ICD-10 one year later: The drama is over, the re­wards yet to ma­te­ri­al­ize

Modern Healthcare - - NEWS - By Joseph Conn

It’s been a year since the big lift of con­vert­ing the en­tire claim stream of the health­care in­dus­try to the larger and more gran­u­lar ICD-10 fam­ily of di­ag­nos­tic and pro­ce­dural codes.

The Oct. 1, 2015 launch went smoothly com­pared with the warn­ings of tech­no­log­i­cal melt­down and cash-flow Ar­maged­don that pro­voked three de­lays to­tal­ing four years.

Claims flows, mea­sured by claims de­nial rates, re­turned to nor­mal af­ter a few months, ac­cord­ing to the CMS and con­firmed by in­dus­try ex­perts.

“This is the Y2K of cod­ing,” said Dr. John Cuddeback, chief med­i­cal in­for­mat­ics of­fi­cer of the Amer­i­can Med­i­cal Group As­so­ci­a­tion. “I think peo­ple did a pretty good job of pre­par­ing.”

But this month, physi­cians face a new ICD-10 chal­lenge. Last year, the CMS granted physi­cians a one-year grace pe­riod, promis­ing not to deny Medi­care Part B claims for lack of speci­ficity of ICD-10 cod­ing. Many com­mer­cial pay­ers sim­i­larly gave physi­cians “flex­i­bil­ity,” but that grace pe­riod ended Oct. 1. Ear­lier this year, the CMS and HHS re­leased up­dates to the codes that con­tained what Sue Bow­man, se­nior direc­tor of cod­ing pol­icy and com­pli­ance at the Amer­i­can Health In­for­ma­tion Man­age­ment As­so­ci­a­tion, called “some hic­cups in the hos­pi­tal DRG sys­tem,” But, she added, “I think we’re past most of that.”

Ex­perts say it’s too early to tell whether the switch to more strin­gent cod­ing re­quire­ments will snag docs’ claims. “We’re keep­ing our ears open to see if that has had any im­pact on claims,” said Robert Ten­nant, direc­tor of health in­for­ma­tion pol­icy for the Med­i­cal Group Man­age­ment As­so­ci­a­tion, a trade as­so­ci­a­tion for man­agers of physi­cian of­fice-based prac­tices.

But the prom­ise of ICD10 in­volved more than a rev­enue-cy­cle up­grade. The new codes were touted as es­sen­tial paving stones on the road to val­ue­based pur­chas­ing, lead­ing to im­prove­ments in health­care data an­a­lyt­ics, pop­u­la­tion health man­age­ment, care qual­ity and lower costs. Those ben­e­fits have yet to ma­te­ri­al­ize.

“I don’t ex­pect to see any­thing along those lines un­til an­other year or two,” said Rhonda Buck­holtz, a 25year health IT vet­eran and vice pres­i­dent of strate­gic de­vel­op­ment at the Amer­i­can As­so­ci­a­tion of Pro­fes­sional Coders, which rep­re­sents the work­ers who en­sure health­care claims are af­fixed with the ap­pro­pri­ate ICD-10 codes.

USMD Health Sys­tem, Irv­ing, Texas, has used ICD-9 coded data to iden­tify high- risk pa­tients and is mov­ing now to use pre­dic­tive an­a­lyt­ics pow­ered by both ICD-9 and ICD-10 codes to iden­tify pa­tients on the bor­der­line be­tween well­ness and sick­ness so care­givers can in­ter­vene be­fore more ex­pen­sive ail­ments de­velop.

But Dr. Charles Van Duyne, the mul­ti­spe­cialty group’s CMIO, said he’s still “cau­tiously skep­ti­cal” that ICD-10 will ever pay off in clin­i­cal qual­ity im­prove­ment com­men­su­rate with the money and ef­fort put into the con­ver­sion. “Yes, ICD-10 gives you more gran­u­lar­ity, pro­vid­ing you’re do­ing the cod­ing cor­rectly. But hav­ing more in­for­ma­tion isn’t nec­es­sar­ily bet­ter. What you’re re­ally look­ing for is in­sight into the data and ac­tion­able in­for­ma­tion out of that data.”

USMD Health Sys­tem par­tic­i­pates in mul­ti­ple value-based pay­ment mod­els, in­clud­ing three years at full risk un­der Medi­care Ad­van­tage.

“This is the Y2K of cod­ing. I think peo­ple did a pretty good job of pre­par­ing.” JOHN CUDDEBACK Chief med­i­cal in­for­mat­ics of­fi­cer, Amer­i­can Med­i­cal Group As­so­ci­a­tion

Such ar­range­ments re­quire sig­nif­i­cant in­vest­ments in tech­nol­ogy and training, but often the data re­quired are not in ICD-10 di­ag­no­sis and pro­ce­dural codes. For ex­am­ple, blood glu­cose read­ings for di­a­betic pa­tients are far more im­por­tant over time than the ini­tial di­ag­no­sis code for di­a­betes.

Some ex­perts say that a cou­ple more years of build­ing up data­bases of med­i­cal records coded in ICD-10 will be needed be­fore a fair as­sess­ment of the ef­fects of the codes can be made.

“It’s not just go­ing to be ICD-10,” said Mark Morsch, vice pres­i­dent of tech­nol­ogy for Op­tum360, the rev­enue cy­cle and ser­vices man­age­ment arm of Unit­edHealth Group. “It’s go­ing to be a com­bi­na­tion of things like com­puter-as­sisted cod­ing, and tools to link the cod­ing data to un­der­ly­ing clin­i­cal data and pro­cesses that will pro­vide the re­turn on in­vest­ment on this.”

It will be hard to point to ICD-10 as driv­ing the im­prove­ment, he said, “but that in­for­ma­tion is go­ing to be in­cred­i­bly help­ful as you look to lever­age an­a­lyt­ics and look at pop­u­la­tions and de­cide how chronic dis­ease needs to be man­aged.”

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