Insurers Prepare for ICD-10
By Liz Carmack Texas Medicine February 2012

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Symposium on ICD-10 Conversion – February 2012

Tex Med. 2012;108(2):34-36.

By Liz Carmack

Texas' major medical insurers and the Medicaid and Medicare programs are preparing for the federally mandated change from International Statistical Classification of Diseases and Related Health Problems (ICD)-9 to ICD-10. Payers say improved claim adjudication, more accurate payments, and fewer rejected claims should result from the new coding system's increased level of specificity.

 Most every insurer has developed resources to help health care providers prepare for the transition and meet the Oct. 1, 2013, deadline. (In November, the American Medical Association adopted a Texas Medical Association resolution directing AMA to ask CMS to stop implementation of ICD-10.)

In 2009, Blue Cross and Blue Shield of Texas (BCBSTX) took its first steps toward ICD-10 implementation by completing a management impact assessment. Today, the company is on schedule with internal development and testing, says Margaret Jarvis, BCBSTX senior manager of media and public relations.

"We expect to be testing with vendors and trading partners by the fourth quarter of 2012 to ensure we meet the Oct. 1, 2013, mandate," Ms. Jarvis said.

According to Ms. Jarvis, BCBSTX plans to run parallel ICD-9 and ICD-10 processing systems for two to four years after the deadline because "we could potentially have ICD-9 claims that were filed before the deadline and require adjustments," she said. However, she emphasizes that on or after Oct. 1, 2013, BCBSTX will accept only claims in ICD-10 format for outpatient services. That also applies to claims for patients discharged from the hospital on or after Oct. 1, 2013.

By law, insurers must require ICD-10 diagnosis and procedure codes on all inpatient claims for discharge dates on or after Oct. 1, 2013, and ICD-10 diagnosis codes on all professional and outpatient claims made as of Oct. 1, 2013. The change will not affect physicians who use other codes, such as Current Procedural Terminology (CPT), Healthcare Common Procedural Coding System (HCPCS), and Revenue Codes, Ms. Jarvis says.

To help providers get accustomed to using the new codes, BCBSTX has committed to reviewing and analyzing a year's worth of ICD-9 claims for its clients with an eye toward ICD-10 transition.

"We will identify the primary ICD-9 diagnosis codes those providers used during that period, and BCBSTX coders will work with providers to translate them into ICD-10, validating results and sharing information with the providers to ultimately automate the process," Ms. Jarvis said. "We need to work with providers because, unless we have accurate diagnosis codes that are consistent with procedure codes [CPT], it will affect claims processing and possibly cause delays."

CIGNA has spent the past couple of years assessing ICD-10's impact and preparing for the implementation.

"We have a thorough and comprehensive approach to implementation, and we will be ready when the compliance date arrives," said Gwyn Dilday, senior director of public relations at CIGNA. "This also includes working with clearinghouses for a smooth transition."

The company's efforts include collaborations with other stakeholders, such as the Healthcare Information Management Systems Society, the Workgroup for Electronic Data Interchange, AMA, and the Centers for Medicare & Medicaid Services (CMS).

Ms. Dilday said CIGNA's actions in 2010 focused on the overall planning and analysis of ICD-10's impact. The company completed high-level system application and business resource estimates. Assessments included reviewing primary operational functions, such as medical management, claim processing, and customer service for customers and health care professionals.

In 2011, CIGNA reviewed its remaining functions – including sales, underwriting, analytics, and reporting – to assess ICD-10's impact on those areas.

Ms. Dilday said that during the second half of 2011, CIGNA finalized its project planning and began preparations for project delivery in 2012. She said a multiyear ICD-10 training program for CIGNA staff is also in progress.

Humana is pulling together its plan by assessing in-house changes needed for ICD-10 compliance, says Louis Hochheiser, MD, Humana's medical director for clinical policy development.

"It's a massive undertaking," he admitted. "It not only affects the claims system, but there's also a tremendous amount of information technology work [needed] to meet the new requirements."

