Can We Now Officially Say that ICD-10 Is Going to Happen?

With the announcement that came a little over a week ago about CMS and AMA working together on ICD-10, does that mean that we can officially say that ICD-10 is going to happen? The ICD-10 Watch blog has a good summary of what CMS committed to do in the announcement:

  • CMS is creating an ICD-10 Ombudsman to deal with healthcare providers’ ICD-10 problems. More on how this will work later.
  • Without using the words “safe harbor” or “grace period,” CMS promises that Medicare will not deny any medical claims “based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”
  • Quality reporting programs such as Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use 2 (MU) will suspend penalties that may result because of lack of specificity.
  • There will be advance payments available if the Medicare system has problems.

The second and fourth items have gotten all the buzz. Most have interpreted that the second one means that CMS won’t deny ICD-10 claims that weren’t done correctly. That’s an overstatement, but it does decrease the number of denied claims that will occur with the switch to ICD-10. The fourth item listed above was a major concern that I raised, but it applied to all payers and not just CMS. So, it’s nice that CMS has addressed the cash flow challenges that slow claims processing of ICD-10 claims will cause, but that still leaves all the other payers.

With the “peace treaty” signed between AMA and CMS, can we finally say that ICD-10 will not be delayed again? One person suggested to me that it just leaves the AHA as a possible opponent that could stop it. However, I also heard it suggested that they weren’t looking for a delay.

While usually avoiding trying to predict the unpredictable Washington, I’m going to say that we can safely assume that ICD-10 will not be delayed again. We might see an overture or two still that tries to delay it, but if I were putting my money down in Vegas I’d put it all on No ICD-10 Delay in 2015. Are you putting your organization’s “bet” in the same place?

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.

9 Comments

  • Here’s my big beef with these solutions from CMS:
    1. What is the Ombudsman number now? I’d like to test my claims but CMS refuses since I go thru a clearinghouse. My clearinghouse cannot test. Plus you have to be one of the few hundred that they randomly pick out of the hundreds of thousands of providers. So, let me speak to this mysterious ombudsman now? Will they take calls? Emails? Where is this office? Sounds like a farce to me.
    2. What is the definition of “family” in ICD-10 codes? After the period? Will ANY ICD-10 code work? What is a ICD-10 code family, I have no idea.
    3. What does lack of specificity mean for Quality programs?
    4. So exactly HOW do we apply and get paid when this whole thing comes crashing down in October?
    5. How do we re-send claims that have issues AFTER 10/1 when the date of service is PRIOR to 10/1? Do we use ICD-9 still? Do we have to change the code to 10? Its obvious medicare will HAVE to allow dual coding for a while because of this…why not let dual coding happen for a while until all the bugs are worked out? Trust me there will be big bugs. Everyone seems to forget the ACA rollout. Its still an IT disaster.

    If you have me betting I think the over under is 60/40 for ICD-10 rolling out. I think as the time draws even closer the pressure will be applied. So I think that there may be a dual coding (take your pick ICD9 or 10) transition.

  • While I don’t think anything is ever a “done deal, official” when the government and politicians are involved, I think ICD-10 will go off on 10/1 of this year. Certainly with the AMA “on board” a large thorn in ICD-10’s side has been removed.

    And while #meltoots makes some good points (#2 & #3) about “family” and “specificity” that definetly need some clarity, I disagree with the statement that “this whole thing comes crashing down in October.” I just don’t see that happening.

    And to answer #meltoots question #5: You DO NOT change ICD codes on re-submitted claims. Code selection is based on date of service for professional claims and discharge date for institutional claims. Submission date has nothing to do with code selection. So in all instances, use ICD-9 for claims prior to 10/1 and ICD-10 for claims afterwards. Additionally I don’t think that “dual coding” is required unless the submitter wants both codes for other purposes.

    Finally, I’d like to hear from #meltoots as to what he/she things the “big bugs” will be.

    BTW, this recent paper from Navigant provides a good summary of where ICD-10 stands now. http://www.naviganthrp.com/wp-content/uploads/2015/07/HC_PulseAlertICD10DeadlineApproaching_NSL_0715.pdf

  • 1). Medicaid concerns with crossover non-specific ICD-10 codes

    2). Legislative action [HR3108] potentially allowing a “transition period” of dual codes not many are prepared to handle

    I agree that many systems are prepared to handle claims based on Date of Service and will handle ICD9 claim adjustments based on DOS.

    We will have to wait and see.

