Products & Technology

Countdown to ICD-10: Are you Ready?

With the countdown to Medicare's ICD-10 implementation well underway, providers must ensure they're in compliance with the massive revision.

ICD-10As the standard diagnostic tool for epidemiology, health management and clinical purposes, the World Health Organization’s ICD-10 (the 10th revision of the International Classification of Diseases) is the biggest ICD revision ever unleashed upon the healthcare community. ICD codes are currently the basis of classifying diseases, injuries, health encounters and inpatient procedures in morbidity settings.

The U.S. Department of Health and Human Services (HHS) issued a rule finalizing Oct. 1, 2015, as the new compliance date for healthcare providers, health plans, and health care clearinghouses to transition to ICD-10.

Although the ICD is under constant revision, ICD-10 has major modifications, taking the number of ICD-9 codes from 3,824 (procedure) and 14,025 (diagnosis) to 71,924 (procedure) and 69,823 (diagnosis).

The reason for the latest change: The U.S. has been using ICD-10 since 1979, and it is no longer clinically accurate, with limited data about patients’ medical conditions and hospital inpatient procedures. According to CMS, ICD-10 helps improve patient outcomes, provide detailed data, improve quality tracking and reporting, and survey public health issues.

Are HME Providers Ready?

With HME providers poised to adopt ICD-10 last year before the most recent implementation date change, there is hope that most have been preparing for October 15. However, Andrea Stark, reimbursement expert with MiraVista, LLC, believes that there will still be too many suppliers who may stumble, and too many who mistakenly believe that their software vendors can crosswalk every code for them without intervention. Lack of preparation will be costly, she said.

“The pathway to a smooth transition begins for DME providers with consideration of how the transition will affect recurring rentals and supplies, as well as new setups,” Stark says. “For many providers with product concentrations there may only be a few key diagnosis codes to migrate. These early, thoughtful considerations will also rely on collaboration from HME providers’ billing software vendor and referral sources.”

Stark says a transition plan is necessary. It should require compatibility with billing software and that it is important to communicate with your software vendor prior to building your action plan to ensure that your strategies are in line with that of the software vendor. Some of the questions HME providers should ask include:

  • Will ICD-9 codes automatically be crosswalked by the software vendor?
  • Will there be any manual intervention required by your staff to transition existing sales orders or codes with multiple mappings?
  • Will there be a protocol for scrubbing claims prior to submission to ensure that codes have been properly transitioned?
  • If so, what will this process look like and will there be action required from your staff to move these claims forward?
  • Has the vendor already participated in, or will they be participating in, the ICD-10 testing opportunities?

Stark recommends using a data export from your billing software to determine your top 10 ICD-9 codes and then create a map to the new ICD-10 codes. Also, determine if additional information will be required from your referral sources and start to proactively gather information on new setups that will allow you to make a coding conversion by October 1.

For new orders being introduced into the system, she said to ensure that your referral sources are educated and are contemplating their plans. Getting those doctors to proactively send the correct ICD-10 codes will go a long way to easing your transition.

As new orders come through, intake personnel will need to be well versed on the difference in codes to ensure that the correct code is logged to your system prior to order confirmation. Incorrect codes will cause the claims to reject or deny and tie up revenue.

“ICD-10 is incredibly important, as every claim for every service will be required to reflect ICD-10 coding on the effective date of the change for every payer in the country,” says Kim Brummett, vice president of regulatory affairs for the American Association for Homecare. “It is rare for any software change no matter how small to be 100 percent successful. The odds of this transition being smooth for every payer, every software application and every supplier/provider type are quite frankly zero. This means cash flow will be an issue somewhere along the healthcare continuum from hospitals, labs, optometry, drugs, DME, etc.”

Brummett also says that suppliers are only as ready as their software systems and the referral sources/prescribers. She points out that theoretically, suppliers will not ‘code’ a patient’s medical record; rather, they will rely on physicians and others to provide appropriate ICD-10 codes with the referral.

“For those products and services that require explicit codes, they will compare and ensure that the patient meets requirements,” Brummett explains. “The challenge will be dealing with all of the on-going patients who are on service and having to ensure that an appropriate ICD-10 is associated with that patient as of October 15. I think most suppliers are working to be as ready as they can going into the change.”

Brummett’s advice for HME providers is congruent to Stark’s: “Be sure your software vendor is ready and understand what the changes will be and how that affects your operational processes,” she says. “Determine how many patients will require manual intervention to move from ICD-9 to ICD-10 and how they will handle these requirements.”

Brummett says that providers should determine:

  • What the software vendor is doing to be ready
  • When they will make the software update
  • What the steps are to convert current patients to ICD-10s manpower necessary to complete this process and plan for it

“This is a very simplistic look at some of the steps suppliers need to be prepared for,” she adds. “Quite frankly, the list is very long and CMS does have some excellent references for suppliers to look at that include step-by-step guidelines to consider. I have not referenced the change in intake, sales, and support that all members of a supplier must be aware of as of the effective date.”

Software Vendors Help Lead the Way

As noted by Brummett and Stark, software is a major driver in ICD-10 preparation. In fact, an HME provider contacted for this article to discuss where they sit in ICD-10 preparation said, “We are currently not doing anything so I wouldn’t be much help. We are relying on our software to do the work for us.”

Kimberly Commito, director of product management for Mediware Information Systems, said software supports the ability to code accurately and effectively. By providing tools to match ICD-9 to ICD-10 codes and allow for a smooth and automated transition, healthcare providers can be assured they are addressing the movement from the old code set to the new one in an accurate way.

