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ICD-10: Do They Mean It This Time?

Dan Haley, athenahealth VP of Government and Regulatory AffairsAs athenahealth’s frequent ‘guy in DC’ I’m always asked the same ICD-10 questions: Is the October 2015 deadline real this time? Are the feds going to punt again? They aren’t ever going to pull the trigger on ICD-10, right?

All reasonable questions, especially after the October 2014 deadline — supposedly a hard-and-fast date — was unceremoniously kicked down the road by a year.

When it comes to ICD-10, providers fall generally into two categories: Those who actually invested time and money to be ready for October 2014, and, having been burnt once badly, are leery of approaching the ICD-10 stove again. Then there are providers who feel validated that they had correctly bet the feds would blink — and may be more comfortable making that bet again next year.

The policy meteorologists uniformly predicted stormy weather. Yet a whole lot of people went outside without an umbrella and ended up enjoying a beautiful, sunny day. Why shouldn’t the same scenario play out again in 2015?

Despite all of the time I spend in the company of federal health IT policymakers, I have precious little insight to offer. The people in DC who are in charge of the transition are emphatic, both in public and behind closed doors: this time, they say with uniform certitude, the deadline is real. Count on it. Tomorrow the sun will rise in the east, this winter the New England Patriots will make the playoffs (hey, I’m in Boston), and in October 2015, the nation will switch over to ICD-10.

Considering past performance as an indicator of future action, skeptics can certainly be forgiven for their lack of faith. So how can we at athenahealth say, with a straight face, we think this thing might just be real this time? A few reasons:

  1. The 2014 delay was almost certainly political. With the nation just barely over the calamitous roll-out of, there was no way the White House would implement a massive code switchover that could well have rendered a majority of the country’s providers temporarily unable to be paid for their services, just one month before the midterm elections. Unequivocal statements by everyone including Centers for Medicare & Medicaid Services (CMS) head Marilyn Tavenner notwithstanding, this year’s delay was entirely predictable. 2015, on the other hand, is not an election year. Even if providers are not appreciably better prepared for ICD-10 next year than they were in 2014, it may not matter — chaos is more politically palatable in an off year.
  2. The recent Ebola scare lends a new degree of urgency to upgrade U.S. systems to match the code set already in use in much of the world, to better enable the disease identification and tracking necessary for a global health crisis response. Nothing motivates change in Washington like an emergency.
  3. Of course, there is the Affordable Care Act. With the rolling implementation of the law, provision of and reimbursement for care is getting more complex. At some point, the continued use of a code set rolled out in the Watergate era, and long-retired in much of the modern world, becomes untenable.

Regardless of the continued uncertainty surrounding the October 2015 deadline, at athenahealth we are encouraging providers to get ready for ICD-10 and are preparing and testing on our clients behalf. Our cloud platform had our entire provider base ready well before October 2014, and will have it ready again months before October 2015, at no additional cost to those clients. And we are working hard — again — to make the transition as easy and painless as possible.

Like meteorologists, political prognosticators are often wrong, sometimes radically so. Even though we sometimes get to enjoy unexpected blue skies, eventually it pays to dress for stormy weather. DC is again confidently predicting a switch to ICD-10 on October 1, 2015, and there is no upside to bet against that happening. No matter when it does, athenahealth will be holding the umbrella for providers.


The Waiting Game: Next Steps for ICD-10

The latest ICD-10 delay (signed into law in April), has demonstrated that Congress really can get things done — when it comes to legislating procrastination. The delay (not supported by CMS) was brought about by a single 45 word statement inserted into a much larger bill regarding the Medicare SGR payment policy. This deferment of action on ICD-10 leaves us with no clear next steps; the law states that the U.S. Department of Health and Human Services (HHS) may not adopt ICD-10 earlier than October 1, 2015, allowing a number of scenarios to play out (2015? 2016? Not at all?) The Centers for Medicare and Medicaid Services (CMS) has indicated they are targeting a 2015 ICD-10 transition date, and that a rule is forthcoming, but there’s no solid deadline so far, leaving an entire industry in regulatory purgatory. Where does that leave practices and providers attempting to manage this [theoretical] transition?

As we discussed with athenahealth clients at our annual User Conference last month, there are three major lessons we’ve learned from this delay for those leading change in their practices; insight that reinforces a clear strategy to manage ICD-10 effectively.

