Imagine a non English-speaking patient being screened in the emergency room through an interpreter with a few basic questions. Now try to accomplish the same task by asking 72 questions.
This complicated, time-consuming scenario is akin to what will soon play out for hospitals and medical practices for all patients. Starting on October 1, the codes healthcare providers use to get reimbursed will increase seven-fold from 24,000 codes under the current ICD-9 system to 170,000 codes under the pending ICD-10 codes.
Try saying that out loud to see how it sounds, because as a radiology practice manager I am concerned. The billing codes for a simple sprained ankle will go from four to up to 72. This means there will now be nearly 20 times more opportunities to annoy patients and to be denied payment. The Center for Medicare and Medicaid Services (CMS) has already warned practices like mine that ICD-10 is going to be painful. To quote CMS:
"Your practice's ICD-10 coordination manager will need to work with vendors and third parties to anticipate implementation issues and risks and develop strategies to streamline ICD-10 implementation To do this effectively, consider creating a risk inventory for your practice that: identifies the chance a risk will occur, its degree of potential impact, and relevant ways to avoid risk like offering training, identifying alternate vendors, and building up cash reserves or increased lines of credit."
Commercial insurance companies are not saying much at all – at least anything encouraging. George Vancore, a senior manager with Florida Blue Cross and Blue Shield (BCBS), where my practice is located, recently stated:
"The individual physicians have a different situation: Their financial risk is non-existent in this space because the individual practice bills with HCPCS codes (and) aren't changing with ICD-10. But the rub (my emphasis) is that the diagnosis codes are ICD-10, so they need to know those...Anyone who sends me an ICD-9 claim on Oct. 1 will be identified as non-compliant and become a named entity in my action plan for CMS. If they can't send me an ICD-10 enabled claim, I can't pay them."
Although CMS has advised Medicare administrators such as BCBS to be flexible in the Medicare Part B physician fee schedule transition from ICD-9 to ICD-10, I am doubtful. To paraphrase Donald Rumsfeld, we don't yet know what we don't know. The popular thinking that physician practices will adapt quickly because it's our revenue at stake is true for processes under our control. Consider the electronic health record (EHR) conversion of a few years back. It offers a good sneak preview of what happens when processes are out of our control.
Under EHR conversion my practice spent $270,000 in pursuit of an objective that has still not been realized – interoperability. The envisioned ability to instantly share and view medical records across information systems was a key driver for government funding to hospitals and doctors, but to date its performance is spotty and inconsistent at best. In the first two and half weeks of our EHR conversion, the HL7 interface (out of my control) failed suspending payments to the practice for two and half weeks. At the same time, CMS decreased its payment rates yielding a negative outcome of almost twice what it cost to install EHR. The fall-off in reimbursement will no doubt happen under the ICD-10 reimbursements because these changes never mean more revenue for providers.
To be fair, I will say that EHR did create cost efficiencies valuable as medical practice margins get thinner and thinner. But the ICD-10 conversion is an even trickier prospect. While one of the goals – to provide more quality and outcome data – may be achieved under ICD-10, I predict that denials will increase for providers. I think insurance companies are watering at the mouth to accelerate their already 30 percent rate of denial of claims. Achieving and expanding this rate of denial is one of the reasons the CEOs salaries at the top five health insurance companies increased on averaged in excess of $12 million in 2014. Denials are money in the bank.
The traditional private physician practice ownership model is under enormous pressure. Our numbers are dropping and account now for only 36 percent of medical practices. With every government change – from EHR to the Affordable Care Act to ICD-10 - more doctors opt to be employed by hospitals or medical practices. In 2014, 60 percent of primary care doctors and 50 percent of surgeons opted for employment. The private practice model is the backbone of the American health care system. Quite frankly, doctors work harder when it's their business. ICD-10 could be beginning of the end for independent practitioner practices.
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