By: Chuck Buck

ICD-10 is the lollapalooza of healthcare. It's the curtain going up on a Broadway premiere. It's the opening seconds of the worldwide telecast of The Oscars. It is the solid clank of the metal safety harness pressed hard against your legs on the Cyclone roller coaster on Coney Island, when you hope (and pray) you'll walk off in one piece.

It's 71,920 ICD-10-CM diagnosis codes and 89,000 ICD-10-PCS procedural codes. It's costing healthcare between $425 million to $1.5 billion, according to a RAND study. It's been bullied by the leadership of the American Medical Association and cited as the reason small physician practices will fold up and shutter. It's been on America's healthcare agenda since 1995. It's been postponed, questioned, and even declared DOA by some members of Congress. It's been many things, and for many reasons.

It's also the law.

Like boxing's great Jersey Joe Walcott, it's been punched around quite a bit, too.

But it is still the law.

And depending on when this publication goes to print, there will be roughly a year before the curtain goes up on America's beleaguered healthcare industry.

Think the opening ceremony of England's 2012 Summer Olympics, with her majesty parachuting into the stadium, millions of watchful eyes hoping and praying the parachute opens, allowing the queen to make a soft, on-point landing. She had one chance to get it right before all those viewers. And she did. God save the Queen.

Make no mistake: this country's transition from the International Classification of Diseases, Version 9, to version 10 is no dress rehearsal. This will be for real.

Come the morning of Oct. 1, 2014, all of healthcare will be on full display, revealing the results of years of cajoling, postponing, pontificating, procrastinating, prodding, pushing and pulling of caregivers, administrators, executives, insurers, exchanges, and clearinghouses. For unlike congressional bickering that leads to compromises neither side really likes, the transition to ICD-10, as required for HIPAA-covered entities, is the law of the land.

Will claims be adjudicated on the first couple of days, say, Oct. 3 or 4, 2014? Will an already-large backlog of denied claims start to grow exponentially? How will balance sheets look on Nov. 30, 2014? How will patients be affected, and will they really care if their illness was coded as SIRS or sepsis under ICD-10? And will the rationalization of some CFOs finally put to rest the notion that the conversion from ICD-9 to ICD-10 was more than just a coding and software issue?

Progress appears to be being made.

In a poll conducted by ICD10monitor for its weekly Internet radio program, Talk-Ten-Tuesday, listeners of the Aug. 13 broadcast seemed to be on track. The results:

"Is your ICD-10 implementation plan on schedule?"

Yes, we are on track:                  35%
We are over 50% on task:           23%
We are less than 50% on task:    27%

"This is definitely good news to see that about two-thirds are right on track or close to being on track," wrote Kim Charland, senior vice president of clinical consulting services for Panacea Healthcare Solutions, in a statement to ICD10monitor.  "However it is very alarming at this point in time to see that about one-third are not.  With only about a year to go, these organizations and providers have a lot to do in a short period of time.  Those who are behind or have not done anything will need to step up their game to catch up by identifying an ICD-10 Project leader internally or contracting with one will help to get a catch up plan written.  Then it will be a matter of fast-tracking some of the tasks that will need to be done to catch up."

Roadblocks Ahead: The Laggards

There is still growing concern among some healthcare professionals that slow adopters could have a disastrous effect on the industry. Writing on the subject for ICD10monitor, Ellen VanBuskirk recently expressed her concern about those she labeled "laggards."

"We need to accept that the laggards in the ICD-10 transition are primarily providers  and we also need to embrace the reality as to the risk they place threatening industry-wide compliance as of October 2014," VanBuskirk wrote in the Aug. 20 edition of ICD10monitor e-news. "We cannot assume that laggards have an intentional aversion to compliance; on the contrary, there are many issues that are cause for concern."

Among the reasons that VanBuskirk cited, one in particular seems to hold a magnifying glass to the healthcare industry, noting how healthcare, unlike financial services, hasn't adopted "enterprise-wide solutions."

"The (healthcare) industry historically has embraced legacy, homegrown IT applications and/or off the shelf' applications to run their businesses, especially small- to mid-size hospitals that traditionally have not been able to afford some of the enterprise-type software available in the market," VanBuskirk wrote. "We also know that, unlike in other industries that have enterprise-wide applications, healthcare has been slow to develop fully integrated enterprise software."

Helping the Laggards

Deborah Grider, the president-elect of the Indiana Health Information Management Association and a senior healthcare consultant for Blue & Company, has been chronicling for ICD10monitor her firsthand experiences working with hospitals that might be considered "laggards."

"I have been traveling the past month, presenting ICD-10 awareness information to various groups, including hospital boards of directors, hospital executives, and physician groups," Grider wrote recently. "I find it interesting that many still don't understand how ICD-10 will impact each and every organization, and that some executive stakeholders apparently do not really comprehend what ICD-10 really is."