Lessons from the Delay

  1. ICD-10 is now not only a matter of policy, but also of politics
    Prior to April’s delay, ICD-10 policy was principally in the hands of policymakers at HHS and CMS. Because these organizations are executive branch entities, policy around ICD-10 was bound to the federal rule-making process, requiring periods of public comment and analysis for change, activities that make the ICD-10 transition relatively transparent. However, with this recent delay, we saw that ICD-10 could be used as a political bargaining chip, allowing for changes to ICD-10 policy as part of any legislation. As such, the path for the ICD-10 transition increases significantly in uncertainty – requiring a flexible and time-sensitive strategy, which we outline below.
  2. Co-sourcing regulatory change demands can greatly reduce costs
    As with other regulatory changes subject to legislative uncertainty, relying on a networked service provider to manage technology, operations, and process changes can greatly reduce costs to health care providers. Specific ally, the costs of development, testing, and deployment of updates for changes like ICD-10, can be taken on by the service provider, and not many times over by every health care entity.
  3. Agility is key
    Opportunity cost — if we spend time and money on X, we can’t accomplish Y — is a central concern for software and services organizations, and a principle focus of product managers. In the current environment, being able to reallocate people and time in the face of uncertainty is critical to effectively managing large regulatory disruptions like the ICD-10 delay, and avoid high opportunity costs. Agile approaches for product development allow for rapid change by breaking off work in incremental chunks and employing a process that not only allows for adapting to change, but expects it. This way opportunity costs can be reduced by not overinvesting in long term initiatives.

Where to Go from Here
With these lessons in mind, providers and practices can follow a clear path forward for managing the ICD-10 transition.

Resources should not be spent preparing for ICD-10 until there is a high confidence that a transition date has been set — otherwise the risk of doubling or tripling costs spent on training staff, testing systems, and readying processes remain. As people and systems are both likely to change — new resources are hired, systems are updated — preparing too far in advance could easily mean repeating ICD-10 work. In the interim, resources should be used to pursue initiatives that have tangible value like Meaningful Use Stage 2 and better care coordination.

However, there are pre-requisites for pivoting like this: using systems and services that take on the majority of the work change and share the same incentives as your organization. Costly activities with longer lead times, like system remediation and testing, should be handled by a services provider as part of their core service, without additional fees passed on to clients. With such systems and services in place, the work, cost, and time required to decelerate and reaccelerate an ICD-10 initiative is greatly reduced and allows for provider organizations to focus on the highest value work.

Once a deadline is finalized, your organization should bring ICD-10 back into focus within a timeframe that has a low risk of regulatory or legislative change. At athenahealth, we think that window is about 10 months out from the transition date; if the transition is finalized for October 1, 2015, providers should begin preparation on January 1, 2015. With this approach, you’ll have a higher probability of your resources being used wisely, and a reduced risk of waste.

If your current systems and processes pose limitations to such an approach, consider if investing in agile systems and operations ready for change may be worth more than readying current systems for a hypothetical transition date.

Finally, if your organization is properly prepared when the transition arrives — whenever it does arrive — remember to stay cool. Keep calm and bring ICD-10 on.

Healthcare Policy & Reform | ICD-10

ICD-10 Dismay

Way back, when we were still struggling to run a successful birthing practice called Athena Women’s Health, I shared a dank, cramped house in San Diego with Jonathan Bush, my brother Todd, and the other athenahealth co-founders. I slept on a mattress on the floor with a 30-pound tower computer as a headboard and for months would wake up every day, roll out of bed, and write code. Line by line, I built rules around medical billing claims so providers could get paid faster and more accurately for delivering care. Down the road at the clinic, the providers were consumed with weightier challenges, like lowering the C-section rate and reducing NICU days. It struck me then, and still does, that we had landed on a fair and smart division of labor. Providers would focus on delivering care and we’d invent technology and services to wick away the paperwork and hassles, and get the caregivers paid for doing the right thing.

To my mind, that is the fundamental social contract — or it should be — behind the $31 billion health IT (HIT) industry that’s grown up around US caregivers. Which is why news of the vote to once again delay the ICD-10 transition is disappointing, and symptomatic of an ongoing breach of that contract by technology vendors. Whether the adoption of an already two-decades-old coding system is going to meaningfully transform care is certainly up for debate. But as a proxy for the HIT industry’s ability to handle change on behalf of providers, the latest ICD-10 delay is a troubling canary in the coal mine.