As is the case with other insurers, the switch will affect the company's products, policies, and communications to members and providers.

"Humana intends to have its systems set up so that we will be able to continue to pay claims in a quick manner, and there will not be any interruption in claim payment," Dr. Hochheiser said. "We'll be in a position to identify glitches coming from providers and will get that information back to them quickly so that we understand one another. We will have people available to talk to providers to make sure that there are no issues around payment."

UnitedHealthcare formed a team that is dedicated to ensuring the company is fully compliant with ICD-10 by Oct. 1, 2013, says Kim Whitaker, the company's director of public relations.

"The team has scoped the impact of these changes on our systems and policies for commercial, Medicare, and Medicaid claims processed by all of our health care plans," she said. "And we are working closely with the provider community to understand the impact of these changes on physician offices and facilities, while working with their venders, such as software systems and clearinghouses, on how to best facilitate this transaction."

Spokesperson Anjie Coplin said Aetna is implementing ICD-10 changes, as well.

"We have engaged the impacted areas of our company in business assessments and are planning for the move from 18,000 ICD-9 codes to 140,000 ICD-10 codes," she said. "We are developing a three-year roadmap that incorporates remediation of our impacted systems and vendor tools, our affected business processes, and our policies."

Aetna will work with the medical community to share input on the conversion process and minimize disruptions related to the ICD-10 conversion, Ms. Coplin says. The payer also is joining a consortium of organizations, such as America's Health Insurance Plans, to address ICD-10 transition and implementation challenges. Aetna plans to align itself with the direction given by CMS, Ms. Coplin said.

Meanwhile, on the state level, the Texas Health and Human Services Commission (HHSC) has formed several interdisciplinary workgroups to cover issues regarding ICD-10 policies, provider outreach, and systems migration, says spokeswoman Stephanie Goodman. HHSC is communicating closely with its business partners to ensure that there will be no disruptions to providers or to recipients during the transition.

As of last summer, Medicaid and Medicare programs were in the final stages of compiling an ICD-9/10 business and technical impact analyses, says Ms. Goodman.

"This will be used to develop an implementation plan to ensure compliance with the deadline set by the U.S. Department of Health and Human Services," she said. "Texas Medicaid is committed to ensuring a smooth and successful transition. We have a dedicated ICD-10 project team that was established just shortly after the announcement of the final rule on Jan. 16, 2009, and that will continue well past the Oct. 1, 2013, deadline.

"We are well connected with major health care workgroups and provider organizations throughout Texas to ensure that we are continually exchanging information and keeping everyone well-informed," she said.

According to the CMS website, as early as 2008, the organization was working with the American Health Information Management Association to identify and assess the business processes, systems, and operations under CMS' direct responsibility that potentially would be affected by the ICD-10 transition. In 2009, it began collecting feedback from the health care industry about the code change. Providers can review CMS' findings so far online. 

More Accuracy, Fewer Rejections

Payers anticipate a number of positive results due to ICD-10's more extensive coding set.

"Two benefits of the new ICD codes are that they will improve claim adjudication through more precise coding and improve health care payment through improved medical coding accuracy and detail," said CIGNA's Ms. Dilday.

Ms. Jarvis of BCBSTX said her organization expects the ICD-10 codes will lead to:  

  • Accurate payments to providers for new procedures not currently covered by ICD-9 coding;
  • Fewer rejected claims, thanks to the more specific and defined code designations;
  • Improved patient disease management; and
  • Synchronized disease monitoring and reporting worldwide.  

Humana's Dr. Hochheiser agrees that claim processing should improve as a result of ICD-10.

"When used appropriately by providers and Humana, there will be fewer times when we have to question claims," he said. "The review process should be much smoother, which should mean that providers' office staff won't have to be resubmitting so many claims. We should be able to auto-adjudicate many claims quicker, reducing everybody's costs."

