May 2009

Deborah Levenson

No worries here, report billing software companies when asked about their ability to meet the revised deadlines for adopting ICD-10 and 5010 electronic transaction standards for HIPAA. The bigger issue, they say, is whether laboratories, hospital systems, physician offices, and payers will be ready for this next step in the U.S. health care system’s transition to an electronic health care environment.

Under pressure from physician organizations and health plans, the Centers for Medicare and Medicaid Services earlier this year post-poned adoption of the 5010 electronic standards and the long-awaited move to the International Classification of Diseases, Tenth Revision code sets, or ICD-10, established under the Health Insurance Portability and Accountability Act. Physicians had complained that the earlier deadline did not give them adequate time to upgrade their billing systems and other aspects of their practices.

CMS rolled back the deadline for adopting ICD-10 to Oct. 1, 2013, from Oct. 1, 2011. The agency extended the deadline for adopting the 5010 standard, a prerequisite to adopting ICD-10 codes, to Jan. 1, 2012, from April 1, 2010.

While CMS could again change the implementation dates for 5010 and ICD-10, further delay is unlikely because the latest deadlines have been published in final federal rules and, therefore, can only be changed through federal legislation, litigation, or a new rule-making process.

Moving forward whether the dates were to change yet again is irrelevant to most of the billing/accounts receivable system companies contacted by CAP TODAY, as the majority of them are either offering compliant products or in the process of ren-dering their products compliant.

Telcor and Healthvision offer billing systems compliant with 5010 and ICD-10. “We knew that the [U.S.] switch to ICD-10 would hap-pen, so compliance was designed into the system,” says Mitch Fry, senior vice president of Telcor. “And from our perspective, 5010 com-pliance is just another release of software.”

Healthvision made the switch to accommodate its Canadian clients, who are already using ICD-10, says Jim Schroeder, the company’s product manager for MediAR. Health-vision can install programming for 5010 to run alongside the earlier 4010 version of the HIPAA standards. “So the client will only have to flip a switch,” Schroeder says.

“During this time of transition, Healthvision’s MediAR software will allow clients to bill with either ICD-9 or ICD-10, based on payer-specific billing rules,” he adds.

Sunquest Information Systems is updating its Sunquest Clinical Financial software so it will be 5010 and ICD-10 compliant by April 2010, says senior product manager Debbie Tillman. And Hex Laboratory Systems is making inroads as well. The compa-ny plans to begin testing 5010 changes no later than January 2011, “or when-ever Med-icare carriers are ready for us to test,” says Susan Bol-linger, Hex’s sales and marketing director. Planned changes include expanding a five-digit diagnosis code field to seven digits to accommodate the longer ICD-10 codes. “The 5010 changes will be included in a version upgrade when the time is appropriate and should have minor impact on Hex’s customers,” Bollinger says. “The adaptation of ICD-10 will be much more difficult for customers to adjust to and will re-quire re-education on the part of physicians.

“Our clients,” Bollinger adds, “have already been through the first HIPAA change, and we had everything in order then, and we will do the same with these changes.”

Xifin and Cortex are formulating plans to update their billing systems too—Xifin by year end. “In total, this conversion is much simpler than the initial conversion to 4010 from proprietary formats with payer-specific formats,” says Xifin CEO Lale White.

Cortex president Stan Gordon is also taking implemen-tation of the new standards in stride. Rendering Cortex’s sys-tems compliant should be fairly simple, he says, because Cortex’s medical billing system has key ICD codes at the individual charge level, rather than at the claim and requisition levels.

The companies interviewed by CAP TODAY predict that 5010 and ICD-10 changes will not affect their billing systems’ ability to keep abreast of CMS’ changes to advanced beneficiary notices, medically unnecessary edits, and other billing-related procedures and docu-ments. The vendors report having staff dedicated to monitoring these changes, or subscribing to services that do so, and that they incor-porate necessary changes into their regular updates.

Preparing laboratories ensuring that their billing/accounts receivable systems are 5010 and ICD-10 ready is just one small aspect of labs’ preparations for the revised standards. The switch to 5010 and ICD-10 “is impacting the entire hospital and health care system, almost on a scale equivalent to Y2K,” says Sunquest’s Tillman.

Staff involved in the flow of patient data need to be prepared, explains Healthvision’s Schroeder. “Doctors need to learn the new ICD-10 codes and be able to transmit them,” he says. “Labs need to be prepared to accept the codes and transmit them. And so do payers.”

“Anything that sends, stores, or processes ICD-9 codes now will need to be tested to see if it can handle ICD-10 codes,” and that’s a daunting task, echoes Telcor’s Fry. Those tests will involve all internal and external systems that play a role in the flow of information into and out of the lab. Communication with older programs and homegrown applications is likely to be the most challenging, Fry continues. That’s because these programs are larger than more recent commercial software and contain millions of lines of code that need review.

Education too will pose a challenge. Lab staff—and everyone else who routinely uses ICD-9-CM (Clinical Modification) codes—must learn the ICD-10 codes. ICD-9-CM contains about 13,600 codes, versus ICD-10’s 120,000, says Hex’s Bollinger. “The switch [for medical professionals] isn’t going to be simple and easy.”

Jennifer Randall, a certified professional coder and medical billing technical support analyst for Cortex, deemed the move to ICD-10 “a huge ordeal” for her profession. “The numbers coders know by heart are going away,” she says. Randall urges laboratories to train staff well and to ensure that requisition forms reflect the new codes.

Labs should be alert to problems that originate in physician offices due to lapses in staff training, says Bollinger. To be fair, she adds, the learning curve for physician offices is steeper than for laboratories because clinicians will need to select from many more codes under ICD-10. Lapses in training could lead to claims being filed incorrectly, she adds.

Covering all angles the switch to 5010 and ICD-10 may not go smoothly on the payer end either. “An insurer could ignore ICD-10s for a while or insist on both the ICD-9-CM and ICD-10 codes,” says Cortex’s Gordon, speaking from ex-perience with CMS’ earlier switch to the 4010 standard. “You can’t predict what payers will be ready to accept at the deadline,” he adds.

Laboratories, billing systems, and payers should be prepared to accept both ICD-9-CM and ICD-10 codes for some time, says Tillman. “Our plan is to leave ICD-9s in our system and give it the capability to handle ICD-10s,” she explains. That means labs will need to test both capabilities in Sunquest’s forthcoming update to its clinical financial system. Lab staff should ask physician practices when they will start sending ICD-10 codes to the lab, she advises. And, at the same time, labs should know when they will be ready to receive ICD-10 codes and transmit them to payers.

“The bottom line is that the required changes to software, for any vendor, aren’t the biggest challenge,” says Gordon. “The major problem will be getting everyone else ready. And labs won’t know until they’ve flipped the switch if payers will accept ICD-9 or ICD-10.”

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