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ICD-10 Déjà vu

April 2015

Published in the April 2015 issue of Today’s Hospitalist

ON OCT. 1, 2014, I WROTE a note to my hospitalist colleagues, reminding them that ICD-10 was only 365 days away and that we needed to spend the next year getting ready. To some, that message seemed like déjà vu “and I actually entitled the note “345.5,” the ICD-9 code that could be used for déjà vu and my nerdy attempt at humor.

Now, the ICD-10 due date is only six months away. Hospital systems have been able to use these months to conduct more tests, while coders have been able to practice more with dual coding and hospitalists “hopefully “have continued to hone their detailed documentation.

Everyone has to get over the skepticism that settled in last spring. 

But gearing up for ICD-10 this time may be even harder than last year. Why? Because everyone has to get over the skepticism that settled in last spring. That’s when the U.S. Senate passed a bill to temporarily prevent reductions in physician reimbursement, staving off SGR-driven cuts one more time, but slipping in a one-sentence statement delaying ICD-10 implementation for a year. Once that delay was signed into law, steam started leaking out of most preparation efforts.

An uncertain deadline
The extended deadline was a sigh of relief for some providers. But it left many of us who had invested heavily in planning with more questions than answers. The biggest question, of course, is whether the go-live will be pushed back even further. I don’t expect that it will, but I’m not 100% sure.

What is clear is that the lobbying efforts of both the pro- and con-delay camps are out in full force. The Centers for Medicare and Medicaid Services, along with the American Hospital Association and the American Health Information Management Association, have accelerated their efforts to stick to the new Oct. 1, 2015, deadline. On the other side, the AMA and other medical organizations are leading the charge to delay implementation even further.

At a congressional hearing on ICD-10 held earlier this year, the chair of the subcommittee on health within the energy and commerce committee made it clear that he and several other committee members weren’t in favor of delaying the go-live any more. And the idea you sometimes hear that we should just “skip” ICD-10 and go straight to ICD-11 in a few years isn’t even on the table. Nor is it realistic: ICD-10 is a prerequisite for the later version.

Still, ICD-10 has now been “politicized,” and doubts about its implementation date may be hard to overcome.

In fact, the SGR fix voted in last year, which mandated the ICD-10 delay, expires March 31, 2015. Everyone expects Congress to pass another one-year fix. Will that bill contain more delay language? That’s such a moving target that by the time this article goes to press, ICD-10’s debut may have been moved again.

No time to waste time
So why should hospital administrators and physicians fight the tendency to procrastinate? The biggest reason is the magnitude of the potential aftermath when ICD-10 does take effect, if providers aren’t prepared. Those changes will be so extensive that a botched conversion would have significant financial fallout.

Every coder will need to code charts with the new nomenclature, or bills “and cash flow “will be delayed. Nearly all the software we use in the hospital includes ICD codes, so IT needs to be vigilant about scanning through every EMR field.

Doctors who don’t incorporate enough detail in their documentation will be bombarded with requests for clarifications and queries, holding up claims and increasing their computer time. And auditors may jump on nonspecific codes to request further documentation, adding insult to injury.

The good news is that, at least according to recent surveys, vendors and insurers are more prepared for the conversion now than they were this time last year.

And my health care system plans to be ready, regardless of what is going on in Washington. Most preparation activities have resumed and are back up to speed. Testing is underway, as are IT preparations. In the next few months, coders will again resume dual coding (in both ICD-9 and ICD-10) and continuing education, and providers will again have access to online training modules.

One important step is planning for the “cut-over” period in September when hospitals will have to handle patients who are in-house during the conversion. Those patients will have ICD-9 codes one day that will need to be deactivated as their ICD-10 equivalent codes kick in the next. Large hospitals will want to create a “command center” to manage that crosswalk and monitor key financial metrics after the conversion.

Keeping the momentum
Where are physicians in all this? I am surprised that most hospitalists I talk to don’t have strong opinions one way or another, although they do express some “change fatigue.” Their practice is changing so fast with so many initiatives coming at them “to reduce readmissions and length of stay, master value-based purchasing and learn a new EMR “that they have less bandwidth to effectively maneuver them all.

Fortunately, our emphasis as hospitalists all along has been on good documentation practices. Much of the concern in outpatient practices is due to the fact that many of those doctors choose their own codes, unless they have software to help choose tools. In the hospital, coders do that for us, so ICD10’s extra specificity would be a side effect for us.

Focusing on how to improve clinical documentation to prepare for ICD-10 has already had a positive impact. It’s helped that we’ve stressed only those documentation concepts that really affect our cases “like the acuity of common diseases and condition etiology “and haven’t overwhelmed doctors with rarely encountered ICD-10 codes.

And physicians themselves are starting to notice ICD-9’s shortcomings. A good example last year was the Ebola crisis: ICD-9 has no actual code for Ebola and instead lumps it into a generic viral illness code.

Most hospitalists also realize how important it is to capture patient data more accurately to flesh out quality metrics. Readiness efforts have already paid off as hospitalists tend to document more completely and in more detail than other specialties, with hospitalists doing a better job of fully capturing severity of illness.

Under ICD-10, those skills will lead to better, quicker coding, a higher case-mix index and, and in my opinion, a business advantage that hospitalists may choose to use. In certain circumstances, it may create a push to have hospitalists admit more patients for more services if subspecialist documentation starts to flag. That may be good news for some programs and not good for others, but it should in any event increase hospitalists’ clout and value in their hospitals.

Waiting for solid evidence that the new implementation date will not move is not a good strategy. Instead, we should keep pushing for better documentation “which pays off in the here and now, regardless of when ICD-10 becomes a reality.

Sam Antonios, MD, is a hospitalist at Via Christi St. Francis Hospital in Wichita, Kan., and the ICD-10 physician advisor for Via Christi.