Bruised by ICD-10 de­lay, health­care ex­ecs hud­dle over what to do next

Modern Healthcare - - NEWS - By Joe Carl­son, Joseph Conn and An­dis Robeznieks

Ex­ec­u­tives at Catholic Health Ini­tia­tives had to roll out new elec­tronic health-record sys­tems across 89 hos­pi­tals na­tion­wide while meet­ing the Oct. 1 federal dead­line for im­ple­ment­ing the com­plex new ICD-10 cod­ing sys­tem. They knew the two big health in­for­ma­tion tech­nol­ogy tasks couldn’t both be done in the time avail­able.

So CHI of­fi­cials de­cided to spend mil­lions of dol­lars re­me­di­at­ing out­dated “legacy” soft­ware pro­grams in some hos­pi­tals so that they could run on ICD-10 cod­ing for as many years as it would take to in­stall new EHRs.

That re­me­di­a­tion money may have been wasted thanks to Congress’ sur­prise de­ci­sion to de­lay the switch from ICD-9 to ICD-10 at least un­til Oct. 1, 2015, and maybe longer.

“We made de­ci­sions 18 months or two years ago that we are go­ing to do cer­tain things and post­pone cer­tain things based on hav­ing to im­ple­ment ICD-10,” said Michael O’Rourke, se­nior vice pres­i­dent and chief in­for­ma­tion of­fi­cer at the $11 bil­lion Catholic Health Ini­tia­tives sys­tem, head­quar­tered in Denver. “Had we known this would be de­layed, things would have been dif­fer­ent.”

Health­care providers, in­sur­ers and other or­ga­ni­za­tions now will have to wres­tle with when they think the govern­ment will ul­ti­mately push the but­ton on ICD-10 in de­cid­ing when they should start—or restart—train­ing their doc­tors and work­ers. They also are cal­cu­lat­ing how much time and money they wasted in train­ing and pre­par­ing for this Oc­to­ber, since doc­tors’ and coders’ mem­o­ries of the in­tri­cate ICD10 codes will fade fast with­out daily use.

O’Rourke and many other top health­care ex­ec­u­tives around the coun­try met in pri­vate con­fer­ence rooms last week to wring their hands, re­write time­lines and try to divine when the next dead­line will be. They have to de­cide whether to cut back for now on their staffing and IT in­vest- ment in ICD-10, and when to ramp it back up. Since last week’s de­ci­sion was the third such de­lay, they are won­der­ing how much stock they should put on the next an­nounced dead­line—and how to con­vince skep­ti­cal doc­tors and staff to go through an­other round of in­ten­sive train­ing.

Come 2015, “what if the govern­ment says for some rea­son, we won’t go to ICD-10?” asked Dr. Alistair Ersk­ine, chief clin­i­cal in­for­mat­ics of­fi­cer at the Geisinger Health Sys­tem in Danville, Pa. “What if we (as a na­tion) de­cide we’re go­ing to go (straight) to ICD-11? Now we’re stuck.”

Like most ev­ery­one else, the CMS was caught flat-footed by Congress’ in­ser­tion of the ICD-10 de­lay in the an­nual tem­po­rary patch of Medi­care’s sus­tain­able growth-rate for­mula. At dead­line Fri­day, the CMS had not pro­duced a state­ment telling the in­dus­try about its plans to im­ple­ment the law signed by Pres­i­dent Barack Obama April 1.

“We are ex­am­in­ing the leg­is­la­tion and will pro­vide guid­ance to providers and other stake­hold­ers soon,” CMS spokes­woman Rachel Maisler said late last week.

In 2012, the CMS had es­ti­mated that a one-year de­lay in the ICD-10 switchover would cost an es­ti­mated $306 mil­lion. The cost may be higher now be­cause many or­ga­ni­za­tions were far along in their prepa­ra­tions.

