Bruised by ICD-10 delay, healthcare execs huddle over what to do next

Executives at Catholic Health Initiatives had to roll out new electronic health-record systems across 89 hospitals nationwide while meeting the Oct. 1 federal deadline for implementing the complex new ICD-10 coding system. They knew the two big health information technology tasks couldn't both be done in the time available.

So CHI officials decided to spend millions of dollars remediating outdated “legacy” software programs in some hospitals so that they could run on ICD-10 coding for as many years as it would take to install new EHRs.

That remediation money may have been wasted thanks to Congress' surprise decision to delay the switch from ICD-9 to ICD-10 at least until Oct. 1, 2015, and maybe longer.

“We made decisions 18 months or two years ago that we are going to do certain things and postpone certain things based on having to implement ICD-10,” said Michael O'Rourke, senior vice president and chief information officer at the $11 billion Catholic Health Initiatives system, headquartered in Denver. “Had we known this would be delayed, things would have been different.”

Healthcare providers, insurers and other organizations now will have to wrestle with when they think the government will ultimately push the button on ICD-10 in deciding when they should start—or restart—training their doctors and workers. They also are calculating how much time and money they wasted in training and preparing for this October, since doctors' and coders' memories of the intricate ICD-10 codes will fade fast without daily use.

O'Rourke and many other top healthcare executives around the country met in private conference rooms last week to wring their hands, rewrite timelines and try to divine when the next deadline will be. They have to decide whether to cut back for now on their staffing and IT investment in ICD-10, and when to ramp it back up. Since last week's decision was the third such delay, they are wondering how much stock they should put on the next announced deadline—and how to convince skeptical doctors and staff to go through another round of intensive training.

Come 2015, “what if the government says for some reason, we won't go to ICD-10?” asked Dr. Alistair Erskine, chief clinical informatics officer at the Geisinger Health System in Danville, Pa. “What if we (as a nation) decide we're going to go (straight) to ICD-11? Now we're stuck.”

Like most everyone else, the CMS was caught flat-footed by Congress' insertion of the ICD-10 delay in the annual temporary patch of Medicare's sustainable growth-rate formula. At deadline Friday, the CMS had not produced a statement telling the industry about its plans to implement the law signed by President Barack Obama April 1.

“We are examining the legislation and will provide guidance to providers and other stakeholders soon,” CMS spokeswoman Rachel Maisler said late last week.

In 2012, the CMS had estimated that a one-year delay in the ICD-10 switchover would cost an estimated $306 million. The cost may be higher now because many organizations were far along in their preparations.

Nearly every clinical and financial computer system will be affected by the switch to ICD-10. Every hospital visit, every inpatient dollar flowing from a payer to a provider would have been coded using the complex new system. ICD-10 includes more than 68,000 potential codes for discrete medical conditions, up from the 13,000 codes under the current system, ICD-9.

Erskine said Geisinger leaders will probably come to a decision on their way forward at a staff meeting this week. The physician-led integrated delivery system in central Pennsylvania had planned to have all of its physicians trained on ICD-10 by May; that's when it would have activated the onboard ICD-10 coaching function already installed in its EHR system. That would have given physicians five months to get comfortable with the new codes before the Oct. 1 compliance deadline.

People on the financial side at Geisinger also were preparing intensively, Erskine said. They planned to take the records the doctors coded in ICD-10 and convert them to ICD-9 for both billing and analysis of the coming financial impact from the code shift.

With the delay, Geisinger now has some choices to make. Should the organization simply continue running in ICD-10 and “dual-code” for billing in ICD-9 until 2015? Or should the organization put that plan in mothballs until this time next year?

