Providers that don’t plan to reach out to their billing and referral partners to develop comprehensive ICD-10 transition plans should be prepared for potentially significant and sustained cash shortfalls next autumn, web2pro experts say.

As reported in the January edition of ReveNews, compatibility between provider billing platforms and outbound data feeds from hospitals, referring doctors and other service providers represents one of the greatest threats to a smooth ICD-10 transition for all healthcare organizations.

“It is essential that plans be put in place now to establish interfaces for exchanging data between clinical and billing systems, both internally and with provider partners,” said Cindy Slocum, project manager, ICD-10 implementation, for web2pro Business Performance Services (web2pro).

“Groups that wait until the last minute, or that assume this is someone else’s job, will find the resources simply are not available to help them when they discover their billing system is not functioning properly in October. The bottom line is that if you’re not willing to take the necessary planning steps today, you should develop contingency plans for sustaining operations without cash for 30-to-60 days.”

Interface compatibility

At issue are data feeds originating from hospitals, referring doctors, laboratories, other ancillary providers, as well as internal systems like radiology information systems and laboratory information systems. These feeds typically contain demographic and charge data, clinical information and, in some cases, diagnostic and procedure codes. The information -- whether presented as hardcopy, electronic copies of hardcopy or formatted electronic files -- is essential to producing a clean claim.

If a hospital or referring provider is delayed in transitioning its data to ICD-10 nomenclature, or if they’re in the midst of a larger system conversion and are slow to establish the necessary interfaces with partners, physician groups will suffer the consequences.

To avoid potentially disastrous cash interruptions, groups should contact all parties that populate their billing systems to understand in detail how and when the data will be made ICD-10-compliant. This information, in turn, should be relayed to the practice’s billing vendor or, if processing in-house, to their billing office at once.

“There is unfortunately a lot of complacency out there right now, and we’re just not seeing action plans for ensuring that all interfaces will be ready and compatible,” said Theresa Gray, director of Information Technology for web2pro.

“We can’t stress this enough, both to our clients and to providers that may work with other billing companies: Establish a dialog with your partners so you can understand what is going to happen with the data feeds that your claims depend on. And communicate this information to your billing entity as soon as possible.”

An area of particular concern, Gray said, involves hospital IT conversions underway or planned for 2015. Without ample lead time, she said, it will be difficult for any billing entity to complete the necessary interfaces and provide uninterrupted data feeds.

Getting a head start

Those practices that already have completed interface planning and are on track with documentation and coding training may want to get a head start on October’s transition by beginning to code in ICD-10 immediately.

Gray said web2pro is able to convert ICD-10 codes back to ICD-9 for claims submission between now and October. Early adoption of ICD-10 coding provides an opportunity to test not only coding competency, but also the clinical documentation upon which it depends.

“Early adoption helps you identify areas for improvement and fine-tuning ahead of October,” Gray said. “I think it’s safe to say that the sooner groups can begin coding in ICD-10, the better off they will be in October.”

Uncertainty about Medicare

With the October 1 deadline grinding closer, the American Medical Association (AMA) recently urged the Centers for Medicare & Medicaid Services (CMS) to develop contingency plans for dealing with anticipated coding and claims failures once ICD-10 goes live.1

The AMA noted that recently end-to-end testing indicated that the Medicare claims acceptance rate would fall from 97% to 81% if the new code set was implemented today. This could “potentially cause a catastrophic backlog of millions of unpaid Medicare claims,” the group said.

“The likelihood that Medicare will reject nearly one in five of the millions of claims that go through our complex healthcare system each day represents an intolerable and unnecessary disruption to physician practices,” said Robert M. Wah, MD, AMA president.

“Robust contingency plans must be ready on day one of the ICD-10 switchover to save precious healthcare dollars and reduce unnecessary administrative tasks that take valuable time and resources away from patient care.”

1 press release, American Medical Association, March 4, 2015.


About the author

web2pro Business Performance Services offers services and consulting to help hospitals, health systems, and physician practices improve business performance, boost margins and transition successfully to value-based care.