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ICD-10: One CMIO Questions Its Value

December 9, 2014
by Rajiv Leventhal
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During “roundtable” discussion, experts discuss what lies ahead in regards to ICD-10
Jed Rosen, M.D., CMIO, Carroll Hospital

Healthcare providers and physician groups are spending hundreds of hours and millions of dollars in preparation for the switch from ICD-9 to ICD-10.  For those smaller medical practices and physician groups that don’t have the means to hire consultants and spend a vast amount of resources to manage the changeover, they are turning to their associations for help.  

Undoubtedly, it’s a very hot topic among healthcare associations as their members navigate the complex process in anticipation of the current Oct. 1, 2015 implementation deadline. The Healthcare Billing & Management Association (HBMA), for one, is a nonprofit trade association dedicated to healthcare revenue cycle management, and is working with its members—medical billing companies— to develop best practices and contribute meaningful dialogue in preparing for ICD-10.

HBMA’s most recent ICD-10 readiness survey, taken this fall, revealed that its members are getting increasingly confident in their system’s capability to handle both ICD-9 and ICD-10 concurrently. On the other hand, 23 percent of respondents reported that system updates are not complete, and 37 percent of those that have not completed updates have no scheduled time for completion. As a result, internal testing is still lagging, the survey found.

Since then, there has been no shortage of controversy surrounding the transition to the new coding set. Recently, a number of medical groups urged Speaker of the House of Representatives John Boehner (R-OH) to include a provision in an upcoming bill that would delay the ICD-10 compliance date another two years. Meanwhile, last month, the Coalition for ICD-10 sent a letter to House and Senate leaders urging them not to delay the ICD-10 implementation date again.

HCI Associate Editor Rajiv Leventhal recently spoke with various HBMA members and others about this ongoing debate, asking them about the level of preparedness that they’re seeing, as well as the industry’s overall take on this mandate, and what lies ahead. Included in this discussion are: Andre Williams, executive director, HBMA; Brian Langerman, executive director, InSight (a user group for McKesson customers); Dr. Jed Rosen, M.D., chief of surgery and CMIO at the Westminster, Md.-based Carroll Hospital; and Jeanne Gilreath, HBMA president.

What trends are you noticing in organizations’ readiness for ICD-10?

Gilreath: The additional time has given our membership time to prepare and our readiness rates have gone up considerably. The combined “somewhat confident” to “very confident” response is now in the 97 percent range. There is a difference between “somewhat” and “very,” but the fact of the matter is we have had more time to work with vendors, providers, coding staffs, and even payers to determine that readiness.

Rosen: I agree. We started a much more formal education process with our providers so that we were really prepared for the additional documentation requirement that comes with ICD-10.

Are vendors and payers more ready than providers, as recent research might suggest?

Langerman: Providers aren’t as ready as the vendors. They don’t have that mass of weight to get someone to approach that, and at InSight, we want to be that mechanism between the vendor, Mckesson, and the individual users to get them individualized education. Physicians are up to their elbows in several other things, including meaningful use and other mandates that they’re dealing with in today’s healthcare, so they have pushed ICD-10 to the back burner because no one was really helping them on an individual basis. And that’s what we’re trying to do. But ICD-10 is an increased level of documentation from the doctor’s view.

Brian Langerman

From a financial standpoint, did folks feel hamstrung when the delay was announced?

Langerman: From a funds perspective, we have heard from people that operational funds could have been spread out from a planning perspective over multiple years had they known there would have been a delay. From a planning perspective, we heard that folks who took it seriously, who were planned and ready, were working with vendors on the actual work plan and strategy for implementation. So even with the delay, those people were prepared for some remediation. From a vendor standpoint, they already planned out schedules, so the delays bottlenecked things more because their schedules were already pushed to the limit in terms of what they could do.