“You could imagine, there is a heated debate within the organization,” Erskine said. “The revenue cycle team has no intention of slowing down. They will continue to absorb hours getting people across the line for ICD-10. On the other hand, I don't think I'd be able to find any physician out of a staff of over 1,000 who would say, 'Please, give me more ICD-10.' ”

Other providers also are searching for answers. “I have a communitywide call with all the CIOs in Massachusetts on April 7,” said Dr. John Halamka, CIO for Beth Israel Deaconess Medical Center in Boston. “I'm going to recommend we do our very best to move forward with ICD-10 testing and go ahead with as much ICD-10 as possible,” including dual-coding, using ICD-10 data in house, and ICD-9 data for billing.

“Doing nothing but waiting on ICD-10 is not an option,” he said. “I can't imagine wrapping it in a bow and putting it on a shelf and then losing our investments.”

That's good advice, said Lynne Thomas Gordon, CEO of the American Health Information Management Association, the Chicago-based organization for medical records professionals that has strongly advocated for the change to ICD-10. “Even if you slow down, don't stop,” she said. “What we're saying is use this to your advantage. Strengthen your clinical documentation programs.”

Better documentation will add value for both ICD-9 and ICD-10 users, she added. “Make sure you have your coders and stakeholders trained in ICD-10. If you're dual-coding, keep doing it.”

AHIMA held its first post-rollback webinar on ICD-10 Friday, just to bring its people up to date on what happened. This week, the organization will conduct a webinar for its members on what to do about its credentialing exams, she said. The sudden delay is a particularly touchy subject with AHIMA members, and not simply because their organization has been a leading advocate for the ICD-10 conversion for more than decade. It essentially lost the congressional lobbying battle to stay on schedule for the Oct. 1, 2014 launch.

Physician groups such as the American Medical Association and the Medical Group Management Association were openly stumping for an ICD-10 delay. It's not known which House members actually inserted the ICD-10 sentence into the Medicare doctor-payment bill or what backroom deal led to that provision.

So far, the winners of this lobbying battle aren't openly gloating. The losers have only their suspicions about who was responsible. “When you find out let me know, because we have about 75,000 people who are ready to wring their necks,” Thomas Gordon said.

About 35,000 people are currently enrolled in accredited health information management training programs with ICD-10 components, the AHIMA leader said. Of them, about 3,500 are taking ICD-10-specific coding courses.

Technically speaking, those organizations planning to dual-code over the long haul won't be terribly challenged, said Russell Branzell, CEO of the College of Health Information Management Executives, the Ann Arbor, Mich.-based association of hospital CIOs.

“The geek part of this really isn't all that difficult,” Branzell said. “It's pretty easy to map backwards,” converting ICD-10 to ICD-9. “I've talked to two CIOs in the last couple of days who have already made this decision. They've been dual-coding for months. There's no way they're going to stop. They're getting better documentation from providers and better data from a research perspective.”

Still, Branzell said, there was “pretty significant overwhelming disappointment” among CHIME members about the delay.

Beyond disappointment, there was serious money at stake. Hill Physicians Medical Group, an independent physician association with 3,800 doctors based in San Ramon, Calif., and its management services organization, PriMed Management Consulting Services, had invested $2.1 million in ICD-10 preparations, said Dan Robinson, the chief administrative officer and vice president of corporate services.

He said the delay will increase costs by at least 8% to 10%. But “we are not going to take our foot off the pedal.”

Some smaller hospitals and physician practices welcomed the delay. Dave Clark, the interim administrator for Hardeman County Memorial Hospital-Quanah (Texas), said it will help his 18-bed critical-access hospital survive. The hospital filed for bankruptcy last May, and Clark said he expected the ICD-10 conversion to disrupt the hospital's reimbursements to the point of forcing closure. The delay will give it time to build up a reserve. “This gives us our best shot,” he said.

Even some who believe they were ready for the big conversion said there is some advantage to the pause. “Time is a very rare gift to be granted,” said CHI's O'Rourke. “When someone grants you more time to do something … you sort of say, hey, that's not a bad deal. That is actually good for an organization, to do more testing and be more prepared.”

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