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Whether healthcare firms are ready or not, the U.S. government's upcoming deadline for ICD-9 to ICD-10 conversion stands firm. On Oct. 1, 2015, healthcare providers must submit all of their claims using ICD-10 codes. With no grace period, technology and service providers are preparing their clients for the transition any way they can.
ICD-10 expands the number of claims codes from around 17,000 to more than 140,000. "The whole purpose is to get to a more granular level. That's why there are so many new codes with ICD-10," said Crystal Ewing, senior business analyst and manager of regulatory strategies for ZirMed Inc, a provider of cloud-based financial and clinical performance management offerings for healthcare based in Louisville, Ky.
But that isn't where the difficulty lies: "The challenge is more in terms of practitioners wrapping their heads around the new code set. Because the transition will happen all at once, it's difficult to predict how it's going to impact their practice and workloads," said Elysha Fiabane, product innovation manager and overall ICD-10 project lead for athenahealth Inc. The company, based in Watertown, Mass., provides cloud-based services for electronic health records and other healthcare applications.
"This is not just an IT problem. This is more of a business problem. Look at it this way: The system can ingest the data, but the data has to be good. The data has to be quality," Ewing said.
She explained: The diagnosis must match the ICD procedure code, and the code must be verified and appropriately documented and billed. "There's an intervention that has to happen there, and there can be many business processes that have to change to make sure that can happen," Ewing said.
Helping coders face ICD-10 transition impact
Coders and those who bill medical claims will be most impacted. "They've been using ICD-9 for 30 years, and most of them have the codes memorized. ICD-10 is completely new, so ZirMed provides tools to help them understand what they do today and what the impact will be tomorrow," Ewing said.
Crystal Ewingsenior business analyst and manager of regulatory strategies, ZirMed Inc.
For example, ZirMed's analytics platform helps healthcare providers understand the payers to whom they submit the most claims and the codes they use. Ewing said this allows providers to "build critical benchmarks to understand what they're doing today so they can identify if there's going to be a problem tomorrow."
Peter Kinhan, vice president and general manager, ambulatory practice solutions for GE Healthcare, a medical technology and service provider, agreed. "Even if you are ready [for ICD-10 conversion], there's going to be a learning curve and that potential impact on your cash flow can be a real threat for small practices," Kinhan said. To this end, GE Healthcare offers a productivity assessment to help organizations with their business processes. "We do anything we can to help them be as efficient as possible and alleviate some of that impact."
Systems testing is also expected to help reduce the impact of the transition. Athenahealth has been testing its web-based systems using 350,000 practice claims submitted by practitioners. "We've created a readiness center that pulls real data to determine what the most commonly used codes are. These practice claims help us determine what life will be like post transition," Fiabane said.
The onus isn't only on healthcare providers. "Payers have a tremendous amount of work to do to get their systems ready," Kinhan said. "It's unclear how ready they are, but there's a real handshake that happens between the provider and the payer, and it's difficult to test that at scale with all the different combinations that exist in the market."
Athenahealth has been working with payers, too. "We conduct in-depth insurance payer testing on [our clients'] behalf, reaching out to payers to understand when they'll be ready to accept ICD-10-coded claims -- and which will still need ICD-9 codes," said Carey Manning, athenahealth's product marketing manager.
Regardless of the technology and service providers' testing efforts, there's still no telling what the final impact of the ICD-10 conversion will be. "That testing and end-to-end confidence that you'll be effective is hard to get until Day 1 hits. It has a little bit of Y2K feeling to it. You can do lots of preparation, but you don't know what will happen until it comes," Kinhan said.
ICD-10 conversion: The cost of failure
One thing is certain: The cost of not being ready on October 1. "We believe this is a huge deal. If you look at the attention that meaningful use got and the stakes involved with that, ICD-10 is a magnitude higher in terms of risk and potential financial impact. Many of the practices we support are small businesses. Cash flow and denial rates are critically important," Kinhan said.
The business problem:
- Healthcare companies that don't adopt ICD-10 codes face the rejection of their claims and the resulting financial impact.
The channel opportunity:
- System upgrades, billing and EMR in particular
- Business process productivity assessment
- System testing
Ewing agreed. "If a payer is not accepting ICD-9 codes and the provider can't send ICD-10 on their claims, then they're in a bad position," she said. "They can't get claims out the door and especially the small providers -- that's how they make payroll and that's how they're funded."
To that end, healthcare industry specialistssare prepared to help their clients beyond October 1.
"Not everyone will get over the line smoothly. We anticipate there will be some bumps in the road. If there are some who need to revert back, we want to make sure we can accommodate that," Manning said.
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