Nearly ev­ery clin­i­cal and fi­nan­cial com­puter sys­tem will be af­fected by the switch to ICD-10. Ev­ery hospi­tal visit, ev­ery in­pa­tient dol­lar flow­ing from a payer to a provider would have been coded us­ing the com­plex new sys­tem. ICD-10 in­cludes more than 68,000 po­ten­tial codes for dis­crete med­i­cal con­di­tions, up from the 13,000 codes un­der the cur­rent sys­tem, ICD-9.

Ersk­ine said Geisinger lead­ers will prob­a­bly come to a de­ci­sion on their way for­ward at a staff meet­ing this week. The physi­cian-led in­te­grated de­liv­ery sys­tem in cen­tral Penn­syl­va­nia had planned to have all of its physi­cians trained on ICD-10 by May; that’s when it would have ac­ti­vated the on­board ICD-10 coach­ing func­tion al­ready in­stalled in its EHR sys­tem. That would have given physi­cians five months to get com­fort­able with the new codes be­fore the Oct. 1 com­pli­ance dead­line.

People on the fi­nan­cial side at Geisinger also were pre­par­ing in­ten-

sively, Ersk­ine said. They planned to take the records the doc­tors coded in ICD-10 and con­vert them to ICD-9 for both billing and anal­y­sis of the com­ing fi­nan­cial im­pact from the code shift.

With the de­lay, Geisinger now has some choices to make. Should the or­ga­ni­za­tion sim­ply con­tinue run­ning in ICD-10 and “dual-code” for billing in ICD-9 un­til 2015? Or should the or­ga­ni­za­tion put that plan in moth­balls un­til this time next year?

“You could imag­ine, there is a heated de­bate within the or­ga­ni­za­tion,” Ersk­ine said. “The rev­enue cy­cle team has no in­ten­tion of slow­ing down. They will con­tinue to ab­sorb hours get­ting people across the line for ICD10. On the other hand, I don’t think I’d be able to find any physi­cian out of a staff of over 1,000 who would say, ‘Please, give me more ICD-10.’ ”

Other providers also are search­ing for an­swers. “I have a com­mu­ni­ty­wide call with all the CIOs in Mas­sachusetts on April 7,” said Dr. John Halamka, CIO for Beth Is­rael Dea­coness Med­i­cal Cen­ter in Bos­ton. “I’m go­ing to rec­om­mend we do our very best to move for­ward with ICD-10 test­ing and go ahead with as much ICD-10 as pos­si­ble,” in­clud­ing dual-cod­ing, us­ing ICD-10 data in house, and ICD-9 data for billing.

“Do­ing noth­ing but wait­ing on ICD10 is not an op­tion,” he said. “I can’t imag­ine wrap­ping it in a bow and putting it on a shelf and then los­ing our in­vest­ments.”

That’s good ad­vice, said Lynne Thomas Gor­don, CEO of the Amer­i­can Health In­for­ma­tion Man­age­ment As­so­ci­a­tion, the Chicago-based or­ga­ni­za­tion for med­i­cal records pro­fes­sion­als that has strongly ad­vo­cated for the change to ICD-10. “Even if you slow down, don’t stop,” she said. “What we’re say­ing is use this to your ad­van­tage. Strengthen your clin­i­cal doc­u­men­ta­tion pro­grams.”

Bet­ter doc­u­men­ta­tion will add value for both ICD-9 and ICD-10 users, she added. “Make sure you have your coders and stake­hold­ers trained in ICD-10. If you’re dual-cod­ing, keep do­ing it.”

AHIMA held its first post-roll­back we­bi­nar on ICD-10 Fri­day, just to

So far, the win­ners of this lob­by­ing bat­tle aren’t gloat­ing and the losers have only their sus­pi­cions about who was re­spon­si­ble. “When you find out let me know, be­cause we have about 75,000 people who are ready to wring their necks.”

—Lynne Thomas Gor­don CEO of the Amer­i­can Health In­for­ma­tion Man­age­ment As­so­ci­a­tion

bring its people up to date on what hap­pened. This week, the or­ga­ni­za­tion will con­duct a we­bi­nar for its mem­bers on what to do about its cre­den­tial­ing ex­ams, she said. The sud­den de­lay is a par­tic­u­larly touchy sub­ject with AHIMA mem­bers, and not sim­ply be­cause their or­ga­ni­za­tion has been a leading ad­vo­cate for the ICD10 con­ver­sion for more than decade. It es­sen­tially lost the con­gres­sional lob­by­ing bat­tle to stay on sched­ule for the Oct. 1, 2014 launch.

