States’ ICD-10 cod­ing work­around may cause prob­lems, IT ex­perts warn

Modern Healthcare - - NEWS - By Joseph Conn

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.

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