More than four years after preparations for it began, ICD-10 became the official coding system of the land Oct. 1.

If you missed the trumpets and fireworks, you’re not alone. The switch from ICD-9 to the ICD-10 system for coding diagnoses and procedures has been in the works for several years. The Centers for Medicare and Medicaid Services (CMS) originally mandated the change for Oct. 1, 2013. It was delayed then and again the following year, largely because of determined opposition from the American Medical Association (AMA), which feared the vastly expanded number of codes under ICD-10 would bury physicians under an avalanche of documentation requirements.

So when the big day finally arrived, it was a little like the moments after the clock ticked past midnight on January 1, 2000, said Ellen Schedel, senior director of coding and clinical information for UCHealth. Like the doomsday predictions that surrounded Y2K, the change to ICD-10 produced barely a whimper, let alone a bang, at UCHealth’s hospitals.

“It was a non-event,” Schedel said.

Taking no chances

But the lack of noise on Oct. 1 was the result of meticulous preparation by teams from Coding, Business Services, and Epic, as well as physician leaders, Schedel said. “We’ve been preparing for this for several years,” she said.

The most recent efforts included putting a hard stop on the visit “diagnosis calculator,” a tool used to assist physicians with selecting the most specific term possible – and encouraging them to do so.

“ICD-10 is something new for physicians, and we expected frustration,” Schedel said. “We don’t expect physicians to be coders; we want to give them the tools within Epic to assist them so that the experience isn’t so painful.”

In addition, UCHealth began ICD-10 training modules for coders about two-and-a-half years ago. They’ve been dual coding in ICD-9 and ICD-10 for more than a year.

The double duty was painful but necessary, said Terri Rowley, inpatient coding manager for UCHealth. “That had to happen to be as ready as we were for ICD-10,” she said. She credited the Epic team for doing the background work that enables coders to make their coding entries and edits easily.

“They were a big part of this effort,” Rowley said.

Online training across the UCHealth system, educational meetings, monthly conference calls to discuss coding topics in specific clinical areas, and audits of patient records to ensure accuracy and feedback to coders were mainstays of a system designed to avoid surprises and disruptions on Oct. 1, Rowley added.

Under ICD-10, coders have tens of thousands of new alphanumeric diagnostic and procedural codes to apply to the medical record documentation, but they are not on their own, Rowley said. They get help from computer-assisted coding software developed by Optum, a health services company specializing in data and analytics.

If a physician diagnoses a patient with congestive heart failure, for example, the software pulls up and displays the relevant codes, which the coder can then select with as much specificity as necessary. For example, if a coder has a question about the documentation, such as whether the heart failure is left- or right-sided, he or she can direct it to a clinical documentation improvement specialist, who in turn can contact the physician for clarification.

Uncertainties remain

While the ICD-10 launch passed largely without notice, important questions lie ahead. Rowley is concerned, for instance, about the difficulty of finding inpatient coders, who are responsible for mastering both the new ICD-10 diagnostic and procedural manuals. Outpatient coders, by contrast, use the same CPT codes for procedures as they did pre-ICD-10 go live. Rowley said contractors are responsible for half of UCHealth’s inpatient coders.

Another unknown is how timely insurers will be in processing claims with ICD-10 coding. Schedel said answers will become clearer in the next couple of weeks after the first large group of claims has gone through.

“Few have gotten adjudicated claims back from payers,” Schedel said. “We don’t have a good idea yet what will be denied.”

It’s an anxiety-producing question, she added. At a recent national conference that included a session on ICD-10, she heard representatives from several small hospitals report that they had taken out lines of credit as protection against denials of ICD-10-coded claims.

“It’s something we are holding our breath on,” Schedel said.

Pay to play?

In an attempt to test the waters before the official launch of ICD-10, UCHealth submitted claims with ICD-10 codes to payers through its clearinghouses for both hospital and professional billing, said Agnes Tatarka, ICD-10 project manager. Most were “acknowledgement tests” designed to confirm that the payers received the claims without error, Tatarka said. With one payer, however, UCHealth conducted “end-to-end testing” to determine if the claims were both received and what the reimbursement would be. There have as yet been no results from that payer, she said.

Tatarka called the uncertainty about reimbursement for ICD-10 claims “a sensitive issue” for both UCHealth and the industry as a whole. Not many hospitals were able to conduct end-to-end testing, she said, to get a clear understanding of how claims will be adjudicated. That means, at least for now, that it is hard to know what the financial impact of ICD-10 will be, Tatarka said in an email.

Schedel acknowledged that uncertainty, but said the greater diagnostic and procedural detail that ICD-10 requires in documenting the medical record could help UCHealth hospitals and providers paint a much clearer picture of the care they provide. That could, in turn, improve quality scores, a key to maximizing reimbursement from CMS, state agencies, and private insurers.

The switch could also be good news for an academic medical center like University of Colorado Hospital, Rowley said. Hefting the massive ICD-10 book for diagnostic codes, she said, “This book gives more specificity. “It will help with research and data collection across the United States.”