Early ICD-10 Reports: Fortune Favors the Prepared

It's too early for a victory lap yet, but health systems and physician groups that prepared for ICD-10 are faring well. Revenue cycle implications are yet to be seen, however.

Having stared at tables full of ICD-10 reference books last week at AHIMA's annual convention and flipping through a few code books myself, I can sympathize with those clinicians and coders who are looking up all the new billing codes on paper.

But why would anyone put themselves through that?

It is too early to take anything like an ICD-10 victory lap—and there are future implications of the new code set that I address later in this column. But the initial reports are that those who prepared, and armed themselves with a technology assist, are doing okay with ICD-10 so far.

"No major surprises," says John Showalter, MD, chief health information officer of the University of Mississippi Medical Center, writing to me at the start of the week in an email. "Systems are functioning well, and with a little extra effort, coding days are still at pre-ICD-10 levels. We have submitted a few claims where the remittance has already come back, and all of our major payers have accepted a claim submission.

ICD-10: Post-Implementation Challenges

"It has mostly been a non-event (still need to make sure we get paid though)," Showalter says. "When there isn't a one-to-one mapping, we need to manually make the best selection. We started with about 12,000 and will be down to about 2,000 by the end of the day. Luckily, we have been able to do most in large batches because it is primarily affecting providers with a narrow clinical scope, like transplant."

Showalter recently described some of the preparatory steps he took on the road to ICD-10. (I will moderate his presentation on this topic in a HealthLeaders Media webcast on October 20.)

The medical center's primary technology assist comes from M*Modal's natural language processing, which converts unstructured text or narration into structured data. Another tech assist offers prompts within the healthcare system's Epic EHR from Intelligent Medical Objects, suggesting ICD-10 billing codes.

"Since March, all our physician billing has been ICD-10-level," Showalter says. Until October 1, these codes were backtracked to ICD-9 codes for submission to payers.

The medical center also did three rounds of testing with Medicaid in the state of Mississippi. And analytics dashboards help Showalter and his team keep on top of it all.

A Physician Group Is Doing Fine

But what about physician groups, which have been notable for catastrophic predictions about ICD-10?

A day after the ICD-10 transition date, I spoke with Chris Kean, chief operating officer of San Antonio (TX) Orthopaedic Group, to see how her group was faring.

"We're doing just great, as if nothing ever happened, honestly," Kean says. "We're doing really, really well."

The group's 27 surgeons, practicing across eight locations, are doing all the coding. The practice is otherwise free of ICD-10 coders. The EHR is provided by athenahealth.

In explaining the group's success, Kean says the surgeons started by hitting the books.

"We did a coding class, brought in somebody to teach us about the code, learned how to use the books—exactly as if you were doing it in the ICD-9 world—brought all the providers in, all the billers," she says. "We had several evening meetings in order to make sure that everybody was able to grasp it."

Around that time, athenahealth launched a portal to offer a way to learn ICD-10 online instead of focusing on book learning, Kean says. The group decided to finish the book-oriented course because "if something goes wrong, we're going to need to refer to the book to figure it out," she adds.

"So we taught the book, taught how to use it, but then at the very end of the class, after all the doctors were freaking out thinking they were never going to ever survive this, we said, Now athena's developed a tool to show you how this is going to work," Kean says.

"The relief that was on their faces when we showed them that—they said, 'Why didn't you just show us that in the very beginning? We wouldn't have been freaking out,' " she recalls.

On day one last week, the group's administrators fanned out to all the offices. "We just supported the doctors as they tried to figure out their codes using the athena product," Kean says. "We created cheat sheets for them on their top codes in ICD-9 before, to show them how it would convert over into the ICD-10 world, but they really didn't need the cheat sheets at all. They really just started right away within the athena product and started clicking off the codes, and they got to where they needed to be. It was such a relief for someone like me not to have to worry about that."

The pivotal day for the organization turned out to be the next day, October 2. "The administrative folks were not even in the clinics," Kean says. "We went back to our offices and said, 'Call us if you need us.' " There were very few calls.

Kean is certain that any physician just trying to look up ICD-10 codes in a book, without the technology assist of an athenahealth or other technology provider, will definitely get bogged down.

"That's probably true for anybody who's using that book, I am sure. Because I would think that it would take at least five minutes to look up a code—if you're proficient at it at that point; right now, they're not proficient at it—so maybe it would take them 10 minutes to look up a code, times the number of patients that you're seeing."

Revenue Cycle Implications Are TBD

Like Showalter, Kean is still waiting to see how her organization's revenue cycle plays out in the weeks and months to come. Because San Antonio Orthopaedic Group's payer mix is 16% workers' comp, she expects a rise in initial claims denials, as the workers' comp insurers use ICD-10's more specific information to determine that someone else should cover the medical bills for an injury.

"If this is a fall from a ladder, now they know, on a code, real quick, it's a fall from a ladder," Kean says. "Now [if] I'm an insurance carrier, I'm looking at that going, 'Well, is that my responsibility as an insurer? Did it happen at your home? Did it happen at work? Did it happen at somebody else's property?' So what will happen, I believe, is that will trigger an ability for the insurance carrier to quickly identify that, send that letter to the patient to say, 'How did this injury happen? Where did it happen?' And if it happened at somebody else's property, they're going to say, 'We're denying the claim. Go after the homeowner.' "

So an unexpected outcome of ICD-10 could be not just more work for physicians, but also more work for patients as well as property owners, who will have to provide better documentation of the circumstances of certain injuries.

I am sure there will be numerous other ripple effects on healthcare from ICD-10, if Kean's story is any indication. I'll be keeping an eye on them in the weeks and months ahead.

HealthLeaders Media Webcast: Health Systems Success Keys for ICD-10—Physician Alignment, Support and Technology, will be broadcast on Tuesday, October 20, 2015, from 1:00 to 2:00 p.m. ET. Hear from the University of Mississippi Medical Center's Chief Health Information Officer as he discusses how his organization overcame the obstacles of implementing ICD-10, the experience so far, and what to expect in the months ahead.