Healthcare providers, payers and claims clearinghouses have rolled past another major milestone in the full implementation of the ICD-10 codes with no major disruptions.
The launch of the complex diagnostic and procedural coding system, postponed three times, occurred without a hitch Oct. 1.
Now, it appears the second possible hiccup, a precipitous drop in claims submissions because of inadequate physician documentation and coding complexity, may also fail to materialize, providers say.
“This was a big test and I'm glad to see we're doing well,” said Dr. Stephen Michaels, chief medical officer and chief operating officer at 10-hospital MedStar Health System's St. Mary's Hospital, Leonardtown, Md., and the hospital's lead physician on the ICD-10 conversion.
There were some early technical glitches with a few of the hospital's dozens of computer systems that were reconfigured for ICD-10, Michaels said.
For example, one system loaded all of the many thousands of new ICD-10 codes, including a number of what Michaels described as “future codes.”
At launch, algorithms in the computer system would include those future codes among the codes for current billing, Michaels said.
“Those had to be stripped out of the system and we had to work with the vendor to get that accomplished,” Michaels said. But “overall, I would say that the process at MedStar has been very, very smooth. When we compare it with other larger integration projects like EHRs, it's not been like that at all.”
Tim Marshall, managing director of the Claro Group, a healthcare consulting firm, said most commercial payers had glitches accepting the first wave of ICD-10 claims, with problems centered on “transitional claims” for patients' stays that began in September but extended into October and needed to be coded in both ICD-9 and ICD-10.
“Most of the large national payers have had some issues on the transitional claims,” Marshall said. “In most cases, they've already been able to address those system issues.”
The second milestone along the path to ICD-10 integration is getting claims for services coded in ICD-10 out of providers' doors, either to payers directly or to an intermediary, typically a claims clearinghouse.
Marshall said he's seeing first signs of a possible increase in a key metric—claims for patients that have been discharged but for whom no final bill has been issued, abbreviated as DNFB, also more broadly called Discharged Not Final Billed.
Any rise in DNFB would most likely be attributable to a few causes. One is inadequate physician documentation to support the more complex and specific ICD-10 codes. The other is that coders lack speed because of their unfamiliarity with the new coding system.
Estimates of an early drop in coder productivity have run as high as 50%, eventually rising back only part way to a permanent coder productivity decline of 25%.
“We definitely are seeing some productivity decreases,” Marshall said.
At MedStar, the cause could be inadequate physician documentation for the more specific and complex codes, or simply coders taking more time per claim than they had in the past, or both. The data is insufficient to say for sure, Michaels said. “We'll know more in a week or two, but I think it's safe to say the bulk of it is because of taking longer to code a record rather than (insufficient) documentation from physicians.”
The 300 physicians and physician extenders at Access Community Network had been dual coding in ICD-9 and ICD-10 on their electronic health-record system for about a year prior to the Oct. 1 start dates, so, “We were really ready to go live,” said Mahomed Ouedraogo, chief financial officer for the Chicago-based federal qualified health center, which operated 35 care sites in the city and suburbs.
The percentage of claims slowed by ICD-10 rose on the first day, but “in two days, we went back to the level prior to ICD-10,” Ouedraogo said.
Sandy Wolfskill, director of healthcare finance policy at the Healthcare Financial Management Association, is similarly uncertain about whether ICD-10 is slowing claim preparation and submission.
“Pretty much, it's still too early to tell,” Wolfskill said.
The association is using the website ICD10Central.com to track revenue-cycle impacts, with days to final bill the key metric for now.
“What we're seeing is that days to bill still indicates that even at this point providers are still getting out their (ICD-9 coded) claims for the end of September,” Wolfskill said. “I think the overall average across the country is running, on the hospital side, around 16 days. And that's less than one day higher than what the national average has been for July, August, September and the first part of October.”
“There's a slight uptick in the last seven days,” she said. “But overall, we're not hearing anything yet.”
For all providers, hospitals and office-based physicians, the average days to final bill for October has gone down slightly, compared with the averages in July and August and—on Friday—was tied with September's average. Data used by the website is gleaned from claims processed by RelayHealth, the clearinghouse owned by McKesson.
Joshua Berman, director of analytics and ICD-10 at McKesson, said the counterintuitive dip in days to final bill after Oct. 1 is likely attributable to coders working overtime to clear their decks of ICD-9 coded claims.
There are other markers in the road to full implementation. One is how well and how quickly payers are receiving and turning around claims from providers. The final marker is how closely payments match expectations.
The metrics to watch for those are days to payment, the time between a provider submitting a claim and receiving payment from an insurance company, Medicare, Medicaid or third-party payer; the claims denial rate, the percentage of claims rejected; and the reimbursement rate, how much of the billed amount is actually paid.
First payments on the providers' early ICD-10 coded claims are only trickling in, Berman said, so it's too early to tell how ICD-10 is impacting those later milestones.
For now, though, “We don't have any hold ups for ICD-10” with small and large health plans alike, Berman said. “It's been a nice surprise.”