As an author of a white paper that helps HME providers find ICD-10 transition success, Commito offers the following tips:

1. Refresh knowledge — Providers should review information about the ICD-10 code set in order to gain a basic understanding of the changes from ICD-9 to ICD-10. This understanding will be needed in order to conduct an impact analysis and determine how the move to ICD-10 will affect their business practices and systems. They also should complete an inventory of all your systems, electronic and manual, that use the ICD-9 codes.

2. Contact software vendors — Contact software vendors for specific details on the installation of the ICD-10 upgrades to their systems, including dates and any costs. Providers should be sure to ask their vendor if they will maintain updates to the ICD-9 and ICD-10 code sets during the transition period and if they will be providing any crosswalk tools between the two code sets.

3. Contact clearinghouses and payers — Contacting clearinghouses, payers and/or billing services, if you used, for preliminary information on when they expect their ICD-10 upgrades will be completed. This will let them plan for testing.

4. Perform internal testing — Once the upgrades are completed, they will need to conduct internal testing of their systems to ensure they can generate necessary transactions with the ICD-10 codes. Allow extra time to resolve any issues that may arise and work with their vendors to address these.

5. Update internal processes and conduct staff training — Any internal processes used to support coding need to be updated, such as “superbills,” encounter forms, quality data collection forms, public health data collection forms, etc. Providers need to take the time to review clinical documentation to ensure it captures the necessary details of the patient’s diagnosis. They may want to look at the most common diagnoses reported. Coding staff will need to receive training on the ICD-10 code set prior to the compliance date. Coding staff may wish to practice internally using the ICD-10 codes on sample claims, such as current claims, prior to the compliance date. Clinical staff must also receive training on ICD-10, although it does not need to be at the same detail as training for the coding staff.

Richard Mehan, president of HME software company Noble House says that software is a key element to transitioning to ICD-10, which includes help in generating a report of patients, grouped by physician, where there is more than one possibility of a corresponding ICD-10 code. This allows the provider to call the physician and update the patient records accordingly.

On top of the tips already offered in this article, Mehan says that HME providers should methodically convert each patient to become ICD-10 ready and monitor claim submissions after October to ensure a smooth transition without disrupting cash flow.

According to Steve Rogers, vice president of product management for HME software service Brightree, notes “Based on our observations, many providers are not ready for ICD-10 conversion and are currently playing catch-up. That said, it is very important for providers to take the transfer to ICD-10 seriously, as the switch is bound to occur soon and effective preparation is needed to ensure a smooth transition.”

If you’re an HME provider who is not prepared to transition to ICD-10, Rogers says you need to assess your organizations and identify internal champions who can pave the way for this conversion. Company leaders must focus on implementing ICD-10 training programs and adjust processes accordingly so that they are prepared when ICD-10 compliance is required.

“Key steps that should be taken to get on track with becoming ICD-10 ready include putting emphasis on both internal and external communication and processes in order to efficiently bring employees and referral sources up-to-speed on how to best manage the transition to ICD-10,” he explains.

Rogers also offers the following tips for HME providers:

1. Build a team and strategy — Select a project leader and define a budget.

2. Assess the impact of transition — Review internal and external business processes and identify the potential impact of shift on documentation, forms and reporting.

3. Perform a gap analysis — Identify top ICD-9 codes used and employ General Equivalence Mappings (GEMs) to identify correlating ICD-10 codes.

4. Update technology.

5. Communicate internally and externally — Communicate changes and what to expect to internal staff as well as to external constituents including payers, physicians and referral sources.

6. Train staff — Train staff on role specific updates and plan out timing of training for maximum retention to coincide with ICD-10 transition.

7. Test and monitor — Test internal team on retention of training and new processes and monitor and adjust processes as needed.

Final Thoughts

“The ICD-10 implementation schedule calls for a hard cut off in the use of ICD-9 codes as of September 30, 2015,” Stark says. “This means that claims submitted with dates of service on or after October 1st with ICD-9 codes will be returned as unprocessable. Likewise, outside of the testing period, claims submitted with dates of service prior to October 1, 2015, with ICD-10 diagnosis codes will be returned as unprocessable. At no time can claims be submitted with both ICD-9 and ICD-10 codes. Claims that are submitted at any time with a combination of both ICD-9 and ICD-10 diagnoses codes will be returned as unprocessable.”

While contemplating service dates and transition schedules, it is important to also consider date spans, she said. Due to the nature of DME, it is not uncommon for providers to submit claims using date spans for recurring rentals (outside of Medicare) or purchase items (enteral nutrition, diabetic supplies).

“As we approach the cutoff date for the use of ICD-9 diagnoses codes, CMS has provided direction regarding the use of date spans,” Stark explains. “For DMEPOS items that span across the implementation date, for example, the ‘from’ date of service occurs before October 1, 2015, and the ‘to’ date of service occurs on or after October 1, 2015, suppliers should base diagnosis coding on the ‘from’ date of service. This means that claims with a beginning date of service prior to October 1, 2015, should be submitted using an ICD-9 diagnosis code. Remember, for recurring rentals that bill beyond the transition date, ICD-9 codes will need to be cross-walked to a valid ICD-10 code for future service dates beyond the transition to pass edits.”

She also said that suppliers will not be required to secure updated paper scripts, but they must be able to support a coding determination when making the migration.

The WHO reported that ICD-11 will be released globally and across all sectors some time in 2017.

This article originally appeared in the February 2015 issue of HME Business.

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