Avoid payment delays by ramping up for ICD-10

Some providers are hedging on whether the transition from ICD-9 to ICD-10 will actually occur on October 1, 2015. After all, the deadline has already been postponed twice.

The federal government has stated the reason for the delay to 2015 was that small providers were not ready. Unfortunately, the 12 months of extra prep time might not do much to make providers any more prepared for the change.

“Providers think if it has already been delayed once, it could be delayed again,” says Jacqueline J. Stack, director of ICD-10 training and education for the American Academy of Professional Coders (AAPC). “If you give providers five more years, will they be any more ready than they are today? And the answer is: probably not.”

Change is difficult under any circumstances. However, the start-and-stop nature of ICD-10 preparation has not helped matters.

“The constantly changing deadline for ICD-10 implementation has largely caused a loss in momentum,” says Mary Givens, product manager of healthcare reform at Qualifacts Systems, Inc. “With healthcare reform creating so many other priorities for providers, including integrated care, outcomes measurement, and meaningful use, most organizations decided to focus their time and resources on other projects with harder deadlines.”

Moreover, many behavioral healthcare organizations have come to see ICD-10 implementation as a moving target. For many chronically underfunded behavioral healthcare organizations, the lack of a firm deadline has forced them to focus attention and resources on more pressing matters. While it is still possible that ICD-10 implementation will be postponed yet again before next year, behavioral healthcare organizations cannot reasonably assume that they can put off implementation indefinitely. Instead, the best approach is to act as if implementation will occur as planned.

There are compelling reasons to be ready for ICD-10 implementation by next fall. For example, consider the financial consequences of not being prepared, which translates into delays in receiving reimbursement for claims that do not include appropriate ICD-10 codes or paid claims that are flagged during payer audits. It could wreak havoc on cash flow. In short, if behavioral healthcare organizations have not begun seriously preparing for the changeover to ICD-10 coding, they need to begin doing so now because the process isn’t a simple switch. Rather, many providers will spend six months or more from preparation to adoption.

Changing culture

The International Classification of Diseases, 10th Revision (ICD-10) is the system developed by the World Health Organization (WHO) that all healthcare providers must use for coding diagnoses, symptoms, and procedures. After two postponements, the Centers for Medicare and Medicaid Services (CMS) has announced that the changeover to ICD-10 will occur starting on October 1, 2015, for the United States.

One of the key difference between ICD-9 and ICD-10 is the number of codes used. While some diagnoses will have fewer codes under ICD-10, most will have more. Another difference is the greater specificity required by ICD-10 in coding and documentation.

In fact, if there is any guiding principle in using ICD-10, it is the need to be as specific as possible in diagnoses and documentation.

For example, “bipolar disorder uses a typical diagnostic of bipolar disorder or bipolar unspecified,” says Stack. “ICD-10 requires more specific coding, such as hypomanic or depression with bipolar.”

Similarly, when diagnosing depression, ICD-10 requires codes based on severity, whether in remission (full or partial), any psychotic features and so on. The documentation accompanying the code must be similarly specific and, most important, match the code provided. Therefore, providers must not only choose the appropriate code but understand what documentation is required to support that code.

“People may hear this and assume that the system will make more work,” says Stack. “However, it is just adding a few more words. If we know depression is mild/moderate/severe, now we can pull a more specific code.”

For behavioral healthcare organizations, the changeover to ICD-10 is also likely to require a shift in mindset among providers. Technology is an asset in the coding process, but it merely provides a structure. The clinician’s experience and education is needed to marry the diagnosis with the right code. In essence, they must think in terms of ICD-10 to optimize their reimbursement.

“Most mental health practitioners do not understand that they need to use the ICD-10 moving forward,” says Lisette Wright, executive director of Behavioral Healthcare Solutions. “They are beholden to their DSM and they don't think that ICD-10 applies to them. They don’t realize that in some regards they have been using ICD-9 codes that have aligned with the Diagnostic and Statistical Manual (DSM) IV-TR codes.”

The confusion arises because some payers use both: DSM for clinical documentation for preauthorization and utilization review, and ICD for billing.

Wright notes that the issue has deep roots in the profession. For example, graduate schools in the fields of mental health and substance abuse tend to teach the DSM and not ICD coding.

“The number one priority is to educate your staff on the relationship between the ICD and the DSM,” she says. “But before you can do that, you have to understand it yourself.”

This is not to say that the DSM will be obsolete.

