Five Unknowns to Consider
By Rex A. Stanley, RN, CPC, CMM, PCS, CHBC, CRS, CPCO, President of Alpha II, LLC
Twitter: @Alpha_II
How the ICD-10 delay was wrapped into the SGR bill, approved by Congress, and signed into law with such lightning speed may remain a mystery forever. Depending on how prepared you are to transition from ICD-9 coding to ICD-10, however, physicians and hospitals can demystify some of the unknowns caused by the delay to govern their organizations effectively. In my opinion, the top unknowns are as follows:
- What is the real deadline? The deadline to implement ICD-10 has been delayed from October 1 this year until October 2015 at the earliest. If your organization is on schedule for the switchover, or you haven’t begun to prepare for the new coding, knowing the real deadline will significantly influence how you manage the delay and your bottom line. If you’re on track for ICD-10, do you retain your training team and stay the course, only on a slower and steadier pace? Or do you dismantle it and try to rebuild it later? Either way, the decision affects human resources and expenses. Further complicating matters, there are still discussions of bypassing ICD-10 and jumping directly to ICD-11 by 2018.
- Will CMS release ICD-9 updates? ICD-9 and ICD-10 codes were frozen to accommodate the transition, but now that implementation is stalled, will CMS update ICD-9 codes soon to meet the pressing need for new procedure codes? Hospitals particularly will need to watch this closely to update systems faster than usual to have codes ready by October.
- Will modifications to ICD-10 codes be issued? The ICD-10 Coordination and Maintenance Committee did not plan to release the 500-plus modifications to ICD-10 until a year after implementation. Now that the timeline is extended, will they release them now? If so, and if you’ve already begun ICD-10 training, you’ll have to adjust your education and the code sets in your software. And, since we don’t know when these might come out, you’ll need to be prepared to move quickly to accommodate these significant changes.
- How will LCD (Local Coverage Determination) policies affect coding, claims and billing? Preliminary policies, reflecting ICD-10 coding, appear to be woefully inadequate, mapping ICD-10 codes to GEMs (General Equivalence Mappings) and resulting in at least one ICD-9 code that maps to 1, 467 ICD-10 codes. Does that sound right to you? Physicians and hospitals using automated coding, claims and billing solutions may fare better than others. By being able to edit their own claims and mine proprietary databases they can continue to demonstrate medical necessity and ensure appropriate payment, regardless of ineffectual policies.
- Will training support be available? If you started training and suspend it temporarily and hope to resume it later, or if you expected to train at the last minute, there may not be resources available. When the last ICD-10 deadline was pushed back from October 1, 2013 to this year, many training companies saw their business plummet, but decided to remain in business despite losing money. With the latest delay, will they be able to hang on further or will they be defunct by the time you need them? If you haven’t started training, I suggest engaging training resources now to ensure support when you need it. Again, providers using robust coding, compliance, claims editing and revenue analysis software are in the strongest position to weather this period of indecision because extensive clinical and administrative training may not be necessary.
The first three unknowns above rely on the government, so all you can do is be aware of them and monitor them closely to see how they roll out. But physician and hospital leaders can take control now by leveraging IT resources that put you in the driver’s seat for ensuring payment, protecting you from ineffectual policies, and lessening your reliance on training resources that may not be there to help at the crucial time.
About the author: Rex Stanley is president of Tallahassee, Fla.-based Alpha II, LLC, a company that develops data content and rules engines that drive ICD-9 and ICD-10. With more than 35 years of experience in healthcare, the former CEO of Unicor Medical, Inc. in Montgomery, Ala., has extensive knowledge of coding, reimbursement, compliance, and fraud and abuse issues. He has held a variety of clinical and administrative leadership positions, including chief financial officer for a 68-physician multi-specialty group. A member and former leader of numerous professional and honorary associations, Mr. Stanley is an esteemed consultant and a nationally known speaker at conferences across the United States.