extension offers an opportunity for healthcare professionals to get better prepared, and its website urged its members to “Keep calm and code on.”
“The postponement allows improvement of anatomical knowledge, review and adjustment of documentation quality and clinician education, and adjustment of coding and billing procedures,” AAPC said in a statement.
Although healthcare professionals have another year to comply, experts stress the need to make the ICD-10 transition a priority long before the October 2015 deadline. Tips include:
Work with software vendors. Check with vendors of your billing system, electronic health records (EHRs) or any software that contributes data used for coding and billing, advises the American Health Information Management Association (AHIMA). Fields should exist in templates for all the pieces of information needed to code for ICD-10—for example, what type of contrast agent is used in a study. The fields are usually there, notes AHIMA, but not always in a logical spot.
Insist on complete documentation from the referring physician. Detail is the distinguishing feature of ICD-10. For example, if a patient has a broken finger, the system has codes for which hand, which finger, which part of the finger, what type of fracture and perhaps even the cause of the injury. A diagnosis of localized pelvic pain needs to note the precise area and type of pain. The radiologist can deduce some information from the study itself, but probably not enough to get paid under ICD-10. “Radiologists will have to be more diligent about asking for information from referring physicians,” says radiology coding expert Renée Engle of Management Services Network of Locust Grove, Ga.
Wean yourself from “unspecified” codes. Radiologists who try to make up for inadequate diagnosis documentation by using “unspecified” codes, as they often do for ICD-9, may not get paid at all. ICD-10 is so much more specific that its unspecified codes are rarely appropriate and payers will return the claim for more details, says Melody Mulaik, president of Coding Strategies in Atlanta. “Payers and CMS have said that they’ll quickly identify where unspecified codes aren’t appropriate,” she says.
Determine where your own documentation needs to improve. Radiologists will need to supply higher levels of detail in their reports. The more detailed their interpretations, the more accurately we can code, says AHIMA
For training resources, visit ahima.org/education/onlineed/Programs/ICD10.
Editor’s Note: The June issue of RSNA News will feature a full report on the ramifications of the “Protecting Access to Medicare Act of 2014.”
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