ICD-10: Now the Bad News
On February 2, 2012, Dr. James Madera, CEO of the American Medical Association, sent a letter to HHS Secretary Kathleen Sebelius urging her to “immediately halt the HIPAA-required implementation of ICD-10.” Two weeks later to the day she did just that, although ultimately the “halt” proved to be a delay of just 1 year. The gist of Madera's letter, slanted toward the specific concerns of oncologists, is outlined in the paragraphs that follow.
ICD-10 is a massive undertaking that expands our current 13,000 codes to 68,000 codes. It will impact nearly all business processes in a physician's practice: verification of eligibility, pre-authorization, clinical documentation, research activities, public health reporting, quality reporting, and claim submission. It will require education, software implementation or updates, coder training, and coordination and testing with vendors and payers. The cost of implementation is projected to cost $83,000 for a 3-physician office and $285,000 for a practice of 10 physicians. It can be anticipated that for oncology, with its already complicated billing systems, implementation will cost more than average. This is at a time when oncology reimbursement has already taken a significant hit as a result of the Medicare Modernization Act, and when sustainable growth rate (SGR) cuts continuously loom on our horizon. It is conceivable that many oncologists in private practice would find this to be the last straw.
The comparatively simple conversion to version 5010 billing software this year has not been without significant problems, resulting in disruptions in claims processing and delayed payments. It is noteworthy that these payer problems disproportionately hurt providers. This is dramatically amplified when physician services include chemotherapy. Presumably small delays can result in cash flow problems that put a practice seriously in arrears with regard to financial obligations to distributors, employees, and landlords. Stories of practices that can no longer buy drugs on credit or that have had to rely on physicians' personal loans to meet financial obligations have fueled the migration from private to hospital-based practices. If the ICD-10 conversion is allowed to put more pressure on these stress lines, patients will suffer.
Staring down ICD-10 would be a lot easier if it didn't have a whole lot of company. Physician practices are already struggling with mandates for e-prescribing, electronic health record (EHR) meaningful use, and the Physician Quality Reporting System (PQRS). The struggle to keep up with all the various IT and reporting requirements leaves little time for oncologists to get engaged in finding their place in accountable care organizations or patient-centered medical oncology homes as envisioned by the Affordable Care Act. It was, perhaps, this argument and a chart showing the penalties associated with noncompliance with each mandate that carried the day with Secretary Sebelius.
However, there is more. Implementation of ICD-10 will have a huge impact on physician productivity. Even among proponents, there are misgivings about the demands that ICD-10 will place on physician documentation. Gone are the days of “breast cancer NOS.” A physician note that does not indicate that the breast cancer is an estrogen receptor–positive breast cancer in the upper outer quadrant of the patient's left breast without evidence of metastases and that it has been completely excised will be getting coding queries up to ying yang. Where physician financial productivity is tied to high volume and poor documentation, throughput will have to take second seat.
When all is said and done, it is not a given that ICD-10 will make good on its promises. ICD-10 is heavy into anatomy and light on histology. It is much more interested in knowing what lobe a metastatic lung cancer began in than in descriptors such as cancer cell type, stage, and histologic grade, which are far more important in determining what drug to use. The improvements in ICD-10 do more for primary care, ambulatory care, mental health, and preventive medicine encounters than they do for specific disease states such as cancer. Time will tell, but ICD-10 may prove to be little more than a very expensive stop gap to an ICD-11.
Taking Ownership and Getting Prepared
Short of burning tires in the streets (and maybe even then), ICD-10 seems bound to happen, and whether you herald it as a dramatic improvement or the lesser of two evils, putting off preparation would be a mistake; better to take ownership of the problem and command of the situation.
The first step in preparation is to take an appraisal of where you are at now, and that means not only your practice but outside entities such as your EHR and other software vendors, claims clearinghouses, outsourced billing services, and payers. If they aren't ready, you aren't either.
In the process of this stock-taking, you will identify diagnosis coding tools, superbills, public health reporting tools, compliance plans, and documentation templates, to name a few, that will need to be updated and translated from ICD-9 to the new Greek of ICD-10. It is important to recognize that this project is much more than a billing issue—you must be sure to identify all those who will need training in ICD-10 and what that training will entail. Once the size of the task is understood, a budget and timeline can be established and oversight assigned to practice management. A physician champion, if you can roust one, will prove invaluable.
Staff training will be an arduous task, but the rewards of a job well done will be self-evident. When Canada converted to ICD-10, it reported a 55% reduction in productivity that took 6 months of on-the-job training to reverse. It may well be that the most critical and resistant group to train will be physicians who are reluctant to tighten up their notes. The goal is not to turn doctors into coders, as they should focus on being good clinicians; however, good documentation is good clinical practice.
These steps should all be accomplished well before the deadline for compliance, to allow time to conduct in-depth internal testing, so as to ensure that you can generate transactions with ICD-10 coding accurately and efficiently. Then turn to your vendors and payers to make sure that ICD-10–coded transactions can be sent and received.
Even then, be prepared for possible delays in payments and negative impacts on revenue cycles. If cash flow could be a short-term problem, establish lines of credit ahead of time. Keep in mind that on a longer-term basis, industry estimates ominously suggest that it could take up to 5 years post ICD-10 to stabilize cash flow.
Finally, prepare to specifically monitor ICD-10 coding and billing on the back end for at least 6 to 12 months. Identify best practices in the clinic and bring staff members who lag behind back for additional training sooner rather than later. Identify high-frequency diagnostic problems and fix them. At the end of the monitoring program, integrate your findings into your compliance program going forward.
Choosing to Survive
I'm still not clear what “getting sucked into a jet (aircraft)” means. But given that it is a diagnostic code, I figure that it means that it is possible to survive it. After a hard look at ICD-10, the good things and the bad things, and trying to put it all into the context of 21st century healthcare and my oncology practice, I don't think that ICD-10 is a jet (aircraft). Whatever it is, though, we are getting sucked into it, and we might as well plan to survive.
Financial Disclosure: The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.