On Oct. 1, 2013, nearly the entire U.S. healthcare industry is scheduled to start using the ICD-10 family of diagnostic and procedure codes in response to a federal mandate.
It's a date that, without close examination, still seems comfortingly distant. But distances in healthcare, as they can be in the desert, are often illusory.
Many experts say the industry will be hard-pressed to complete the long, hard trek to the ICD-10 Promised Land in time to meet the federal deadline. That's because of a confluence of factors, most prominent of which are the industry's own congenital procrastination as well as the government's compressed time frame for its health information technology incentive program under the American Recovery and Reinvestment Act of 2009.
Adding to the pressure, federal policymakers are looking to ratchet up the 2013 meaningful-use criteria that providers must meet to qualify for electronic health-record system payments.
The mandate for the switch to ICD-10 comes from the Health Insurance Portability and Accountability Act of 1996.
So, where do we stand on ICD-10?
This is nearly the midpoint into the 56 ½-month rollout period granted by HHS for preparation and conversion to the robust new codes, and according to many health IT cognoscenti, the industry is nowhere near where it should be in terms of ICD-10 readiness.
In addition, the deadline for an upgrade to the ASC X12 Version 5010 transaction standards, a vital precursor to ICD-10, is now only 9 1/2 months off—Jan. 1, 2012. Think of 5010 standards as the new, bigger buckets needed to carry the longer and more voluminous ICD-10 codes (See graphic on the evolution of the ICD).
Stanley Nachimson is the principal of Nachimson Advisors, a health IT consultancy, and a former senior technical adviser for health IT activities at the CMS.
Nachimson is serving as a consultant with the Workgroup for Electronic Data Interchange, a health IT trade group that in 2009 helped develop an unofficial but detailed ICD-10 implementation timeline for providers, payers and IT developers and service vendors—all of which will be profoundly impacted by the 5010/ICD-10 conversion.
Last November, WEDI and its partners felt compelled to publish an “alternative” timeline with, by necessity, squeezed time frames for virtually every preparatory task. Industry surveys, including those by WEDI, pointed to so much foot-dragging that the original timeline was a dead letter.
“WEDI has conducted surveys every six months, and the surveys continue to show ICD-10 has not been a high priority,” Nachimson says. “Instead of saying, ‘Oh, good. We have plenty of time to do it right,' some folks have thought, ‘We have two years to put it off.' ”
“I fail to understand this industry,” Nachimson says. “A lot of entities don't seem to learn the lesson of being prepared early.”
One oft-repeated reason for procrastination is the industry's communal hope that the government will blink and simply roll back the ICD-10 compliance deadline. That could be a costly assumption, since “all the information we have from HHS and CMS is the timeline will hold,” Nachimson says.
Meanwhile, some unprecedented heavy lifting looms for each major group of affected parties—providers, payers and IT vendors, he says.
“I don't think there has ever been the change of the magnitude that ICD-10 brings with that hard and fast a date,” he says. “This is far more resource intensive than we initially thought.
“If you don't get this right, you might not get paid,” he says. “If you don't do the appropriate analysis and preparation, you won't generate the right ICD-10 codes, you won't get the right amount. If your revenue drops even 1%, that's a serious drop to a hospital. If you're a plan, what happens if your payouts are 3 to 4 percent higher? That's a serious loss of money.
“The real point that the (new) timeline makes is that almost every step gets squeezed,” he says. “There is less time for the business and technical strategy and that's important.”
Joe Miller leads e-health projects at AmeriHealth Mercy, Philadelphia, a for-profit provider of Medicaid managed-care programs and other services in 11 states. Miller led a packed educational session on ICD-10 readiness at the Healthcare Information and Management Systems Society conference in Orlando, Fla., last month and was the author of a report on a survey conducted in December by HIMSS on 5010 and ICD-10 readiness that, like the WEDI poll, indicated trouble ahead.
According to the HIMSS survey in which 256 hospitals, physician practices and long-term-care organizations participated, only 30% of respondents indicated they planned to start “external” testing of claims and related transactions using the 5010 standards with their payers and other business partners in the first quarter of 2011, which would be in keeping with the government's own 5010 timeline.
Another third (33%) of respondents, reported they intended to delay 5010 testing until the second or third quarters this year. The rest either would put off testing until the fourth quarter or didn't know when they would test. Not smart, according to Miller.
“Healthcare providers would do best to avoid the fourth quarter for testing, when payer and clearinghouse resources will be taxed to the limit,” Miller wrote in the HIMSS report. “The result could delay or negate their receiving payment.”
Meanwhile, other IT projects are competing fiercely with 5010/ICD-10 for attention and resources, the HIMSS survey showed. Meeting federal meaningful-use requirements were cited by 66% of HIMSS survey respondents as a distraction from work on the 5010 conversion and by 70% of those surveyed regarding work on the ICD-10 upgrade.
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Who has the biggest task getting ready—providers, payers or IT systems vendors?
