States’ ICD-10 coding workaround may cause problems, IT experts warn
On Oct. 1, Medicaid programs in California and three other states will not fully convert from the ICD-9 to the ICD-10 coding system, as nearly everyone else is federally mandated to do.
Instead, they have received CMS approval to take incoming claims coded in the new ICD-10 system, convert them into ICD-9 codes, and use the older system to calculate payments to healthcare providers.
Provider groups and health information technology experts warn the patchwork approach creates risks of payment delays and snafus.
All Health Insurance Portability and Accountability Act-covered entities, including hospitals, office-based physicians, claims clearinghouses and health plans must comply with the federal mandate for full ICD-10 conversion on Oct. 1. But the CMS has signed off on a “crosswalk” method to translate ICD- 10 codes into ICD-9 codes and continue to use the older codes as a workaround for Medicaid fee-for-service programs in California, Louisiana, Maryland and Montana. The claims processing systems in those states are unable to perform payment calculations using the new codes.
CMS spokesman Jibril Boykin confirmed that his agency approved the crosswalk approach in the four states. “We have worked closely with each state to understand how they will mitigate any issues that may arise and minimize impact on the accuracy and timeliness of provider payments.” Boykin said the workaround was not approved as “a long-term approach.” Asked if there were time limits, he said “it varies on a state-by-state basis.”
California hospitals are not happy about it. “We do continue to have some concerns about the use of the crosswalk approach and we’ll be raising these concerns during a stakeholder meeting,” said Jan Emerson-Shea, spokeswoman for the California Hospital Association.
Robert Tennant, senior policy adviser at the Medical Group Management Association, which has opposed the federal push to require ICD-10 conversion, expressed concern that such important information about state Medicaid programs and ICD-10 readiness is surfacing less than a month before the compliance date. “That’s exactly what we feared would happen,” he said. “We’ve asked for the readiness levels for Medicaid for five years and we didn’t get an answer from the CMS.”
Health IT consultant Stanley Nachimson said crosswalking isn’t a good solution. “There are some ICD-10 codes that do not crosswalk back to ICD-9 codes,” he said. “They should have gotten their machines ready. They could have talked with some other states and seen how they’ve done it.”
The four state Medicaid programs may not be the only payers using the crosswalk technique, said Holley Louie, president-elect of the Healthcare Billing and Management Association. “We’ve have heard from some of the smaller commercial plans that they’re going to do the same thing,” she said.
Medicaid agencies in Louisiana and Maryland confirmed they will use the crosswalk approach.
In California, Medi-Cal’s crosswalk wasn’t a last-minute fix. Adam Weintraub, a California health department spokesman, said the state approved a six-year, $1.6 billion contract with Xerox Health Systems in March 2010 to upgrade its Medicaid management information-system software. The suggestion to use a coding crosswalk was in Xerox’s response to California’s request for proposals from the beginning, and the CMS signed off on it when the agency approved funding for the upgrade, Weintraub said.
Xerox began work on the ICD-10 enhancement in November 2010 and implemented it in September 2014 after nine months of extensive system testing. The state is continuing the tests, Weintraub said, and got a 95% pass rate in the latest round. Still, California considers the crosswalk a temporary approach.
The four crosswalk states have about 15 million Medicaid beneficiaries, but probably fewer than 3 million of those beneficiaries could have their Medicaid claims pass though the crosswalks. That’s because most Medicaid beneficiaries, particularly in California, are covered through capitated Medicaid managed-care plans, which don’t bill for each service.
Nachimson said the CMS has been keeping tabs on the state Medicaid programs, in part because their systems are largely federally funded. But the Medicaid office at the CMS has been “very quiet” about the readiness levels of the states, he said. “The response from CMS was they did not feel comfortable disclosing the information that the states were reporting.”
The healthcare industry’s deadline to convert to ICD-10 comes Oct. 1. But the CMS has signed off on a workaround for Medicaid programs in California, Louisiana, Maryland and Montana.