ICD-10: What to Expect in 2016

| | Technology & Integration, Utilization Review

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When ICD-10 coding became mandatory on October 1, 2015, many industry professionals likened it to Y2K, fearing an unknown technology-related disaster. But like Y2K, the change was anti-climactic, and we look to 2016 with renewed energy.

Malcom Gladwell theorized it takes 10,000 hours to master something. As we move into 2016, ICD-10 will be a year of mastery and revelation as we start analyzing the new data ICD-10 presents. The new data should help us better understand health care trends and explore new initiatives that can elevate patient safety and quality of care. The drive behind moving to a more complex coding system is to provide more specificity around health care data and bring us a better understanding of the population’s needs and improved ways to meet them.

Grace Period Expires in 2016

In response to many advocacy groups, the Center for Medicare and Medicaid Services (CMS) announced, prior to ICD-10 implementation, a 1-year grace period from October 1, 2015 to help providers transition to ICD-10. The grace period will ensure that claims are not rejected for payment for the sole reason that an ICD-10 code isn’t specific enough. CMS also agreed not to penalize physicians for submitting data with less than perfect ICD-10 codes to Medicare quality programs in 2015.

As long as providers use codes from within the correct ICD-10 families, bills will be accepted and processed. When the grace period ends, claims may be rejected and penalties enforced for a lack of coding specificity and accuracy. With increased enforcement and potential for false or fraudulent billing, health care entities should use the grace period to establish an effective audit protocol to meet the challenges ICD-10 brings.

2016: A Year of ICD-10 Mastery

With leniency toward specificity over the next year, ICD-10 data will not be as granular as we would like for at least another year. But we will be able to capture more accurate data as a more educated and collaborative health care workforce evolves over the next few years. Medical coders continuously work to elevate their clinical understanding around the codes, and physicians are learning to master documentation under ICD-10. These factors will undoubtedly lead to better quality and outcome metrics as health care technology continues to improve in capturing and delivering health care data.

Stay Ready for More Changes

As with any major implementation, ICD-10 will bring lessons learned that will help us better prepare for future updates. After all, we anticipate ICD-11 from the World Health Organization (WHO) in 2018 (although it may be another decade before we actually see ICD-11 in practice). The healthcare industry has the opportunity to plan ahead for system changes to support ICD-11 and start putting measures in place soon. That way, when another transition is on the horizon, it may be better than anti-climactic – it could be just another day at the office.

Lisa Robinson

Director of Quality and Medical Technology for UniMed Direct, Lisa works hand-in-hand with the technology department to design and build advanced clinical decision support within the ReviewStat system. Her intent is to help clients, physicians and all other related healthcare professionals better manage the utilization review process.