Gilreath: Initially, I think the industry stoked up the billing companies and doctors into thinking that the implementation was going to break the bank. Initial reports were that it would cost in the tens to hundreds of thousands to implement. For larger companies, that was probably the case. But HBMA’s membership is primarily 70 percent smaller billing companies and we service some of the smaller clients such as physician practices (although our larger companies service hospital-based groups and multi-specialty large practices). In our September survey, 21 percent of our membership indicated that it cost them under $10,000 thus far to implement ICD-10; a slightly higher number said it cost them between $10,000-$20,000.

Langerman: Acquisitions and consolidation amongst healthcare organizations, specifically in the last 18-24 months has really added a complexity level as far as where different facilities were in the process. They might have been using different vendors, and if they got acquired or consolidation occurred, that could change things in terms of deadlines and such.   

Rosen: I would agree with that. In addition, one of the things that isn’t being calculated from a provider’s point of view is that a lot of physicians have consolidated into bigger groups, or are employees of different groups. You’re talking about a significant loss of income when a provider goes from a private practice to a member of a large group. That cost to the individual doctor could be a 20-25 percent decrease in income, so it while it may have only cost less than $10,000 to implement, an individual doctor could have seen a $100,000-$150,000 loss in income because of it. I think that’s getting lost in the discussion.

There has been some question regarding the usefulness of ICD-10. Do you think it’s useful for providers?

Rosen: From my viewpoint as a doctor, I believe that it’s useless. The reason why ICD-10 was developed was to really get down to the nitty-gritty about diagnoses, down to the level, “Was I bitten by a dog or a turtle?” And those are codes for that by the way! If you want to get down to that level, that’s very helpful if you’re talking about research. It is insane—for lack of a better word—to use that for billing purposes. We’re the only country in the world that is doing that. Other countries are using it for research purposes to really get an idea of what’s happening to their population in terms of health. We’re using it for billing, and that’s a mistake. It’s ludicrous to most physicians.

Gilreath: For many years, the ICD-9 codes and current procedural terminology (CPT) codes were used for billing, but not to treat patients. And the billing system was the lead system for sending claims to payers. Since electronic medical records (EMRs) have taken hold, the billing part is the back end of the process these days. Now, you’re documenting a clinical event. If you take the billing equation out of it, it’s really a natural progression from documenting the correctness in the EMR and transitioning that to the back end, the billing piece. I don’t know how you do one and not the other, and have that impact billing.

Jeanne Gilreath

Rosen: I hate to disagree, but I think billing is the only driver to this change. I don’t know any doctor that believes that the driving of the EMR is for clinical documentation. It’s not, it’s for billing purposes. To believe otherwise is a fantasy. That’s just the way doctors look at it. We would not do this if not for the reason that we wouldn’t get paid if we didn’t. That’s a fact. Being an IT person, I like the data part of it and that we’re documenting more, but the only reason is because of billing purposes. If it was left to our own inclinations, we wouldn’t do it at all; we would do everything on paper. Our efficiency has dropped off so dramatically that most of us are seeing about 50 percent the number of patients that we did just five years ago. If you really want to talk about taking care of patients, that’s where we’re seeing the impact.

From a doctor’s standpoint, is this mandate, along with others, becoming too taxing?

Rosen: It is. I have been practicing for 30 years, and two years ago I made a conscious decision to get out of clinical practice and move into the academic and administrative aspects. It became too much. Those of us at the end of our careers are looking towards getting out of clinical aspects and going into other things. The average age of the 80 surgeons in my department is over 50, and the average person is looking to retire in next 10 years, which is unbelievable.

Do you have confidence in the current ICD-10 deadline of Oct. 1, 2015?

Williams: We have heard from providers who think it’s going to be delayed again, so they’re taking a wait-and-see approach, which is a dangerous one based on what we’ve talked about regarding reimbursement. It’s also a political thing, and that could weigh into the decision.

Gilreath: Last year I was sure it was going to happen, and when it didn’t, I lost that confidence. It’s a roll of the dice; I don’t have that confidence anymore.


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