Defining ICD-10 “readiness”

When Congress voted in March to push back the ICD-10 deadline to at least Oct. 1, 2015, emotions were mixed from payers and providers across the industry. With the 2014 deadline in mind, a WEDI survey in late 2013 revealed that 80% of providers would not be ready to begin testing efforts before the deadline. Also, nearly 40 percent of payer respondents said they’d failed to complete their impact assessments. Now with the delay pushed back to 2015, payers and providers need to take advantage of this extra time, instead of relaxing their compliance efforts and staging another mad scramble next year.

Let’s examine healthcare’s past readiness for this transition to see what steps to take for 2015. The payer side of the industry was 12 to 24 months ahead of the provider side in engagement, planning and remediation for ICD-10. Additionally, the majority of payers were on track for ICD-10 remediation when the second delay was announced. In late January 2014 at the Edifecs Healthcare Mandate Summit, evidence was seen that providers – particularly larger integrated care-delivery organizations – were beginning to close the readiness gap. As the delay was announced, payers were starting to perform collaborative testing with forward-thinking trading partners, including providers. In fact, some providers were also requesting testing with payers.

However, while larger payers might generally be prepared for the transition, numerous second-tier payers are not ready. The reasons may vary for this, but it appears that most laggards in this segment of payers believe their systems don’t use ICD-9 codes extensively.

READ: ICD-10: What now?

Many providers, on the other hand, have reported being set back by conflicting priorities associated with mergers and acquisitions, HIPAA, HITECH, quality measures, and their ICD-10 readiness efforts.

Although the delay of ICD-10 has afforded more time for internal as well as external testing, providers are not always in a position to take advantage of the additional time. With each delay of ICD-10, we have witnessed provider organizations deemphasize ICD-10 in lieu of other mandated priorities. The inertia caused by stopping and restarting priorities increases the cost as the time horizon extends. It also drains productivity associated with the reallocation of resources to other projects and knowledge transfer and loss.

As we look forward to the move to a successful transition in 2015, payers and providers must take certain steps to ensure readiness.

Payers should:

• Complete their remaining remediation efforts and perform internal testing.
• Offer a collaborative/external testing effort with as many trading partners and providers as possible, in order to avoid disruption of the claims and payment ecosystem. Since external testing is the closest to production scenarios, it will identify issues that internal testing cannot reveal. Surface variations in system performance and payments between provider and payer trading partners can be identified ahead of time when they test with one another.
• Create a contingency plan and test that contingency plan.

Providers should: 

• Complete clinical documentation improvement and remediation efforts.  Continually measure and monitor the quality of these activities. Then, perform internal testing.
• Enroll in any testing with CMS and payer systems that are available. By working closely with payers, providers will gain confidence in knowing that the “plumbing” of getting claims back and forth is working. Providers and payers can then focus on understanding the impact of the new coding and documentation requirements on the financial health of service lines and their organizations. Once the impact is more fully understood, more delicate contracting and policy conversations can be guided with data and mutual respect of the trading partners.
• Train, test, monitor and motivate coders as well as clinicians. Keep lines of communication open. Build and nurture relationships that crate quality documentation and coding across the organization. Continue to support training courses for clinical documentation improvement and ICD-10 coding.
• Address the electronic health record/Meaningful Use directive, as it will reflect increased patient measures when ICD-10 is implemented.    

The need for ICD-10 contingency planning cannot be overstated. Be it planning for additional staff for claim processing and provider/member support, or the need to have dedicated staff to recover overpayments, contingency planning should account for risks that are likely to materialize after the compliance deadline. Contingency plans must be practiced prior to the transition date to ensure they address any unanticipated questions or consequences.