CMS nurse consultant Rodney McDonald points out that the ICD-9-CM is simply outdated.

"Technology has changed and evolved over 30 years," he said. "Many of the ICD-9-CM categories are full, and ICD-9-CM codes may not be descriptive enough."

He adds that the ICD-10 coding system will be "flexible enough to quickly incorporate emerging diagnoses and procedures and exact enough to identify diagnosis and procedures more precisely." The end result of all this will be enhanced quality care through better evaluated medical processes and outcomes.

No Grace Period

Payers stress that physicians should already be working toward implementation of ICD-10.

"The transition to ICD-10 will affect all parts of the health care system," Ms. Dilday said. "It's not too soon for hospitals and physicians to plan for implementation, working with their clearinghouses, reviewing contracts if they refer to ICD-9 codes, and considering internal training needs within their organizations to prepare for these changes."

Mr. McDonald echoes Ms. Dilday's comment: "CMS has strongly urged all providers and involved partners to start their planning now, so that they'll be ready to make the switch. Don't delay in getting educated, involved, and prepared for the transition. There will be no grace period or delay in the Oct. 1, 2013, implementation."

Payers urge physicians to review and enhance their record-keeping methods to see how well they align with the more-detailed coding required through ICD-10. This specificity is important if providers expect to receive maximum allowable reimbursements. Although claims cannot be processed using the new ICD-10 code set before Oct. 1, 2013, testing with each payer in advance of the deadline is important. Physicians should reach out to each provider to learn when testing can begin and work that testing into their implementation plan.

"Our recommendation is that the providers move ahead as rapidly as they can," said Dr. Hochheiser.

The main areas of concern for providers should be understanding how moving to ICD-10 will affect their office operations and working closely with their vendors to ensure they're properly prepared for the changeover – steps similar to those being taken by Texas payers right now.

"There is a tremendous amount of work that will need to occur between now and that Oct. 1, 2013, deadline," Dr. Hochheiser said. "We all need to be on top of this."

  Liz Carmack is an Austin freelance writer.  


Payers Provide ICD-10 Transition Resources

Physicians should check payers' websites for information about preparing for ICD-10 and for news and details about what the payers are doing to ensure that the transition proceeds smoothly.

Resources include everything from background information about the code change to frequently asked questions that address what to expect when working with particular companies during implementation.

Physicians can stay abreast of updates and payers' progress toward compliance by paying close attention to the newsletters and other routine communications that insurers send in the coming year by visiting the organizations' websites for ICD-10 news, or, in some cases, by signing up for special email updates.

"Providers should continue to monitor our established channels of communication, especially in the critical period leading up to the compliance date," said Stephanie Goodman, spokesperson for the Texas Health and Human Services Commission.

Aetna spokesperson Anjie Coplin adds, "As our plans progress, we plan to communicate and collaborate with the provider community, and our website contains the most up-to-date information on ICD-10, as well as 5010."

Some payers are presenting webinars and teleconferences to educate health professionals.

"Blue Cross and Blue Shield of Texas [BCBSTX] is offering webinars to provide a general overview of ANSI v5010 and ICD-10," said Margaret Jarvis, BCBSTX senior manager of media and public relations.

The company's website provides information about upcoming webinars, as well as slide shows from previous ICD-10 presentations.

CMS has hosted a series of teleconferences since 2008 to review ICD-10's changes and how they affect providers. The CMS main ICD-10 site provides general equivalence mappings to help physicians convert data from ICD-9 to ICD-10.

Payer-Provided Resources

Main ICD-10 website

Main ICD-10 website
Questions and further assistance: Email ansi_icd[at]bcbstx[dot]com or contact your local facility or professional provider network office.

CIGNA for Health Care Professionals website
Questions and further assistance: (800) 88CIGNA (882-4462)

Centers for Medicare & Medicaid Services 
Main ICD-10 website

Main ICD-10 website

Main ICD-10 website   

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Last Updated On

November 13, 2017

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