ICD-10 Transition Date Set; Medical Groups Balk

Mark Crane

August 05, 2014

As expected, the US Department of Health and Human Services has issued a final rule setting October 1, 2015, as the new compliance date for transition to ICD-10 for healthcare providers, health plans, and healthcare clearinghouses.

The Centers for Medicare & Medicaid Services (CMS) said the new deadline "allows providers, insurance companies and others in the health care industry time to ramp up their operations to ensure their systems and business processes are ready to go by Oct. 1, 2015."

Leading physician groups strongly disagreed and have criticized CMS for not adequately testing the system to make sure physicians can coordinate with their software vendors to meet the new requirements of the ICD-10, also known as the International Classification of Diseases, 10th Revision.

The American Medical Association (AMA) "has long considered ICD-10 to be a massive unfunded mandate that comes at a time when physicians are trying to meet several other federal technology requirements and risk penalties if they fail to do so," AMA President-Elect Steven J. Stack, MD, said in a statement.

"End-to-end testing should be done prior to implementation to properly analyze results and correct any problems identified," he said. "Otherwise, physicians won't learn of problems until after the go-live date, putting them at high risk of claims processing interruptions and payments, which could jeopardize patient access to care.

"We continue to harbor deep concerns about the burden this transition places on physicians, the complexity of ICD-10, the high risk of disruptions to Medicare claims and the industry's capability of converting to ICD-10 on a single date," Dr. Stack said.

Robert Tennant, senior policy advisor of the Medical Group Management Association, agreed that most physicians will face real challenges in trying to comply with the new deadline.

"CMS is mandating new actions for providers but hasn't properly tested its system," Tennant said in an interview with Medscape Medical News. "You can't just flip a switch and hope things go well."

The new deadline, a 1-year delay from the previously announced date, came in response to Congress' passage in late March of a bill that prevented a 24% reduction in physicians' Medicare payments. The legislation also prohibited CMS from setting a deadline for ICD-10 any earlier than October 1, 2015.

"Congress gave them another year and CMS did nothing for months," Tennant said. "This is an abdication of responsibility. Without proper testing, providers won't know if their systems are ready and if payments will be made properly.

"Practices also have contracts with dozens of commercial plans," he said. "Each will adopt a different set of payment rules. The only way for physicians to know if their claims will be processed is for CMS to test the system.

"We've argued that there should have been a limited pilot test at a minimum," Tennant noted. "There are some hospitals and plans that are ready to make the switch. Why not let them go ahead with ICD-10 so we can find out what the bugs and challenges are before imposing the system on all providers?

"There is incredible confusion in this process that's already convoluted. We need greater transparency and need to develop contingency plans," he added. "What if some state Medicaid programs aren't ready? CMS has refused to detail where each of the Medicaid plans is in terms of readiness."

The switch to ICD-10 will force physician practices to spend many thousands of dollars to comply. An AMA report earlier this year estimated it would cost small physician practices between $56,639 and $226,105 to comply with the ICD-10 mandate. That amount includes the cost of new software as well as expected losses in productivity.

A Medical Group Management Association survey earlier this year found that less than 10% of physicians said they had made significant progress toward preparing for ICD-10.

"We don't know what impact on productivity this new system will have," said Tennant. "Will it take an extra 5 minutes per patient encounter? If that's the case, fewer patients will be seen. All of this could have been fully examined if CMS did the pilot testing we've been asking for."

CMS argues that the ICD-9-CM system contained outdated, obsolete terms that are inconsistent with current medical practice, new technology, and preventive services. It added that end-to-end testing will be done sometime in 2015 before the deadline.

"ICD-10 codes will provide better support for patient care, and improve disease management, quality measurement, and analytics," CMS Administrator Marilyn Tavenner said in a news release. "For patients under the care of multiple providers, ICD-10 can help promote care coordination."

The ICD-10 codes on a claim are used to classify diagnoses and procedures on claims submitted to Medicare and private insurance payers, CMS said in a statement. "By enabling more detailed patient history coding, ICD-10 can help to better coordinate a patient's care across providers and over time. ICD-10 improves quality measurement and reporting, facilitates the detection and prevention of fraud, waste, and abuse, and leads to greater accuracy of reimbursement for medical services.

"Using ICD-10, doctors can capture much more information, meaning they can better understand important details about the patient's health than with ICD-9-CM. Moreover, the level of detail that is provided for by ICD-10 means researchers and public health officials can better track diseases and health outcomes," CMS notes.

"ICD-10 reflects improved diagnosis of chronic illness and identifies underlying causes, complications of disease, and conditions that contribute to the complexity of a disease. Additionally, ICD-10 captures the severity and stage of diseases such as chronic kidney disease, diabetes, and asthma," CMS concluded.

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