Physi­cian groups such as the Amer­i­can Med­i­cal As­so­ci­a­tion and the Med­i­cal Group Man­age­ment As­so­ci­a­tion were openly stump­ing for an ICD-10 de­lay. It’s not known which House mem­bers ac­tu­ally in­serted the ICD-10 sen­tence into the Medi­care doc­tor-pay­ment bill or what back­room deal led to that pro­vi­sion.

So far, the win­ners of this lob­by­ing bat­tle aren’t openly gloat­ing. The losers have only their sus­pi­cions about who was re­spon­si­ble. “When you find out let me know, be­cause we have about 75,000 people who are ready to wring their necks,” Thomas Gor­don said.

About 35,000 people are cur­rently en­rolled in ac­cred­ited health in­for­ma­tion man­age­ment train­ing pro­grams with ICD-10 com­po­nents, the AHIMA leader said. Of them, about 3,500 are tak­ing ICD-10-spe­cific cod­ing cour­ses.

Tech­ni­cally speak­ing, those or­ga­ni­za­tions plan­ning to dual-code over the long haul won’t be ter­ri­bly chal­lenged, said Rus­sell Branzell, CEO of the Col­lege of Health In­for­ma­tion Man­age­ment Ex­ec­u­tives, the Ann Ar­bor, Mich.-based as­so­ci­a­tion of hospi­tal CIOs.

“The geek part of this re­ally isn’t all that dif­fi­cult,” Branzell said. “It’s pretty easy to map back­wards,” con­vert­ing ICD- 10 to ICD-9. “I’ve talked to two CIOs in the last cou­ple of days who have al­ready made this de­ci­sion. They’ve been dual-cod­ing for months. There’s no way they’re go­ing to stop. They’re get­ting bet­ter doc­u­men­ta­tion from providers and bet­ter data from a re­search per­spec­tive.”

Still, Branzell said, there was “pretty sig­nif­i­cant overwhelming dis­ap­point­ment” among CHIME mem­bers about the de­lay.

Be­yond dis­ap­point­ment, there was se­ri­ous money at stake. Hill Physi­cians Med­i­cal Group, an in­de­pen­dent physi­cian as­so­ci­a­tion with 3,800 doc­tors based in San Ra­mon, Calif., and its man­age­ment ser­vices or­ga­ni­za­tion, PriMed Man­age­ment Con­sult­ing Ser­vices, had in­vested $2.1 mil­lion in ICD10 prepa­ra­tions, said Dan Robin­son, the chief ad­min­is­tra­tive of­fi­cer and vice pres­i­dent of cor­po­rate ser­vices.

He said the de­lay will in­crease costs by at least 8% to 10%. But “we are not go­ing to take our foot off the pedal.”

Some smaller hos­pi­tals and physi­cian prac­tices wel­comed the de­lay. Dave Clark, the in­terim ad­min­is­tra­tor for Harde­man County Me­mo­rial Hospi­tal-Qua­nah (Texas), said it will help his 18-bed crit­i­cal-ac­cess hospi­tal sur­vive. The hospi­tal filed for bankruptcy last May, and Clark said he ex­pected the ICD-10 con­ver­sion to dis­rupt the hospi­tal’s re­im­burse­ments to the point of forc­ing clo­sure. The de­lay will give it time to build up a re­serve. “This gives us our best shot,” he said.

Even some who be­lieve they were ready for the big con­ver­sion said there is some ad­van­tage to the pause. “Time is a very rare gift to be granted,” said CHI’s O’Rourke. “When some­one grants you more time to do some­thing … you sort of say, hey, that’s not a bad deal. That is ac­tu­ally good for an or­ga­ni­za­tion, to do more test­ing and be more pre­pared.”

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