Nearly Half of Physicians May Not Be Ready for ICD-10

Marcia Frellick

August 06, 2015

Nearly 25% of physicians' offices said in a survey they will not be ready when the new, more complex International Classification of Diseases, 10th edition (ICD-10), hits October 1. Another 25% said they are not sure whether they will be ready.

The latest Workgroup for Electronic Data Interchange (WEDI) survey also found that only about 20% of physician practices have started or completed external testing. That percentage is up from the 10% of physicians who said they had done external testing in results released in March.

Robert Tennant, vice chair of the WEDI group and government affairs senior policy adviser for the Medical Group Management Association, said the trouble is evident in this survey and in a June 2015 readiness survey by eHealth Initiative and the American Health Information Management Association.

"The physician side of the provider community — they're really struggling," Tennant said. "I think the government has not done a very good job about explaining the return on investment for physicians; it's not clear at all why we're doing this."

Also, many "are at the mercy of their software vendors," Tennant said. If the software is not up to date, physicians have no way to submit the codes or test the systems.

"What that tells us in the industry is that we're looking at potentially a healthcare.gov situation, where the light switch is flipped and things don't work," he said.

Rejected codes could "have catastrophic repercussions on cash flow" for physicians, Tennant said. He predicted that the Centers for Medicare & Medicaid Services (CMS) will either produce a contingency plan or will be required to do so by Congress, he said.

Uncertainty About Deadline

Across all industry segments in the survey, which also included hospitals, health systems, health plans, and vendors, a top obstacle was uncertainty about whether the October 1 date is firm, given that it has been delayed three times already.

According to WEDI, although the delays provided more time for the ICD-10 transition, "it seems that many organizations did not take full advantage of this additional time."

The WEDI survey was done before CMS and the American Medical Association (AMA) announced on July 6 that CMS would grant some flexibility in coding: For 1 year, Medicare claims will not be denied or audited solely on the exact ICD-10 diagnosis codes provided, as long as the physician submitted the correct family of codes.

The transition will provided a needed buffer, particularly for small physician offices, AMA President Steven J. Stack, MD, told Medscape Medical News in a statement.

"Two thirds of physicians work in small practices and lack the resources available to other healthcare stakeholders involved in the ICD-10 transition," he said.

"The AMA believes small physician offices would have been hit hardest by the ICD-10 transition without a fair and reasonable period of transition agreed to by CMS. The recently announced transition period will give physicians breathing room as the healthcare system adapts to ICD-10 and will help reduce the risk for financial disruptions to practices so physicians can continue to provide high-quality patient care.

"The AMA will continue to work constructively with CMS to ensure that contingency plans are in place, and to see that emerging implementation issues are addressed," Dr Stack added.

But Tennant said this flexibility may be misinterpreted, and pointed to the Frequently Asked Questions, updated at the end of July by CMS.

"They state virtually categorically that the flexibility does not apply to claims submission. It only applies on the back end of the process, on the auditing.... It's frankly not going to be much help at all to physicians trying to submit claims," Tennant said. "And of course any flexibility on the Medicare side does not apply to commercial health plans."

CMS also announced it will have an ICD-10 ombudsman to help receive and triage physician and provider issues.

WEDI, a nonprofit authority on using health information technology to create efficiencies in healthcare information exchange, was given an advisory role under the Health Insurance Portability and Accountability Act.

As such, it periodically flags issues needing the attention of the Department of Health and Human Services (HHS). To that end, in a July 30 letter to HHS Secretary Sylvia Mathews Burwell, Jim Daley, WEDI past chair and ICD-10 Workgroup co-chair, wrote: "Without a dedicated and aggressive effort to complete implementation activities in the time remaining, this lack of readiness may lead to disruption in claims processing."

Given the latest numbers, WEDI made four recommendations:

  1. HHS should quickly provide full transparency on the readiness of individual Medicaid agencies by state.

  2. The recently announced ombudsman position should be appointed as soon as possible.

  3. The go-live ICD-10 support plan should include leveraging WEDI's and CMS' implementation support program.

  4. Additional outreach is needed to help providers comply with the most recent local coverage determination codes.

Other Areas Are Farther Along

The picture is different in other sectors, the survey notes; for example, nearly 90% of hospitals and nearly all health plans report that they are ready, or will be, by the deadline.

Three fifths of vendors also have completed product development, and one fifth were at least three quarters complete. These numbers show progress from the February 2015 survey, in which just more than one third had completed development.

For hospitals and health systems, almost three fourths had started or completed external testing.

Andrew Boyd, MD, assistant professor in the Department of Biomedical and Health Information Sciences at the University of Illinois at Chicago, told Medscape Medical News he is not surprised health systems are farther ahead.

Health systems are able to dedicate people to work on the transition, and physician practices do not have those kind of resources, he said.

Another problem with the new system is that certain codes do not transition well from ICD-9 to ICD-10, Dr Boyd pointed out.

"Even getting to the right class or family is hard, because the concepts have completely changed," he said.

Dr Boyd gave the example of accidental poisoning by an unspecified drug. Accidental poisoning still exists under ICD-10, but the coder needs to specify what class of drug the patient took, which can be difficult if, for instance, a child has taken several drugs from a medicine cabinet.

Given such complexities, Dr Boyd said small practices with small margins especially are in danger of financial interruptions, and he would like to see more assurance that confusion over coding will not mean a 2- or 3-month delay in cash flow.

The survey had 621 respondents, consisting of 453 providers, 72 vendors, and 96 health plans. This is the 11th ICD-10 readiness survey WEDI has conducted since 2009.

Sources for Help

Here are some resources for physicians looking for help in getting ready for the October 1 deadline:

  • CMS' free help includes the "Road to 10," aimed specifically at smaller physician practices. CMS has also released training videos with ICD-10 implementation tips.

  • The Medical Group Management Association offers this help for transitioning.

  • The AMA also has provided transition information.

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