Six Months (and Many Years) Later – Have The Promises Been Delivered?

The road to ICD-10 implementation was longer than expected due to postponements (among other things). But now that ICD-10 has been on the books for a few months, it’s time to check on the code-set’s progress.
From the beginning, the biggest ICD-10 adoption concerns for most practitioners were the potentially heavy investments of time and money in staff education and software upgrades, as well as the potential for claims disruptions, which could interfere with patient care. The issues with citizen enrollment in the Affordable Care Act didn’t foster optimism among physicians, either.
The transition hasn’t been snag-free, but CMS announced changes last summer to help ease the transition for some physicians, particularly those with limited resources:

  • For the first year that ICD-10 is in place, Medicare claims will not be denied solely based on the specificity of the diagnosis codes as long as they are from the appropriate family of ICD-10 codes.
  • CMS will not subject physicians to penalties for the Physician Quality Reporting System, the value-based payment modifier, or Meaningful Use based on the specificity of diagnosis codes as long as they use a code from the correct ICD-10 code group. Penalties will not be applied if CMS experiences difficulties calculating quality scores for these programs as a result of ICD-10 implementation.
  • If Medicare contractors are unable to process claims as a result of problems with ICD-10, CMS will authorize advance payments to physicians.
  • CMS established a communication center and appointed an ICD-10 ombudsman to monitor and resolve issues as quickly as possible.

Proponents argue that when the dust settles, ICD-10’s higher degree of specificity will allow billing departments to be far more specific when submitting claims, increasing the number of first-pass claims that are accepted.
It will certainly redefine big data. ICD-10 increases the number of diagnosis codes from 13,000 in ICD-9 to roughly 68,000 diagnosis codes. The length of the codes expands from three to four numbers in ICD-9 to seven to eight alphanumeric characters in ICD-10. The reason? ICD’s original purpose was to identify health trends, but in the US, it became a centerpiece of billing systems for payers. Most clinicians found that ICD-9 codes didn’t provide sufficient granularity to pass along to the next physician and tended not to rely on the codes.
The jury is still out on ICD-10, and it will be a long trial. No one would argue that the rollout was simple or cheap. However, physicians aren’t being left out in the cold. In addition to CMS resources, physician organizations and vendors are standing by. In fact, as ICD10Watch points out: “We may have only been using ICD-10 codes for the past few months, but people have been answering ICD-10 questions for much longer.”
The transition to 142,000 new diagnostic and procedure codes from the current 19,000 certainly altersour understanding of care and how to improve it. Still, there are likely to some complicated consequences of the transition. For example, use of ICD-10 might be able to help detect fraud as more data is collected and new formulas get better at separating fraudulent claims from legitimate ones. But it might assist fraudsters in covering up abuse because payers’ systems to detect fraud and abuse are based on patterns of abuse and fraud using ICD-9 codes.

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Last Updated on March 1, 2016