  • Let me be as clear as possible.
    If you need to resubmit am ICD-9 claim after 10/1, you have to be able to search for and find and separate any ICD-9 claims from ICD-10 claims as they are NOT allowed to go on the same 5010 EDI file. Yes, go ahead and panic. So if you are resubmitting claims from Septemtber in October, that you have fixed or whatever, you have to be able to separate those claims from any claims after 10/1 as ICD9 and 10 claims cannot be on the same EDI claim. Think about your workflow to do that. Is it easy? Are you freaked out? You should be. Most systems will have a bugger of a time separating ICD9 and 10 claims. Most systems just batch claims when they are ready to submit, they do not separate ICD9 and 10 claims into separate EDI files.
    Further, no one has tested if clearinghouses and CMS will accept a resubmitted claim after 10/1 with a DOS prior to 10/1 with ICD-9 codes on it. Anyone tested that yet? Any other payers? Does the clearinghouse accept it? Does your software allow ICD9 claims to be resubmitted after 10/1?
    Anyone tested that yet?

    Medicine is a highly complex industry and you cannot test every workflow and system prior to a change like this. It should be TRANSITIONED. Allow dual coding. Why not? CMS has only tested a few thousand providers out of hundreds of thousands. So the vast majority cannot test. Even if they want to. I have been unable to test with ANY payer. Has anyone really had any luck doing that? tell me how. Further, it has NOT been end to end, claim to check.
    I am a front line provider and I can tell you that the VAST majority of providers are NOT prepared for ICD-10. And when it fails and it will, they will be telling their patients that the government did this to them. No matter who you want to blame, providers will be face to face with the patients we care for…and CHIME AHIME and HHS CMS etc. will get major blowback. We will remind them of the ACA rollout. It will not be pretty. We will win in that game. Already CHIME and AHIMA are putting out pressers that are telling providers to hire more coders, be prepared for total payment disruption, expect this to be costly.
    After selling it to HHS and congress that it should be easy and cheap. they are going to lose all credibility.
    The farcical ombudsman office does not exist , so when are they going to take your call? email? Someone explain to me what a ICD-10 family is? Some explain to me what is the necessary specificity of ICD-10 is? Someone tell me exactly how the advanced payments work? Its not clear to me.
    There are many things I am sure I cannot think of that are going to fail. This is NOT an easy transition. The code set is bloated and inefficient. It will not improve care. Further, it will pile on already overburdened providers that are dealing with MU, PQRS, CQM, VBM, MIPS, MOC, etc etc.
    We are literally treading water to stay above this rising tide of regulations. Burned out and stressed providers do not make good caregivers. Every day I hear of more and more providers leaving practice. It takes 14 years just to make a rookie version of me. So we cannot afford to drive us out of practice. Everyone should be fighting to let providers to do what we do best. Care for patients, do our surgeries, and be awesome at that. Not data entry and new coding sets. You are crushing our soul with all this. Don’t take that lightly or mock us. Its easy to tell us to just leave practice, but we are already in a massive shortage of manpower.
    So again let me say, mark my words, this is going to be messy and ugly. And all those ICD-10 cheerleaders are going to have a lot of explaining to do.

  • @meltoots
    Rest assured, ICD-9 and ICD-10 codes can be on the same 5010 EDI file…but not on the same claim segment. You just need to make sure that for professional claims if Date Of Service is prior to 10/01, send in your ICD-9 code (be it original or reissue) and if the Date Of Service is on or after 10/01 just send in your ICD-10 codes. And if the treatment spans both the phases, don’t send whole claim as one. Separate the claims before 10/01 and send them with ICD-9 codes and others that are on or after 10/01 with corresponding ICD-10 codes. We have done numerous testings with payers without a hitch.

    And let me assure you we have checked the reissue claims that are submitted with ICD-9 codes with DOS prior to 10/01 along with the original ICD-10 claims with DOS after 10/01 and received successful reports down to 835s (ERA).

  • Glad you got to test. We have been unsuccessful in ANY attempt to test with any payer. So your testing will not help me if my claims fail after 10/1. We were given very specific guidance from our clearinghouse NOT to put ICD9 and 10 claims on the same 5010 file (even if they are different patients), this was iPlexus now Softcare and Emdeon clearinghouse. Maybe they are as confused as everyone else. Just because you get successful reports does not mean payment, for instance, with Ohio BWC if the codes do not match then you will not get paid, the claim will be denied. Again, its much better to transition and NOT have a hard stop start date. Let us start sending with a claim or two and make sure it works, that would allow us to keep getting paid for the services, and not have to wonder how we are going to be paid. Even a 90 day transition makes sense, better would be a whole year.

  • Great discussion. I just don’t understand why discussions like these aren’t happening on a wide scale across every payer/software/region/etc. Diving into the details like this seems like the only way to make sure things go smoothly on Oct 1. This discussion illustrates how many variables are in play and why there’s bound to be some issues.

  • It is hard to understand what commitments CMS has or even can make wrt Medicaid and, of course, CMS can say little to nothing about private payers without regulatory action.

    The fundamental problem here is not ICD-10 although it did increase the burden of documentation by providers.

    The fundamental problem is the notion of a national cutover on a specific date. The IT is a mess without a cutover but the whole healthcare system is a mess with cutover.

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