Thursday, April 30, 2015

Are we ready to do ICD-10?

Penny Osmon Bahr, CHC, CPC, CPC-I, PCS, 
Director of Healthcare Solutions at Avastone 
Health Solutions
With multiple delays in implementing ICD-10, and the rock solid, “no-more-delays,” go-live date of Oct. 1 fast approaching, PARCA eNews checked in with Penny Osmon Bahr, director of Healthcare Solutions at Avastone Health Solutions, an integrated hardware, software and healthcare operations consulting firm. Osmon Bahr is an executive health care operations expert with over 18 years of industry experience with an emphasis in Medicare compliance, coding and billing, HIPAA privacy and security, quality measurement and health information management. Osmon Bahr is professionally respected for her broad industry knowledge, leadership, and her ability to convey complex information to all stakeholders, making her a sought-after guest speaker at conferences. She most recently presented a case study of a successful ICD-10 implementation at HiMSS 2015. She is a Professional Medical Coding Curriculum Instructor, certified in Healthcare Compliance through the Health Care Compliance Association and an AAPC-trained ICD-10 instructor. Osmon Bahr is a member of the Wisconsin ICD-10 partnership steering team and sits on the HIMSS national ICD-10 task force. She also is a member of the Medical Group Management Association.

Q. Are people better prepared for ICD-10 than they were a year ago?
A. It depends on the type of the provider you are. I think the majority of integrated health systems are fairly ready and will be ready. Small clinics, is a guessing game. Some of them, depending on the region, are really ready and some of them haven't moved the dial at all. If I were to focus on a segment of the population that is in danger I might look at long-term care facilities. I don't think they have done very much to be ready.

Q. Are payers ready?
A. The national payers are ready. All of the big payers, are ready, Medicare is ready, there are a lot of Medicaids that are testing. Traditional state Medicaid programs are among those that somehow make it happen. For local payers you see a little bit slower readiness. I'm from Wisconsin and in Wisconsin we're ready and have been very aggressive in preparing, but there are a few smaller health plans that I would call "in-caution." I would give them a yellow or red flag. The other stakeholders that might draw attention are managed health networks that re-price claims for third party administrators.  With many provider groups contracted with the network, but not the smaller TPAs, there is risk.

Q. Have a lot of the organizations done testing?
A. Testing is ongoing. I have a client that has been testing for over two years. There are a lot of larger systems out there that are in that category. Some people are simply never going to have an opportunity to test, so they will have to network and collaborate with each other to find out, "Have you tested with the Blues, and how did it go?" They've got to rely on evidence that others have tested, as well as their payer and clearinghouse relationships.  Collaborate, communicate, share.

Q. What are the gaps? Where are we most unprepared?
A. I think it is the unknowns. There is a lot of conversation around, “will payers deny claims with non-specific codes?” For the most part we've just heard no, but that is not something you can test for. That is something that when we turn the switch on Oct. 1 and it becomes reality, we don’t know what is really going to happen. Another of the biggest gaps is that there is a small percentage of people in this country, in this industry, who are just never really going to prepare. They don't want to have EHRs, they don't want to do ICD-10, that's a gap. The problem is that we don't call a spade a spade and look at how ICD-10 can benefit us as a country and a healthcare system, and some people are never going to move, so that is a gap.

Q. Do most organization see ICD-10 as a benefit?
A. It depends on the role within the system, or the role within the client. ICD-10 is not going to change outcomes. Outcomes are governed by clinical practice and clinical pathways. What ICD-10 does is it gives us the ability to report at a much more granular level, non-clinical EHR information. Everyone uses Ebola as an example. There is no ICD-9 code for Ebola. So if something like Ebola was to hit America again, beyond what occurred last year, there is no way to track those patients. We don't have a diagnosis code for Ebola, we don't have a good diagnosis code for sports concussions. There are fundamental diagnoses that we cannot track as an industry with the World Health Organization and the CDC and we're the only country that doesn't have it. I spent some time talking to a physician from Australia at HiMSS, and we was just baffled at our inability to adopt ICD-10 and why it is getting so much attention and so much pushback.

Q. Why is it so much more difficult to implement ICD-10 in this country?
A. Because of all the administrative burdens that our multiple payer system brings. There are so many different administrative rules by each payer. Prior authorizations are an example that may be a risk with ICD-10. Prior authorizations tend to be high-dollar imaging, high-utilization, high-dollar drugs, but there are other services that fall into prior authorization and with ICD-10 you can be very specific and we're not really sure what is going to happen. It is one of those areas that could be problematic.

Q. If you are an IT administrator for large provider or large radiology group what is your biggest concern heading into Oct. 1?

A. It depends on whether you are outsourcing your billing, if you are outsourcing your billing you need to make sure any billing company is working very closely with your clinicians from a documentation perspective to make sure they know what needs to be included to support ICD-10 coding. Radiologists in particular are typically hospital based and don't have a lot of interaction with patients – or coders. I don't see it as a high-risk group potentially but there are some diagnosis codes particularly with cancers that you want to make sure documentation is addressing. Another area is cash flow. We don't know what is going to happen. You can test and test,  but once we turn on the production system things can happen and just knowing you have sufficient cash on hand to operate if something should happen with one of your largest payers could be helpful. I think that is where the focusshould be – have contingency plans in place. You have to make sure your revenue cycle today is cleaned up, that you've done everything you can to reduce denials,that you have good relationships with your payers, that you understand where your prior authorizations are hitting your bottom line, and you know your coder productivity. These are just some really good key operational metrics on the business side of the house that can be useful through the transition.

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