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Dual coding proposal is equivalent to mandating another ICD-10 delay

Concerns have been raised about the potential financial impact on small physician offices that do not make adequate preparations for the October 2015 transition to ICD-10, either because their internal billing system is not ready or they have not obtained ICD-10 training. To address this concern, a dual coding system approach has been proposed in which small physician offices would be allowed to submit claims coded in either ICD-10 or ICD-9 during a transition period.

A dual coding system is not a simple solution, but is fraught with difficulties that have the potential to undermine the data infrastructure of the healthcare industry. It will confuse claims processing and negatively impact the handling of important patient clinical information and may affect patient care.

Whether intentional or inadvertent, the dual coding proposal is equivalent to mandating another delay in ICD-10 implementation.

Unworkable, Costly, Confusing. While a dual coding system may sound straightforward, it would require extremely complex and costly changes to major payment, clearinghouse and provider systems that are not practical or feasible. Even more troubling, the communication of health information between providers would be compromised, adversely impacting the quality of patient care and increasing the potential for patient harm.

Impact on Patient Care
Individual providers not only have to submit claims for their services but also have to communicate with other parts of the healthcare system. Ordering tests, prescribing and referring all require the communication of clinical information. Having different parts of the patient care process using different languages (coding systems) undermines the reliability and validity of the chain of communication. Merely knowing which coding system is being used by each part of the healthcare team would be a major challenge.

“From the physician point of view it doesn’t make sense to use dual coding. We aren’t just talking about for billing purposes. ICD codes are used for much more than that in an office setting. We use it for testing, prescribing and referring.  It’s not practical to use two different code sets. You would never know which set to use for the other party to understand what the patient needs. Dual coding defeats the purpose of speaking the same language.”

– Edward Burke, MD, Beyer Medical Group, Fredericktown, MO

As described below, dual coding would require the reengineer of the data infrastructure of the entire healthcare system. Reengineering on such a massive scale would inevitably lead to payment errors and discrepancies and communication breakdowns due to inaccurate processing and linking of claims across providers. This could leave patients bewildered and faced with either paying bills themselves that should not be their responsibility or trying to sort out the confusion with their providers and payers. Dual coding would actually increase, not decrease, the likelihood of payment errors and communication disruptions. Organizations with networks of providers, such as accountable care organizations, would be unable to efficiently communicate across healthcare providers or effectively analyze costs, outcomes of care, and patient safety.

“From an informatics perspective, a “dual-coding” option has the potential to introduce inconsistencies into the patient record (which code is the correct one?), complicates how decision support systems work, and could pose a patient safety risk in both the exchange of the information and its use in decision support systems.”

– Doug Fridsma MD, PhD, FACP, FACMI, President and CEO, American Medical Informatics Association (AMIA)

The net effect on patient care would be disruption in the communication of health information between providers adversely impacting the quality of patient care as well as an inaccurate processing and linking of claims across providers.

Impact on Healthcare Data
The entire data infrastructure of the healthcare industry has been designed to take advantage of the standardization on a single coding standard for electronic health care transactions mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This standardization has dramatically improved the overall efficiency and effectiveness of the healthcare system. Dual coding would undo this standardization requiring payment, clearinghouse and provider systems to be able to switch back and forth on a claim-by-claim basis between ICD-9 and ICD-10. This would necessitate a complete redesign, restructuring, reprogramming and testing of these systems.

Dual coding would require that the ICD-9 and ICD-10 versions of all systems be identical. The October 2015 update not only implements ICD-10 but also contains many other scheduled and required regulatory and system updates. These October regulatory and system updates have all been developed and tested based on ICD-10. The current ICD-9 version of these systems is out of date with the upcoming October ICD-10 based updates. Making the ICD-9 version of all systems compatible with the ICD-10 version and fully acceptance testing those systems would be very costly.

Payment, clearinghouse and provider systems have to deal with claims submitted by multiple providers. Thus, payment, quality assessment and claims adjudication systems that involved the evaluation of claims overtime and across providers would have to be rewritten to allow all possible combinations and permutations of mixed ICD-9 and ICD-10 claims.

The implications of dual coding cascade through the entire data infrastructure of the healthcare industry. For a health care system – hospitals, health plans, providers, coders, vendors, device manufacturers, researchers, and more – that is overwhelmingly ready and has invested tens of billions of dollars to be ready, a dual coding requirement would be an unmanageable and costly burden, even for physician practices.

The Healthcare Industry Strongly Opposes Dual Coding
Due to the problems noted above, CMS has clearly stated that a dual coding approach is not feasible:

“CMS and many commercial health plans are unable to process claims for both ICD-9 and ICD-10 codes submitted for the same dates of service, so a “transition period” – in which providers could submit claims using either ICD-9 or ICD-10 ­­– is not possible.”

Members of the Coalition for ICD-10 strongly agree with CMS:

“BCBSA and Blue Cross and Blue Shield Plans will be fully prepared for October 1, 2015, implementation and we have been actively working with all stakeholders to be ready. Allowing both ICD-9 and ICD-10 for the same dates of service would create confusion for customer service staff supporting both members and providers, increase the complexity of linking claims between hospitals and providers, and make it much more difficult for fraud detection programs to identify aberrant billing patterns. It would also require costly reprogramming of all the EDI and processing systems and re-testing, which inevitably would lead to more delays as there is simply not enough time to change systems.”