“Although behavioral healthcare organizations will face new terms that are not included in ICD-9, ICD-10 is designed to work side by side with DSM-5, which should help with the transition,” says Melanie Endicott, senior director of coding and CDI products development at the American Health Information Management Association (AHIMA).

Costs of being prepared

How ready behavioral healthcare organizations are for full adoption varies.

“Some were ready before the delay, then scaled back preparation and training after delay,” says Endicott. “The key will be to find ways to keep up with that training whenever they can.”

For example, she suggests holding a monthly get-together to keep staff up to date on ICD-10 requirements and preparation to ensure that the transition remains on the staff radar.

As organizations try to figure out how to code under ICD-10, they can use crosswalk tools to translate ICD-9 codes into ICD-10 codes. However, given how much more specific ICD-10 codes are, this is just the starting point.

“With an average of five times the specificity in coding, the change can be substantial,” says Vincent LaRosa, PhD, healthcare IT practice director for the Eliassen Group. “Crosswalk tools should be combined with educated coders.”

Others are more skeptical of how helpful crosswalk tools will be.

“How do you crosswalk codes when there is no longer a one-to-one match but a one-to-many match?” says Wright. “I don’t think there is a perfect crosswalk.”

Instead, she foresees a return to clinicians relying on a manual lookup process. For example, clinicians should expect that generic diagnoses, such as depression NOS (not otherwise specified), will no longer be enough under ICD-10.

“The ICD 10 is much more specific and we cannot use that NOS or general category,” Wright says.

The financial costs of the change are difficult to project because individual behavioral healthcare organizations are all starting from a different point. These costs can range from replacing documents to making sure systems are compatible to upgrading entire systems. Additional costs include training staff and clinicians.

“The largest expenses are likely to be any systems that need to be upgraded,” says Stack.

If an organization has electronic medical records or wants to switch to such a system during the changeover to ICD-10, that could increase costs. Overall, Stack estimates that costs will average between $1,500 to $2,000 per provider in the organization, with plenty of outliers with higher and lower costs. According to a cost study conducted by the American Medical Assn., a small practice might spend $56,639 to $226,105 on implementation.  

Time is another cost when it comes to ICD-10 implementation. When Canada switched to ICD-10, some providers noted an increase in the amount of time spent on specific tasks. According to the AAPC, this included a coding time increase from about 15 minutes to 33 minutes, and an increase in time to get claims paid from 69 days to 139 days.

“When the CPT codes rolled out about 30 changes in 2013, it took some insurers a year to correct those claims and pay the providers correctly,” notes Wright. “ICD-10 includes hundreds of changes.”

Costs of not being prepared

Behavioral healthcare organizations face significant financial repercussions if they are not prepared to manage coding and documentation using ICD-10 on October 1, 2015. Payers will begin to reject claims that continue to include ICD-9 codes instead of ICD-10 codes. If this happens, an organization’s cash flow will slow to a crawl very quickly. The time required to redo and resubmit the corrected claim will delay payment further. However, if organizations are experiencing significant problems with the changeover, they may need to code manually until systems can take over.

Even if payers continue to accept claims, an organization that is not completely up to speed on using ICD-10 could face problems over the longer term.

For example, if an organization continues to use general codes, like depression NOS, “the auditors could say that you could be much more specific and you are choosing not to be,” said Wright. “That is what it comes down to: writing down more words and substantiating that diagnosis in medical records and clinical documentation.”

In these cases, payers could press behavioral healthcare organizations to relinquish payment for those claims that were documented and submitted incorrectly as one way to resolve these situations.

If behavioral healthcare organizations have difficulty with coding, particularly if clinicians are not ready or able to use the ICD-10 codes appropriately, staff will have to go back to clinicians for clarification on the correct coding and documentation. Even so, there will almost inevitably be errors during the transition and problems due to lack of appropriate documentation.

“Work to understand the nuances of ICD-10 and you will be fine,” says Endicott.

In a pinch, there are some workarounds to consider. For example, one way to ease the transition is to develop “cheat sheets” of the top 20 or so codes that staff and clinicians use the most and keep them handy. There will inevitably be some trial and error as organizations find out what payers require and what, if any, additional documentation they will need to process claims.

As they work through this transition, behavioral healthcare professionals need to keep in mind that these changes are happening for a reason.

“Through greater specificity in treatment codes, ICD-10 will lead to improved quality in clinical outcomes data and additional insight into new treatment methods, both of which will lead behavioral health providers to a better quality of care,” says Givens. “Providers will see benefits in the form of data and behavioral health clients will benefit from more cost efficient services and overall improved treatment.”

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