Prepare for ICD-10 worst-case scenarios, vendors say, as switchover looms

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Prior to the Red Sox winning the World Series in 2004 there was a saying in New England that Boston had only two problems: September and October.

Healthcare providers should be able to relate. That's because experts say problems seen in September in testing ICD-10 codes could become disasters when the new diagnostic code set goes live on October 1.

Any delay in the front-end process from coding to billing will be costly, according to Joshua Berman, director, Business Analytics and ICD-10 Lead for RelayHealth.

Doctors have to keep great notes and coders have to code correctly.

"Those two things alone could slow you down or stop revenue," Berman said. "If you're doing a million dollars a day, and on Oct. 1 it's $500,000 a day, it's a hefty accounts receivable to have on the books that's not getting out the door."

[Also: Twitter account posting every ICD-10 code online]

Fletcher Lance, managing director and national healthcare lead at North Highland said, "If you get stuck in your own system, it's adding days. The killer will be time. What was a normal revenue cycle of 65 days is up to 95 days."

The worst case scenario, said Richard Milam president and CEO of EnableSoft, is when "People think that they've finished and everything is ready to go and there's a coding error in the matrix and it has to be done overnight."

Berman and Lance agree worst-case scenarios will happen.

"We fully expect problems and slow downs," Berman  said. "We have test data to show that."

Lance described the ensuing backlog this way: "The trains are running, people are waiting in the lobby and we've got this problem … They're distracted with processing issues versus taking care of me and you."

Providers' biggest concern is making sure all the pieces are place, the systems are set up right, the data is ready and everyone is trained to use it, said Lance.

However correcting problems is more than getting the technology to work, according to Berman.

"This isn't a technology change, this is a process change," Berman said. "If you want to drive healthcare mad, create a process change. There's nothing to fix this, but a great process."

[Also: Healthcare providers in mad dash towards ICD-10]

On Oct. 1, the number of diagnostic codes will increase from an estimated 14,000 under ICD-9 to 68,000 in the new ICD-10.

Milam recommends having readily available a list of the common or most often used abbreviations for ICD-10 codes. Above all, said the ICD-10 vendor experts, focus on the 200 to 500 codes that drive 80 percent or more of revenue.

"How many times do you use 'injured at the opera?'" Berman said, referring to one of the many new codes in ICD-10

"How do you protect key revenue?" said Lance. "One of the things we focus on that works are the codes that matter. Hospitals and physician practices have a set of codes that drive revenue. Don't worry about visits that happen twice a year."

The problem is greater for the 400,000 plus smaller physician practices that don't have the resources of the larger hospitals.

"The worst thing that can happen, which I hope doesn't happen, the smaller providers don't get prepared and their revenue cycle gets knotted up," Lance said. "They can't get their bills out, or they get them out and there are delays. If half of those (practices) have problems, then we've got a problem."

American Medical Association President Steven Stack, who originally voiced support for skipping ICD-10 in favor of waiting for ICD-11, said his concern was for the two-thirds of physicians who work in smaller practices.

However, Stack credits the Centers for Medicare & Medicaid Services for offering a year's grace period in reimbursing claims that are submitted in the correct family of codes.

[Also: CMS reiterates that it won't reject ICD-10 claims ... sorta]

"The AMA believes small physician offices would have been hit hardest by the ICD-10 transition without a fair and reasonable period of transition agreed to by CMS," Stack said in an email. "The recently announced transition period will give physicians breathing room as the health care system adapts to ICD-10 and will help reduce the risk of financial disruptions to practices so physicians can continue to provide high-quality patient care."

The AMA would continue to work with CMS to make sure contingency plans are in place and that emerging implementation issues are addressed, he said.

Commercial payers have yet to give the same assurances as CMS, Lance said, but he believes they will follow CMS' lead.

"None of the big Blues or others are following suit," he said. "I think there will be leniency."

Providers must wait on the back end to see if a claim is paid or denied.

"I think pretty quickly it will level out to determine which payers are taking 10s, then we'll start to see denials in reimbursement rates," Berman said. "You will see more medical necessity denials. Did you get the $1,000 expected or $100, which interestingly enough, could be your fault. If you code it that way, that might be the dollar amount you get."

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Overall, Berman believes greater specificity will lead to better reimbursement.

"In theory as we move towards value-based payments, the more specificity, all the better paid," he said.

"I think everyone's got their heads down plowing to Oct. 1, but Nov. 1 will be pretty telling on how we did. It can be a go time for people not prepared," said Lance.

Other advice for providers: Test key codes with payers; take another look at the overtime budget; have extra cash on hand; educate staff; consider robotic process automation; make sure employees know who to contact if they are unsure of what code to use; update patient intake, insurance and other forms to support the ICD-10 codes.

Twitter: @SusanMorseHFN