Are You Ready for October 1, 2015?
Be prepared for what’s down the road.
By Alpha Lillstrom and Jerry Connolly
September 9, 2015
The Board-adopted PPS 2015 Advocacy Priorities includes the following goal:
Monitor and respond to ICD-10 implementation in a timely fashion with minimum disruption.
The International Classification of Disease, 9th Edition (ICD-9), has been in use in the U.S. since 1998. The United Nations World Health Organization (WHO) began working on the tenth edition of the International Classification of Diseases (ICD-10) coding system over 30 years ago in 1983 and adopted the new classification system in 1994. Countries began adopting the new coding systems as early as 1998, Canada in 2000, and here in the United States the transition to ICD-10 was mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) . The Department of Health and Human Services published the Final Rule requiring the replacement of ICD-9 with ICD-10 in January 2009 , setting the compliance date for October 1, 2013. After many delays and postponements we have now arrived. After 37 years using ICD-9, the day of ICD-10 implementation is just around the corner.
While the transition was inevitable, the date of implementation has been challenged and delayed until very recently. There have been strong lobbying efforts on both sides of the debate. The American Medical Association (AMA) long opposed the transition citing the difficulties, costs, and priorities of electronic medical record implementation and urging the industry to wait for ICD-11. Meanwhile, a number of insurance, pharmaceutical, and health care facilities supporting the transition joined forces as “The Coalition for ICD-10.” The coalition encouraged health care providers to contact their members of Congress requesting that ICD-10 be implemented as planned, arguing that ICD-10 implementation delays have been disruptive and costly across U.S. health care, as well as detrimental to health care delivery innovation, payment reform, public health, and health care spending. The Center for Medicare and Medicaid Services (CMS) has estimated that the one-year delay from 2013–2014 cost the health care industry up to $6.5 billion. In early July, the AMA finally offered public support for the transition, citing recent CMS accommodations and responsiveness to their concerns.
With several years of unparalleled cooperation across the health care community, CMS has developed regulations for new billing processes and formats, and the ICD-10 finish line is less than a month away. On October 1, 2015, our nation makes the transition to ICD-10 for coding medical diagnoses and inpatient hospital procedures. The 155,000 ICD-10-CM (diagnosis codes) and 85,000 ICD-10-PCS (procedural coding system) will be used in conjunction with the AMA’s Current Procedural Terminology (CPT) codes for outpatient, ambulatory, and office-based procedure coding. This July, CMS Acting Administrator Andrew Slavitt sent a letter to all Medicare providers urging them to prepare for ICD-10 and promising to help the health care community be ready.
CMS has recognized that this is a cumbersome and significant transition for both themselves and for providers. In preparation, it planned and administered a set of four acknowledgment testing periods and three end-to-end testing periods for ICD-10 codes to be submitted to the Medicare Fee-For-Service (FFS) claims system. The acknowledgment testing has allowed providers to test their ability to submit ICD-10 codes, and end-to-end testing has simulated a full claims adjudication cycle. To ensure providers are prepared to send and that Medicare contractors can accept the more complex coding system, participating acknowledgment testing providers submitted claims using ICD-10 codes beginning in March 2014. After each testing period, improvements were made. The March 2015 acknowledgment testing resulted in 2 percent of test ICD-10 codes being rejected due to an invalid code (an improvement over the results from the November 2014 testing period).
According to CMS, during the third acknowledgment testing period in June 2015, over 13,000 claims were submitted and 90 percent of claims were accepted nationally. Most of the rejections were the result of improperly developed test claims unrelated to ICD-10. The final end-to-end testing week was held from July 20 to 24, 2015. While the planned testing weeks have been completed, acknowledgment testing remains available at any time to all electronic submitters through September 30, 2015.
In early June 2015, 13 members of the House Ways & Means Health Subcommittee wrote to CMS recommending six steps to smooth the transition to ICD-10, including requesting CMS release a contingency plan for how claims will be processed in the event it cannot handle ICD-10 codes as well as calling on CMS to indicate if less granular codes will be accepted after the October 1 transition date. CMS responded that it developed a plan to monitor, assess, and address issues affecting Medicare FFS claims processing were they to arise after the transition. They have publicly released parts of this contingency plan, including alternative ways to submit a claim should technical difficulties arise. However, all communications make it clear that CMS will only accept ICD-10 codes post transition.
In response to requests from Congress and the provider community, CMS has agreed to allow for flexibility in claims auditing and quality reporting process for program year 2015. For example, Medicare review contractors will not reject ICD-10 part B claims based solely on incorrect specificity—as long as the codes used are from the right family of codes, they will be processed. This same flexibility and reprieve from penalty applies also to Physician Quality Reporting System (PQRS), Value-Based Modifier (VBM), or Meaningful Use (MU). CMS is setting up a communication and collaboration center for monitoring the implementation of ICD-10 as well as naming an ombudsman to receive and triage provider issues.