“I think the lift is fairly well distributed across all three of those groups, and significant for all,” says Carl Dvorak, executive vice president of Epic Systems Corp., Verona, Wis., and chairman of the Electronic Health Records Association, a HIMSS affiliate representing EHR vendors.
The EHRA recently joined a chorus of industry groups, including the American Medical Association and more than 30 medical professional associations, and the College of Health Information Management Executives, in calling for a less aggressive approach by the federal government in drafting Stage 2 meaningful-use criteria.
The Stage 2 rules are currently slated to go into effect in 2013, crunch time for the ICD-10 conversion. The EHR vendors, in their public comments on the Stage 2 criteria, waved a cautionary flag, saying “regulatory pressures on providers are exacerbated by 5010, ICD-10 and other regulations that will go into effect in the next 24 months.”
Dvorak says the nation's ability to meet the 2013 deadline for ICD-10 could be linked to the pace of change on meaningful use. “It will depend on how thoughtfully Stage 2 is constructed and how well the timeline is rethought,” Dvorak says.
Robert Tennant, senior policy adviser for the Medical Group Management Association, says it is still finishing up a membership survey on 5010 readiness, but “preliminary results suggest that our practices are woefully behind, mainly because the vendors are behind,” he says. “They're not getting their upgrades.”
The Version 5010 switch “is almost a test case for ICD-10 in a sense,” Tennant says. “Let me tell you, ICD-10 is 100 times more challenging (than 5010). If we can't get 5010, there's no chance we can get ICD-10 right. If everything goes well with 5010 with vendor upgrades, testing and the plans, if they're able to flip the switch, then ICD-10 has a shot.”
Kathy DeVault is the manager of professional practice resources for the American Health Information Management Association, a decades-long champion of the switch to ICD-10. In 2009 and 2010, AHIMA conducted 13 academies—three-day, eight-hour-a-day sessions—to train 1,300 trainers of ICD-coders.
“We have 21 academies scheduled for 2011,” she says. “We don't have the workforce now. There are places in the country where they can't buy a coder.”
For experienced coders, the conversion to ICD-10 holds two levels of difficulty, DeVault says. “I don't want to minimize ICD-10 and say it's just another update, because it's not. But if you know Spanish, going from ICD-9 to ICD10 CM is like going to French.” There are differences, but also similarities. “But if you're going from ICD-9 (Volume 3) to ICD-10-PCS, it's like going from Spanish to Russian. It's a big difference.”
DeVault and AHIMA are calling for the industry, particularly health information management professionals, to suck it up and meet the deadline.
“This is our time,” DeVault says. “ICD-10 should be owned by HIM, and that's why as an organization we say to our members, you need to step up and be driving this bus.”
Jan Hunt-Shepherd is an assistant professor of healthcare information systems at Western Kentucky University in Bowling Green where there are 55 students enrolled in a two-year certificate coding program. She is a graduate of an AHIMA train-the-trainer program.
“My focus as an educator is getting the coders trained,” she says. Hunt-Shepherd says she hopes the conversion to ICD-10 will create employment opportunities for her newly trained graduates.
Typically, she says, “Providers only want experienced coders, so they're less likely to look at new students, but I think that will change with ICD-10.”
For all the gloomy outlooks, there are some points of light.
When the ICD-10 final rule was released in early 2009, “We knew that this was going to be a big project, so we got on it right away,” says Zelda Greene, administrator of health information management at Lehigh Valley Health Network in Allentown, Pa. “There are over 75 systems that have to be updated and worked on,” she says. “That's quite a job for our IT department. By preparing in advance the way we're doing, our confidence level is pretty high,” Greene says.
Greene and Carolyn Murphy, director of health information managementcoding and clinical outcomes at Lehigh, were presenters on ICD-10 at the HIMSS conference last month.
“Our formal training for ICD-10 starts six to nine months before implementation,” she says. “But we're starting to prepare everyone with anatomy and physiology beforehand.”
Barb Southern, IT director at Palmetto Health, Columbia, S.C., says her organization also got an early jump on ICD-10. The healthcare system is well into planning and should begin in a couple of months external testing of 5010 transactions with its trading partners using its main hospital financial system. Vendor readiness for smaller, ancillary systems is “not there yet,” Southern says. And that's the scary part, exacerbated by a lack of vendor transparency.
“We've already identified 50 systems that use ICD-10 codes. It's a huge coordinating effort, and when I think about what coordinated testing is going to be like, I get concerned.”
Southern says she's begun discussing with Palmetto's chief financial officer about preparations if cash flow takes a hit during—or worse yet—after the ICD-10 conversion.
“My worst fear is reimbursements,” she says. “We've got to run some predictive modeling somehow. Is there going to be a case-mix change? If there is a slowdown, what are we going to do? I might propose more FTE for coders, which no one wants to hear.”
Editor's note: This is an expanded version of the story that appears in the March 14 issue of Modern Healthcare.
