ICD-10 impact on reimbursement, payers, and providers

Z23. That’s the ICD-10 billing code for an immunization encounter. It’s also the only code that stumped the team at Arlington, Virginia-based Privia Health, a national medical group.

“It’s a very common code,” says Maureen Clancy, vice president of revenue cycle management at Privia Health. What caused the hubbub? Everyone thought that an ICD-10 code should have more digits than an ICD-9 code. But Z23 has just three characters.

Privia Health-along with other healthcare providers and payers-discovered the problem when claims were getting denied, she says.

Still, Clancy says the problem was fixed within days. In other words, the expected drama that was ICD-10 was actually a “non-event.”

Clancy counsels that it took years of work for her billing team to prepare for ICD-10. They spent weeks walking page by page through the ICD-10 Guidelines code set, and nine months providing one-on-one, specialty-specific training for the medical group’s more than 600 physicians. They also spent time training the entire administrative staff at Privia Health.

On October 1, 2015, the date of the transition to ICD-10, the medical group made available a hotline phone number for providers to address any questions. Manned 12 hours a day for a couple of weeks, the hotline received very few calls, says Clancy.

While Privia Health is predominantly a primary-care group, it also includes cardiologists, neurologists, endocrinologists, and OB/GYNs. “Some specialties were hit harder [by ICD-10] than others,” says Amy Waller, coding education and audit manager. For example, she spent more time training orthopedic surgeons.

Next:Health plans and ICD-10

Health plans and ICD-10

The experience transitioning to ICD-10 was very similar for major health plans, large hospitals, and integrated delivery networks throughout the West Coast, says Stephen Linesch, senior vice president of administration and development at CAPG, a trade association for physician organizations around the country.

At a recent quarterly meeting of what Linesch describes as “seasoned managed care executives,” he asked about their experience with ICD-10. Their response? The experience has been “operationally very smooth,” meaning that there have been no operational setbacks, interruptions, or delays due to the migration to the new code set.

In fact, many of the respondents compared the experience to the “Y2K moment,” when everyone was afraid of the technology mishaps that would occur when the year switched from 1999 to 2000, says Linesch. Despite much worry and preparation, there were no huge impacts-with Y2K or with the transition to ICD-10.

As was the case with Privia Health, many payer and provider organizations made significant investments in training, information technology systems, and auditing, says Linesch, adding that those investments may be what made the transition to ICD-10 a very smooth one so far.

Reimbursement predictions

It’s unclear how the future will play out with claims and ICD-10. Waller says she checks claims regularly and has seen no significant impacts attributable to the new code set.

Payers contacted about their experience with ICD-10 agree.

Stacie J. Watson, senior director at Aetna, cautions patience as we wait to see how the transition will affect the industry. “It’s too early to fully understand what impact, if any, the transition to ICD-10 may have,” she says. “We will be utilizing operational and financial reporting to monitor any such impacts.”

The experience at Cigna has been similar. “We are not yet seeing any major impact on reimbursement, but it’s too early to tell. We’re still assessing and will know more later this year,” says Mark Slitt, a spokesperson for the payer.