Wednesday, October 29, 2008

The Transition to ICD-10

I'm always enthusiastic about the adoption of new standards that enhance semantic interoperability. The use of modern vocabulary standards such as ICD-10 improve administrative efficiency, enhance the ability of decision support systems to enforce guidelines, and enable a more granular reimbursement process.

The Centers for Medicare and Medicaid Services (CMS) circulated two Notices of Proposed Rulemaking (NPRM) on August 22, 2008 that require adoption of new standards for claims submission (X12 5010) and coding (ICD10)

The 5010 Proposed Rule - Health Insurance Reform; Modifications to the Health Insurance Portability and Accountability Act (HIPAA) Electronic Transaction Standards; Proposed Rule (73 Fed. Reg. 49742)

The ICD-10 Proposed Rule - HIPAA Administrative Simplification: Modification to Medical Data Code Set Standards To Adopt ICD-10-CM and ICD-10-PCS; Proposed Rule (73 Fed. Reg. 49706)

The first step in the transition to ICD-10 is the upgrade of the Electronic Transaction Standard (administrative data communications between payers and providers) from version 4010 to 5010. Once this upgrade is complete, the work on ICD-10 can begin. In the CMS NPRM, the deadline for 5010 implementation is April 1, 2010 and the deadline for ICD10 is October 1, 2011

As much as I support ICD-10, I also know that the change management effort to upgrade systems and train personnel will be huge. The Association of American Medical Colleges (AAMC) summarized the issues in a comment letter that was submitted to Secretary Leavitt.

Recently, the New England Health EDI Network (NEHEN), representing the payers and providers of Eastern Massachusetts, wrote comment letters to Secretary Leavitt recommending a longer transition timeline. By consensus, Massachusetts stakeholders recommended a 5010 implementation date of April 1, 2012 and an ICD10 implementation date of April 1, 2015.

Here are some of the issues NEHEN identified:

HHS expects that HIPAA 5010 and ICD-10 will run as concurrent projects. The supply of experienced and skilled resources to complete work on both efforts is limited. The accelerated implementation of both of these projects would create significant competition for scarce business and technical resources as well as project funding. This is not a recommended approach as it is a high risk, high cost implementation strategy.

The overall cost of implementing this change is technological and operational. For example, there must be modifications to existing training curriculum as well as claim submission and payment policies to ensure no adverse impact to the revenue cycle. I anticipate a real challenge to train, recruit, and retain ICD-10 savvy coders.

NEHEN also identified several unanswered questions:

When can covered entities expect to receive a complete mapping of ICD-9 to ICD-10 codes, both diagnosis and procedure?

What is the exact timeline for payers to be able to accept both ICD-9 and ICD-10 versus ICD-10 only? How does this impact the response transactions?

Should the code set used be validated based on the date of transmission? The start Date of Service or Discharge? The Payment date?

Are paper claim submissions required to use the ICD-10 code sets? If so, what is the timeline for this conversion and acceptance?

How does the change from the ICD-9 to the ICD-10 impact the other code sets used in the transactions (HCPCS, CPT-4, NDC, etc)?

ICD-10 is a needed change to replace the 30 year old ICD-9 coding vocabulary. As with any change, we need the time and resources to bring the people, processes, and systems to a future state while minimizing risks of business disruption. Hopefully CMS will revise its implementation deadlines based on all the comments from healthcare stakeholders so we can align the scope, timing and resources needed to do the project right.