– Justine Handelman, Vice President, Legislative and Regulatory Policy, Blue Cross Blue Shield Association

“ICD-10 has already been delayed twice and should not be delayed again. The goal should be to make our system more efficient. Yet an interim ‘dual-coding’ process is inefficient, ineffective, and will only cause undue confusion and costly administrative challenges in processing payments.”

– Karen Ignagni, President & CEO, America’s Health Insurance Plans (AHIP)

Unnecessary. The rationale for proposing dual coding is to protect small physician offices that do not make adequate preparations for the October 2015 transition to ICD-10 from financial harm. However, dual coding is the wrong solution to the issue. CMS has existing payment policies that it uses when a provider has incurred a temporary delay in its billing process causing financial difficulties for the provider as described in the Accelerated Payments section in the Medicare Financial Management Manual, Chapter 3, Section 150. Approaches such as accelerated payments that are an existing part of the Medicare payment system are more practical and effective than the widespread disruption that would be caused by the dual coding proposal. To minimize any potential negative financial impact associated with ICD-10 implementation CMS has made available free downloadable billing software and allows providers to utilize a MAC claims submission portal to submit ICD-10 claims directly to Medicare. CMS has extensive ICD-10 training resources available for physician offices.

The biggest impediment to a small physician office being ready is the uncertainty of the implementation date. The two prior postponements of the ICD-10 implementation date have created an environment of uncertainty in which some physician offices are postponing preparation for ICD-10 based on the belief that it will once again be postponed. It is time once and for all to remove the uncertainty and reaffirm that October 1, 2015 is a firm and final implementation date.

To restate, as a practical matter the dual coding proposal is just another way to delay ICD-10 implementation. Members of the Coalition are firmly opposed to the dual coding proposal and any further delay in the adoption of ICD-10.

The following are additional quotes from individual members of the Coalition for ICD-10:

“Use of multiple code sets for the same date of service would lead to greater confusion and increased payment errors and disruptions, not less.  For coders who code for multiple providers, confusion, inefficiencies, coding errors, and productivity losses would occur if they were expected to use both ICD-9 and ICD-10 for the same date of service, depending on the provider.  And patients would be the ultimate losers, as they would be faced with payment errors and discrepancies and claims denials as a result of the inability to accurately process or link claims across services from multiple providers.”

– Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA, Chief Executive Officer, American Health Information Management Association (AHIMA)

“Critical benefits that will be gained from the transition to ICD-10 will be more precise diagnostic reporting, an enhanced ability to capture and utilize health data and more cost-efficiency in healthcare operations.   Not only does it make absolutely no sense to further delay ICD-10 implementation and the improvements it will bring, but the concept of ‘dual-coding’ will open the door to unnecessary confusion and complications.  ‘Dual coding’ will only serve as an obstacle to progress, one that has the potential to undermine healthcare delivery and patient safety.”

– Mary R. Grealy, President, Healthcare Leadership Council

“A dual coding requirement would necessitate a reengineering of the data infrastructure of the entire healthcare system. It would require extremely complex and costly changes to payment, clearinghouse and provider systems that are not practical or feasible. The changes necessary to accommodate dual coding would inevitably lead to payment errors and discrepancies as well as disruptions in communication of health information between providers.”

– JaeLynn Williams, Division Vice President & General Manager, 3M Health Information Systems

“Population health management, especially through Accountable Care Organizations or bundled payment models, simply will not work without a uniform transition to ICD-10. The critical data needed to assess care quality and attribute care outcomes cannot be done through ‘dual coding’ of ICD-10 and ICD-9. The efficiency gains made possible through tighter care coordination and better visibility into patient populations will be lost unless the entire care team is using a uniform code set.”

– Jeffery Smith, MPP, Vice President of Public Policy, College of Healthcare Information Management Executives (CHIME)

“Dual coding is a recipe for disaster.  Take a look at what it really means for patients.  One day your family doctor sees you for a GI complaint, codes in ICD-10, and refers you to GI.  Then the next day you’re at the GI doc and they code in ICD-9.  The two are not compatible and there’s no continuity of care, no tracking of the patient visits as related.  When you come back to the family doctor, the specialist information is not associated with the earlier visit.  Payers are also confused and the patient billing is affected.”

– Richard Blanchette, Founder & CEO, Professional Association of Healthcare Office Management (PAHCOM)

“Many provider practices and healthcare facilities/systems have done the work to be prepared for ICD-10 implementation and delaying or changing the rules at this point would be pulling the rug out from under them. In my opinion, it’s setting the stage for massive confusion.  In addition to the fact that you will have some providers that will embrace ICD-10 and some that will not.  If they are given a choice, think about the issues you will have in practices and/or facilities around the country trying to deal with providers having different views and providing care with two different coding systems.  You would have to devise crosswalks that are constantly working both ways to ensure proper communications and consistency.  If providers ran their businesses with this much indecision, they would go out of business quickly.”

– David J. Zetter, PHR, SHRM-CP, CHCC, CPCO, CPC, CPC-H, PCS, FCS, CHBC, PAHCOM member


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