ICD-10 earthquake caused barely a shake

The troops, 125 soldiers, huddled around monitors in war rooms set up in Kansas City, Kan.

Strategist Mike Hourigan had decided what they needed to be ready for battle was food.

“All kinds of stuff, pizza, soda, coffee and bagels,” Hourigan said.

They waited and listened for the first shot, scheduled for midnight, Thursday, Oct. 1, 2015.

But then, “We haven't heard of anything,” said Hourigan, director of consulting and regulatory strategy at health information technology vendor Cerner Corp.

The national conversion to ICD-10 diagnostic and billing coding on its first night was running pretty smoothly.

And the troops at Cerner's offices that were ready to handle problems, questions and crises?

“For a lot of time, they didn't have a lot to do,” Hourigan said.

One of the most maligned and feared events in healthcare history began with a whimper.

“I think, by and large, at least the people we've worked with, they have done so much preparation that they're eager,” said Ed Hock, managing director and ICD-10 guru with the Advisory Board Co., a healthcare consultant. Health IT technology cognoscenti predict most providers of size-large hospitals and health systems, large physician groups and large health plans can handle the numerous, complex and very specific new codes.

If larger organizations experience cramps, they probably will appear later as kinks in their cash flows caused by delays in reimbursements.

The organizations most likely to have trouble, however, are smaller providers and health plans, which lagged in implementing IT upgrades and training to handle the more robust ICD-10 codes.

“Aside from a few technical glitches, so far so good,” said Dr. Stephen Michaels, vice president of medical affairs and chief operating officer at 90-bed MedStar St. Mary's Hospital, Leonardtown, Md., Michaels was the hospital's lead physician on the ICD-10 conversion. He attributed the brief technical difficulty to switching to ICD-10 while phasing out legacy IT systems. He said the otherwise smooth conversion to a single IT platform came from a lot of planning and preparation.

Michaels said the hospitals had been working toward Oct. 1 since last December. A 10-member committee included leaders from tech, revenue cycle, finance, inpatient and outpatient physicians and senior leadership, “but there were multiple subcommittees with multiple members,” he said. “We're talking people meeting weekly for months and months and months.”

“Physicians appear to be calm and stable about it. So far, I'm very happy,” Michaels added.

But even with hospitals, there is an element of uncertainty.

“They're not expecting anything significant or anything to break,” said Russ Branzell, president and CEO of the College of Healthcare Information Management Executives, a professional association of chief information officers, predominately at large hospitals and health systems.

Still, Branzell said, organizations are approaching the code change with caution.

“The real test will be claims flow as we near the end of the month,” he said. “They're going to have to do some pretty close claim adjudication watching.”

The possibility of delayed claims “is a concern,” Hock said. “I don't mean cataclysmic cash-flow impacts. But you talk about the impact of three to 10 days in accounts receivable, that's a big impact for most hospitals. It's just these little paper cuts about denials and delays in coding” that will wound, he said.

Payer readiness, particularly Medicare and Medicaid, is another unknown.

Relative calm also defined the atmosphere among several insurers.

“All is going well,” said Debra Cotter, the ICD-10 project director at Highmark in Pittsburgh. The Blue Cross and Blue Shield plan, which has 5.3 million members and processed 114 million claims last year, had been preparing for the switch to ICD-10 since 2010. It has since tested systems with providers over the past year, and then performed quality checks at midnight on ICD-10 day.

“We're excited to see the years and years and years of work actually in practice,” Cotter said. “We have seen our first claims submitted in ICD-10, and we have finalized a couple claims already.”

But the new code set does not mean ICD-9 will be immediately buried in its grave. For patients who saw their doctor or were admitted to a hospital before Oct. 1, those claims will still have to be submitted in old code. Cotter said Highmark will be ready to juggle both code sets at the same time.

Dr. J. Mario Molina, president and CEO of Medicaid insurer Molina Healthcare in Long Beach, Calif., compared the ICD-10 launch to Y2K, when Americans braced themselves for a technological meltdown.

“We thought the world was going to end, but everything went pretty smoothly,” Molina said. Molina's business processes have been ready for ICD-10 for more than a year, and claims operations at Molina have been status quo so far, he added.

At Security Health Plan, a smaller, 230,000-member payer owned by Marshfield Clinic in Wisconsin, the impact of ICD-10 won't be felt immediately. Security received its first claims files the evening of Oct. 1 for services provided earlier that day, said Sara Foemmel, the plan's claims operations director.

Few hiccups are expected. “We've tested a tremendous amount with all of the providers,” Foemmel said.

But insurers can't rule out potential delays in payment if codes aren't submitted properly.

“The delay would have to do with the provider recoding the claim and resending it to us,” said Robin Mayhall, a spokeswoman for Blue Cross and Blue Shield of Louisiana. “I don't think it would be anything too extensive.”

The second round of glitches could come from the payers—Medicare, Medicaid and commercial—which implemented their own software applications to handle the new codes.

The CMS last week insisted its claims-processing contractors were ready.

“We've tested and retested our systems in anticipation of this day, and we're ready to accept properly coded ICD-10 claims,” Sean Cavanaugh, deputy administrator and director of the Center for Medicare and Medicaid Services, said in a blog post Thursday morning welcoming providers to ICD-10.

But, Cavanaugh says, even the CMS won't know for sure how well the transition to ICD-10 is going for a while.

“Most providers batch their claims and submit them every few days,” he said.

Even after submission, Medicare claims take several days to be processed, and Medicare by law must wait two weeks before issuing payment. Medicaid claims can take up to 30 days to be submitted and processed by states.

By the end of Thursday, CMS spokeswoman Lauren Shaham said it was “business as usual with no reports of unusual activity at this time.”

But most Medicaid plans, including Molina, which has a sizable presence in California, said they aren't expecting any issues.

“Our plans are ready for the conversion to ICD-10,” Jeff Myers, president and CEO of Medicaid Health Plans of America, said in a statement. “Not only is it mandated, but the switchover will give them far better insight into care management, which ultimately benefits the patients they serve.”

Robert Tennant, policy director of Health Information Technology at the Medical Group Management Association, said his organization would survey its members in a few weeks on their experiences.

Many thought the ICD-10 conversion would be another Y2K.

Experts say ICD-10 might have a more recent reference point.

“Remember the exchange site?” Branzell said. “It's not that it didn't work in concept, it was in volume. You may or may not know the issue is there until there are tens of thousands or maybe hundreds of thousands of claims not getting through.”

ICDLogic in Harrison, N.Y., developed a Web-based clinical documentation guide for physicians.

CEO Monique Fayad said that on ICD-10's eve, “The traffic to our website and the downloads to our demos increased 10 times the average for the quarter.”

Repeated delays of the ICD-10 launch, caused mostly by political jockeying, have been a nightmare for Fayad. “For three years we've been waiting for this. It's been so long and drawn out,” she said. “Now, it's like Valentine's Day at a chocolate shop.”

Back at Cerner's war room, staffers will be available, round the clock for the first 10 days of the ICD-10 rollout.

But in 2018 comes ICD-11.

Foemmel said her colleagues have just discussed the new codes, which are in beta testing now.

“We just want to get through ICD-10 in the first couple months, and then we'll get a game plan for ICD-11 once more information is released,” Foemmel said.