Over the last five years, the government has spent more than $20 billion of taxpayer money to install electronic health record (EHR) technologies, many of which cannot implement a change in diagnosis codes that the rest of the world implemented years ago—in some nations, more than a decade ago. ICD-10 readiness for providers is about much more than the availability of mere technical functionality; it’s about having the support necessary to successfully achieve ICD-10 compliance, which includes things like training and business processes. That the government felt compelled to delay the ICD-10 transition reflects not a failure of health care providers, but a failing health information technology industry that’s unable to support providers in navigating change.

Health care providers need and deserve technology partners that will step up and do what it takes to ensure their success in meeting the complex demands of our changing health care system: from the ICD-10 transition to the Meaningful Use program, from the transition to risk-based payments to the demands of care coordination. The government needs to stop subsidizing dysfunction by accommodating technology vendors that, time and time again, leave providers high and dry.

In recent years, caregivers have been asked to do backflips to absorb huge changes to their practices, their approach to care, and the ways they get paid. If health care providers are ever to achieve the ambitious triple aim around cost, quality, and the patient experience, they’re going to need technology partners that can move beyond excuses to keep up their end of the bargain.

Healthcare Policy & Reform | ICD-10

Negative Reinforcement for Laggard Health IT Vendors

Dan Haley, athenahealth VP of Government AffairsEvery good parent understands the concept of negative reinforcement. If you threaten to punish a child’s bad behavior and then fail to follow through, the inclination toward bad behavior is reinforced — making future bad behavior more likely.

The same basic dynamic holds true in the relationship between the U.S. federal government and health IT industry. The government keeps imposing supposed hard-and-fast deadlines — for successive stages of Meaningful Use , for ICD-10 — and then punting when too many health IT vendors fail to do the hard work necessary to meet those deadlines, leaving their care provider clients in the lurch. Worse, the punt too often comes after repeated assurances by top officials that no further delays will be granted.

Today’s news provides us the latest example: The Sustainable Growth Rate (SGR) “patch” legislation just negotiated between House Speaker John Boehner and Senate Majority Leader Harry Reid. The “patch” includes language delaying ICD-10 by yet another year. And just two weeks ago the Centers for Medicare and Medicaid Services (CMS) quietly issued “hardship” exemptions, effectively pushing Meaningful Use Stage 2 out another year.

The bill released today was negotiated quietly (even relevant committee chairs had no scent of it), so there is still a chance that changes could be made…

For those vendors unable — or worse, unwilling — to comply, what do they learn from these repeated experiences? The same thing a child learns when a parent first tells him or her there’s no dessert if they don’t finish dinner, and then proceeds to scoop out the ice cream.

Every time the wider vendor community neglects to put in the effort to meet reasonable (and reachable!) deadlines, and is effectively rewarded for its intransigence with further delays, the lesson learned is clear: these deadlines aren’t real. They can go on selling sub-standard technology into a largely captive market, ensuring that healthcare remains stubbornly mired years behind the rest of the information economy.

ICD-10 | User Conference

ICD-10 Countdown: Symptoms and Treatments for ICD-10 Anxiety Disorder

With the ICD-10 deadline now only seven months away, concern over the transition is growing. This may be misplaced anxiety relative to the other sea-change transitions occurring in health care, but it is pervasive. So much, in fact, that I think it warrants the following addition to the ICD-10 code set: F41.8XXX – ICD-10 Anxiety Disorder (consider it a new member of the F40 phobic anxiety disorder chapter). This new code proposal requires some justification, so let’s take a look at the symptoms that are driving ICD-10 Anxiety Disorder and some of treatments available to its sufferers.

Symptom #1: Paranoia over coding specificity
Treatment: A dose of reality

While it is true that ICD-10 includes codes with greater specificity, unspecified codes are perfectly valid when clinical documentation supports their use. In fact, here’s a fully adjudicated and paid sample charge using an unspecified code, directly from our ICD-10 testing efforts with a large national commercial payer.

