ICD-10 Blows Over Like Y2K

Philip Stella, MD

In the end, it was much ado about almost nothing. Certainly, there have been worse complications brought on by lesser events, said Kathy Oubre, chief operating officer for Pontchartrain Hematology Oncology in Covington, Louisiana, a practice of two clinics, two MDs, a nurse practitioner, and 17 support staff.

The advent of ICD-10—the compendious new set of medical codes that threatened to submerge practices underneath mountains of rejected claims and red tape— turned out to be a lot like the Y2K scare of 15 years ago when a structural programming characteristic dating from the dawn of the computer age seemed likely to cause the digital world to grind to a halt.

ICD-10, more formally known as the 10th version of the International Statistical Classification of Diseases and Related Health Problems, was imposed by the Centers for Medicare & Medicaid Services (CMS). Starting October 1, CMS began requiring medical workers to use codes from among the 150,000 available for diagnosis coding, procedure coding for inpatient services, and other health services. Oubre said staff in her clinic were well prepared for the changeover from the older, smaller set of medical codes known as ICD-9 and that the numbers on payer rejections or denials were no worse in October than they were in September before the switch.

“That was my big concern, what the payers were going to do, but we didn’t have a large rise in denials or claim rejections,” Oubre said. “We’ve seen a slight reduction in our reimbursement from Medicare, but not a significant one.”

Oncology claims consultant Roberta Buell, a principal with onPoint Oncology of San Francisco, said that her data from 150 non-hospital practices, representing 2000 physicians around the country, bears out the statements made by individual physicians for this article in that ICD-10 so far has not caused a significant disruption in the payment cycle.

She cautions that it will take more than a month to get an accurate picture on whether coding issues have gummed up the system in the wake of the October 1 initiation. “I don’t know whether we’re seeing the tip of the iceberg or whether this will hold out. It’s very hard to say. We don’t have a tremendous amount of data.”

Buell said there have been some issues. For example, claims for erythropoiesis- stimulating agents such as Procrit, Epogen and Aranesp have been rejected more than others. Buell said that’s probably because physicians may have assumed that there was a grace period that applied to these drugs and that coding issues would be overlooked. That isn’t the case. In addition, there have been more claims rejected for not being “medically necessary,” and the cause of that may be incorrect coding, but it is not clear yet what is happening, she said.

Newer drugs, for which codes have not yet been established, may be a source of payment bottlenecks, she added.

Ultimately, however, things have gone far more smoothly than she expected, and she said that observation is supported by remarks she has heard from practitioners.

Oubre, a member of the administrative network of the Community Oncology Alliance, sat in on a roundtable in October that included other private practice representatives who also reported only minor problems connected with the changeover.

“Most are not seeing a significant bump in denial rates,” she said. Bigger problems resulted when the Centers for Medicare & Medicaid Services began rolling out National Provider Identifier numbers, which caused a “40% to 50% cut in our Medicare payments,” Oubre recalled.

Oubre is among the oncology professionals who envision strong benefits coming out of the transition, including a far greater store of useful data on cancer that can help to identify trends and population characteristics. For example, a broader array of codes has been established to identify where in a patient’s body certain neoplasms have occurred, such as the left or right breast or the left or right lung. For hematology, vitamin deficiencies can be identified with far greater specificity under ICD-10 than before. (Figure 1, 2) “I’m excited about seeing the data that comes out from this a year from now,” Oubre said. I’m interested in that, and I think that’s going to be really relevant for us. It’ll allow us to tighten our standard of care and understand even better what we can do for the patients moving forward. It might take some extra time right now, but I think it’s going to have significant benefit.”

Figure 1. Hematology - ICD-10 Before and After

Source: Blue Cross Blue Shield of Michigan, 2014.

The extra time involved to look up new codes and input them where appropriate has certainly added to the physician’s daily workload, said Philip Stella, MD, chair of the ASCO Government Relations Committee and medical director of the Oncology Program at St. Joseph Mercy Hospital Cancer Center in Ypsilanti, Michigan. He has not yet seen the numbers on payer denials or rejections and says the greater workload has had the biggest impact so far.

Such an administrative workload addition falls into the ranks of “unfunded mandates,” he said. However, like Oubre, Stella agrees that there will be long term advantages to ICD-10, among them the detailed documentation that will help physicians to make their case that they are improving their game when measured against the new reporting and performance standards that will be imposed under the Medicare Access and CHIP Reauthorization Act of 2015, otherwise known as MACRA.

“A smart practice will figure out ways of making sure that all those comorbidities are in there so that they can really appropriately compare and try to make sure that they’re accurately depicting the patient population,” he said. This will enable fair and realistic comparisons to be made when evaluating practice performance. “They can match it and see how you’re doing, above the mean or below the mean, or whatever cutoff they use, to give you either a penalty or a step up in reimbursement or a bonus,” he noted.

Figure 2. Oncology: ICD-10 Before and After

Source: Blue Cross Blue Shield of Michigan, 2014.

It’s not as though this has been stated officially as a primary reason for switching to ICD-10, but it makes sense for practices that they see the value of these codes in helping to distinguish their efforts where misunderstandings might otherwise arise, Stella added. “What’s going to happen is the more accurately they code to get those co-morbidities, the better off we’re going to be.”

Both Stella and Oubre said that in the aftermath of the heavy training and preparation for the changeover, physicians and other health staff appear to be well adjusted to using the new set of codes. “We had all the docs go through an educational program because [ICD-10] raised huge questions— are people going to be ready?” Stella said. “For all the radiology tests that you have to do, you have to have ICD-10s in there. So, there was a lot of coordination; there was a lot of work to make that happen. By now, we’ve pretty much adjusted to it.”

There’s still a great deal of system integration required to update former ICD-9 codes to ensure payment and tracking continuity, but Oubre said her practice in Louisiana is already back on its former schedule after reducing patient scheduling as a contingency measure during the first part of October. Members of staff are feeling more confident the further along they go with ICD-10, she said. “This was just one other event, and I think we’re stronger because of it. We’re ready to move forward.”