Grider believes that one reason so many are lagging behind is that they think ICD-10 is "just information systems and coding training, so what's the big deal?"

But ICD-10 is a very big deal, as Grider and others acknowledge.

"What can we do to make all healthcare organizations  from hospitals to physician practices to long term care, etc.  understand the enormity of this transition?" she asked. "The bottom line is this: if you are not ready to submit ICD-10 claims on Oct. 1, 2014, you will not get paid."

Dual Coding

If one were to look beyond the laggards, they would most likely find some providers who are moving forward by implementing dual coding - coding claims in both ICD-9 and ICD-10.

In another Talk-Ten-Tuesday listener survey, this one conducted April 2, 2013, the question was asked if facilities intended to undertake dual coding as part of the implementation of ICD-10.

"Are you planning on doing dual coding and when do you plan to start?"
 
 Response Ratio  

A. Yes, we are already doing it  10%
B. Yes, we plan to start in 2013   8%
C. Yes, we plan to start in 2014 58%
D. No we don't plan on doing   9%
E. Not applicable to us 15%

"It's time to join the dual-coding movement," wrote Cindi Doyon, vice president of coding and client services for Precyse in an April 30, 2013 article for ICD10monitor.  "Dual coding refers to coding in both ICD-9-CM and ICD-10-CM/PCS in the same patient health record. Although doing so may make it seem like you are losing productivity at first, the long-term benefits of a dual-coding movement will far outweigh any initial loss."

End-to-End Testing

One of the conundrums facing the industry has been the need to test, provided that all trading partners would be prepared to accept and adjudicate new ICD-10 claims. This is a process otherwise known as end-to-end testing. The problem: end-to-end testing takes time and costs money. All along, subject matter experts have been warning that end-to-end testing would take a full year, which meant that if facilities hadn't started testing by now, they'd be behind the proverbial eight-ball come Oct. 1, 2014. And healthcare's record as it pertains to being on time is not enviable. Take, for example, its grappling with testing in 5010 readiness, considered step one in the implementation of ICD-10.

4010 to 5010

Back in May 2009, the Centers for Medicare & Medicaid Services (CMS) told providers that Jan. 1, 2012 would be the deadline for submitting claims using HIPAA 5010 - a prerequisite for moving to ICD-10, as 5010 could accommodate the more detailed ICD-10 claims better than the older version, 4010.

But then, on Nov. 17, 2011, the CMS Office of E-Health Standards and Services (OESS) announced that, for a 90-day period, it "would not initiate enforcement action against any covered entity that was not compliant with the updated versions of the standards by the January 1, 2012 compliance date."

Then, again, on March 15, 2012, CMS was forced to announce that it would not initiate enforcement action for an additional three months, moving the deadline for 5010 compliance to June 20, 2012.

A Talk-Ten-Tuesday poll conducted during the Jan. 10, 2012 broadcast that featured Denise Buenning, then the director of the CMS Administrative Simplification Group, asked the question, "Which of the following best describes your status with 5010 use as of 2012?"

Twenty-nine percent of respondents reported that they only were using 5010, with less than 25 percent indicating that the question wasn't applicable to their situation.

"I see the results as disappointing, but hopeful," Stanley Nachimson, principal of the healthcare consulting firm Nachimson Advisors, LLC later said in response to the poll. "A little over half of the respondents are in pretty good shape, but that number, to me, should be 80-90 percent or more."

Nachimson at one time was a CMS official, when the agency was working on the initial set of HIPAA transaction standards that went into effect in 2003. That version is now being replaced by 5010.

Nachimson noted similarities between industry participation in adopting 5010 and the industry's actions during the previous implementation of HIPAA standards.

"As an industry, we need to find a way to meet deadlines so that we can move on to other tasks (like ICD-10)," Nachimson said. "Much of the 5010 input to health plans is data converted from 4010 transactions sent by providers, so they really haven't met the spirit of the standards."

The survey results in their entirety:

 "Which of the following best describes your status with 5010 use as of 2012?"

A. We are using 5010 with 100% of our payers/providers 29%
B. We are using 5010 with 75% of our payers/providers  27%
C. We are using 5010 with 50% of our payers/providers  15%
D. We are using 5010 with 25% of our payers/providers  10%
E. 5010 is not applicable to my organization  19%

Lessons Learned from 5010

With memories of the lackluster participation by providers in adopting 5010 still fresh, Holly Laurie, a member of the Healthcare Billing and Management Association (HBMA) and chairwoman of the association's ICD-10 Committee, wrote that providers would need to learn from the mistakes made in the 5010 adoption. 

"In our view, central among the shortcomings in the 5010 transition was the lack of a standard definition of what it meant to be 5010-ready,'" Laurie wrote in an article for ICD10monitor. "What we subsequently learned was that every entity in the claims processing chain had a different definition of the term ready.' We believe it is not possible to be truly ready' until meaningful end-to-end testing has been done."

Laurie went on to say that what the industry did learn from the 5010 conversion was that payer testing had been severely limited.