In ICD-10, there are 11 billable acute sinusitis codes. If those codes are clinically appropriate, then they should be used. But, in this case, the distinguishing attributes (maxillary vs. frontal and ethmoidal vs. sphenoidal, for example) that would lead to a more specific ICD-10 code were not available at the time of service—meaning the unspecified code was the most accurate code which could be billed. As this shows, unspecified codes are valid and, when applicable, do not impact claim outcomes.

Symptom #2: Disorientation due to large numbers
Treatment: User-centered technology

There are indeed approximately 56,000 more codes in ICD-10-CM; that makes for a really thick coding book, comparable to the Yellow Pages. And, as with the Yellow Pages, the new code set has developed quite the usability problem when you’re looking for something specific.

In the case of Big Yellow, user-oriented search engines have helped us easily find contact information; similarly, intelligent diagnosis code search tools can make navigating the ICD-10 code set simple.

Here’s how this works for our clients: athenaNet (our cloud-based platform) uses a combination of SNOMED terms, ICD-9, ICD-10, and keywords to dynamically populate relevant codes based on terms that clinicians actually use, along with dynamic filters that rapidly reduce the number of codes presented to the provider as they search for a diagnosis. Additionally, our usability and research teams continually evaluate the performance of this search tool to refine its performance; the more it’s used, the better it gets.

Comparable approaches that focus on user behavior can help address the inherent challenge of designing solutions for complex code sets; deriving simplicity out of complexity.

Symptom #3: Rigidity of business processes
Treatment: Harmonious software, knowledge and work

At the advent of the ICD-10 deadline, old encounters and claims will need to be resolved in ICD-9 and, as I mentioned in a previous post, not all payers must comply with the new code set. Flexibility is important. As such, the recommended treatment for this symptom is the application of a software-enabled service that takes care of the details so providers, billers and coders can focus on the clinical encounter. Solutions that include dynamic workflows by date of service, reflect up-to-date industry knowledge garnered from daily interactions across a national health information network, and keep track of payer readiness allow for flexible and continuous business processes.

Symptom #4: Paralysis of practice managers and project teams
Treatment: Step-by-step guidance specific to your organization

ICD-10 Anxiety Disorder is most commonly associated with teams paralyzed by uncertainty. Urgent care is often required here, starting with assessing the impacts ICD-10 will have on your organization, which can vary from practice to practice. Ideally, practice systems will self-identify where attention is needed; we’ve built a practice-specific step-by-step readiness tool right into athenaNet. In more complicated systems, this can take some work to uncover. Treatment should focus on the major bottlenecks of ICD-10 readiness:

  • Readying charge capture tools for ICD-10
    Capture solutions (electronic charge capture solutions or paper forms) are where ICD-10 is most apparent to clinicians. Practice managers should look to implement a solution that focuses on ease of use; a 20 page paper super bill is probably not high on the list. (Read “ICD-10: Views from a Practice Manager.”)
  • Updating system interfaces
    Coordinating multiple vendors and [HL7] message formats can take time; practices should recognize this as a potential bottleneck, and prioritize their interface preparation.
  • Prevention of ongoing ICD-9 future orders
    If possible, you should start issuing any orders beyond the October 1 date with ICD-10 codes to avoid future workflow issues and call volume.
  • People readiness
    You should evaluate the readiness of your practice personnel by role (e.g. front desk staff, clinicians, coders/billers, analysts). If this hasn’t yet been completed, assess your needs now and put a plan in place to provide staff the functional knowledge they need prior to the transition date.

Differentials for these symptoms include complicated and rigid software and service models, a lack of agility and change readiness, and solutions that rely only on software. These potential underlying conditions can be exposed by the onset of ICD-10 Anxiety Disorder.

A final note: Good treatment of ICD-10 Anxiety Disorder should target not the symptoms but the cause, the HIPAA-based regulation requiring the code set switch. In this case, the care must be palliative as the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services’ Office of the National Coordinator (ONC) have repeatedly reinforced that the October 1st, 2014 transition date is set. The good news here is that provider organizations undergoing the treatment above will likely overcome ICD-10 Anxiety Disorder this year and move on to other challenges facing health care.


I’ll be presenting at our annual athenahealth User Conference on the topic of ICD-10 so I encourage you to register for my session or feel free to stop me in the exhibit hall to expand on this topic. Hope to see you there.

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