Additionally, CMS has collaborated with providers and other industry stakeholders to create tailored training and tools specifically to help providers and their staff prepare for the transition. Tools available include ICD-10 implementation guides, tools for small and rural providers, general equivalency mappings (ICD-9 to ICD-10 crosswalk), and the Quick Start Guide. The Road to 10 tool was developed with small physician practices in mind; nonetheless, its tips, fact sheets, checklists, and free local training resources could be useful for Private Practice Section (PPS) members to create customized action plans. A Frequently Asked Questions (FAQ) document, provider resources, and other useful documents are warehoused at cms.gov/ICD10. CMS also continues to work with industry groups and organizations that offer free and low-cost ICD-10 resources on their websites. In addition to the CMS resources mentioned above, American Physical Therapy Association (APTA) and Private Practice Section (PPS) have developed resources designed to help physical therapists understand the transitional process and provide tips to ensure a smooth transition. Vendors, health plans, and hospitals are also good sources for ICD-10 information and training.
While CMS has made it clear that it will not maintain ICD-9 after ICD-10 is implemented, some members of Congress have continued to introduce bills to impede full implementation or provide access to dual coding after the October 1 deadline. On April 30, 2015, Representative Ted Poe (R-TX) introduced H.R. 2126, the Cutting Costly Codes Act, which would halt the implementation of the new ICD-10 code sets as well as require a Government Accountability Office report to recommend steps to mitigate the disruption to health care providers that would result from the replacement of ICD-9. The AMA supported this bill. On May 15, 2015, Representative Diane Black (R-TN), introduced H.R. 2247, the ICD-TEN Act, to require a transparent end-to-end testing period and report assessing the Medicare fee-for-service claims processing system during the transition from ICD-9 to the ICD-10 as well as requiring that during this time no claims could be denied due solely to the use of an unspecified or inaccurate subcode. As mentioned above, CMS responded by promising to accept claims in the same family of codes for the 2015 program year. The Coding Flexibility in Healthcare Act (H.R. 3018), introduced by Representative Marsha Blackburn (R-TN) and Tom Price (R-GA) on July 10, 2015, would allow either ICD-9 or ICD-10 codes to be submitted on claims with dates of service after October 1 (i.e., “dual coding”) for a six-month period. Representatives Blackburn and Price are arguing that a transition period allowing the use of either ICD-9 or ICD-10 codes is needed in the event that some provider practices software are not ready to support ICD-10 by October 1. However, this legislative proposal is unnecessary because if a provider is unable to submit ICD-10 claims electronically on October 1, there are alternative claim submission options. None of these bills will be enacted in time to delay the implementation.
While the transition is at the forefront, many stakeholders and policymakers see the real value is in the higher quality and specificity in the data that can be collected as a result of using ICD-10. CMS insists that “ICD-10’s granularity will improve data capture and analytics of public health surveillance and reporting, national quality reporting, and research and data analysis. ICD-10 provides detailed data to inform health care delivery and policy decisions.” That’s the long-term goal.
Today’s goal is to make sure everyone is ready. For Medicare billing purposes, ICD-10 will be required on all claims for dates of service on or after the implementation date. If you do not use a valid ICD-10 code starting on October 1, 2015, you will not be able to successfully bill for your services. While there are alternative methods of submission, all claims must utilize ICD-10 codes; there are no exemptions.
Alpha Lillstrom is a registered federal lobbyist working with Connolly Strategies & Initiatives, which has been retained by PPS. An attorney by training, she provides guidance to companies, nonprofit organizations, and political campaigns. For six years, she served as Senior Policy Advisor and Counsel for Health, Judiciary, and Education issues for Senator Jon Tester (Montana), advising and contributing to the development of the Affordable Care Act, as well as working on issues of election law, privacy, government transparency, and accountability. Alpha has also directed Voter Protection efforts for Senators Bob Casey, Al Franken, Russ Feingold, and Mark Begich. She was Senator Franken’s Policy Director during his first campaign and was hand-picked to be the Recount Director for his eventual 312-vote win in 2009.
Jerome Connolly, PT, CAE, is a registered federal lobbyist whose firm, Connolly Strategies & Initiatives, has been retained by PPS. A physical therapist by training, he is a former private practitioner who throughout his career has served in leadership roles of PPS and APTA. Connolly also served as APTA’s Senior Vice President for Health Policy from 1995–2001.