"The first six months of 2012 underscored this point in that many payers only tested syntax prior to the implementation of 5010," Laurie wrote. "And in many cases the scope of testing did not cover true edits adequately  nor did these efforts involve end-to-end testing with full claim level adjudication and remittances."
 
On an April 30 broadcast of Talk-Ten-Tuesday, we asked where providers were in their testing schedules.

 "What arrangement do you have with your trading partners about ICD-10 testing?"

We have scheduled testing  11%
We have discussed testing but have not scheduled it  23%
I am not planning to test with my trading partners 23%
I don't know 1%

"Testing is part of the CMS requirement to implementing ICD-10," Juliet Santos, executive vice president for The Lott QA Group, wrote recently in another ICD10monitor article. "Organizations that do not plan to test are putting their cash flow and revenue cycle at risk, as well as other processes."

Santos urged providers to have all transactional life cycles tested prior to the ICD-10 compliance date. Santos said that testing with external trading partners could be accomplished through the National Testing Program (NTP) for ICD-10.

"The National Testing Program for ICD-10 was developed as a collaborative solution providing the best of both worlds  commonly used industry-wide test data blended with a mix of participants' internal data for maximized coverage with the highest value test data sets," Santos wrote. "The NTP is needed because, as an industry, we do not collaborate enough to accomplish the level of testing currently required because of (a) disconnected process and a lack of national testing coordination to a level and depth and breadth truly required for substantial testing initiatives."  

The Physician Enigma

The difficulty of gaining physician involvement with clinical documentation improvement (CDI) has been a recurring theme for a number of years. Fear, trepidation, and avoidance have characterized how a large number of health information management (HIM) professionals approach the discussion of ICD-10 engagement with physicians and the need to improve documentation.

During a March 19 broadcast of Talk-Ten-Tuesday, we asked listeners how they were coping with physician engagement as it pertained to CDI. The survey results were not surprising.

 "How are physicians at your facility reacting to ICD-10 and their role in CDI?"

Great enthusiasm and participation  1%
Some enthusiasm and participation 26%
Little to no enthusiasm and participation  45%
Livid with the increase/change in doc requirements 15%
No reaction at all 13%

Paul Weygandt, MD, vice president of J.A. Thomas & Associates, now a Nuance Company, has a keen sense of empathy for his fellow physicians.

"As hospitals and health systems prepare for the transition to ICD-10, many gifted and intelligent individuals in the health information management (HIM) field are becoming increasingly frustrated by the apparent ambivalence of physicians toward ICD-10 education," Weygandt wrote in the March 15 edition of ICD10monitor. "Physicians are generally intelligent and extensively educated individuals. One might anticipate that they would be easily engaged in high-quality ICD-10 education. Yet many physicians remain reserved and somewhat unmotivated to prepare for ICD-10."

Weygandt went on to describe physician ambivalence to ICD-10, noting that there are ways by which to make an impact with them.

"Discussions with physicians always should begin with patient care," Weygandt advised,  "ICD-10 has been adopted by the rest of the developed world because it provides more accurate clinical information, which is essential for epidemiologic study, transitions of care, utilization of the EHR, and many other valid clinical applications."

A stronger argument, however, could be appealing to a physician's sense of professionalism.

"I have stressed to physicians the value of ICD-10, and they have proven very willing to listen," Weygandt said. "As we enter into discussions of ACOs, bundled payments, the CMS-HCC system, and other inevitable evolutions of our healthcare system, physicians can be engaged as advocates of documentation improvement, accurate quality metrics, and, fundamentally, better patient care."

But what tools are HIM professionals using to help educate physicians on ICD-10? The responses to this Talk-Ten-Tuesday poll, conducted in January of this year, reveal what could be the essence of a disconnect between HIM professionals and physicians. The poll asked listeners to respond in terms of their using audits, computer-assisted coding (CAC), ICD-10 documentation audits, or general information.

 "What tools and processes are you using to educate your physicians?"

Perform concurrent I-9/I-10 Audits via CAC    5%
Perform concurrent I-9/I-10 Audits via data analytics 13%
Perform ICD-10 documentation audit 26%
None, we will provide general information 13%
Don't know yet 43%

"These results indicate that not only are facilities not well-prepared for ICD-10, providers are not prepared as well," wrote Becky Rodrian, director of physician consulting services for Panacea Healthcare Solutions, Inc., in a statement to ICD10monitor. "Facilities should develop a plan to prepare, educate, and audit providers for successful implementation of I-10.  Providers must be actively involved in these processes in order to facilitate a smooth transition to I-10."

Concludes Rodrian, "preparation, education and auditing are necessary in order to successfully utilize the new ICD-10 coding structure."

And the clock keeps ticking

Chuck Buck is the publisher of ICD10monitor and RACmonitor and serves as the executive producer and host for both Monitor Monday and Talk-Ten-Tuesday.