The ICD-10 Final Rule

Well, we got a final rule. And, it says little in the regulation besides giving a compliance date of Oct 1, 2013 (coding for services provided on and after that date). Much better than the proposed date of Oct 2011; not as long as some others (including me) had hoped for to assure the industry gets this massive project done correctly.

HHS had quite a discussion in the preamble about comments and why they made the decisions that they did. Lots of discussion on timing. They finally decided on the 2013 date since that is what some health plans asked for, and that matches some of the NCVHS recommendations. They dismissed many provider and other organizational comments asking for more time. WEDI had recommended a specific timeline asking for six years to implement.

The relationship with the HIPAA version upgrade efforts is interesting. HHS stated several times that they expected some of the work and costs to be incurred during the version upgrade process, thereby reducing the time and cost of the ICD-10 upgrade. I don't think that was postulated in the HIPAA version upgrade regulatory discussion.

One interesting piece from the impact analysis.

If I am reading it correctly, the HHS estimates for the total costs and benefits over 15 years (Tables 6 and 7) show a net cost of the effort with a 7% discounted rate for present value. At a 3% rate, there is a net benefit.

Now, these are accounting terms and 15 year projections. However, one could argue that this is a wash, so why go through all of this effort if we are really not going to get a benefit out of it. Excellent question, and one that perhaps HHS can answer for us.

Some other issues covered in the final rule -

The date of service for inpatient hospital procedures will be considered the data of discharge, not the date of admission as some had asked for. This means that a patient entering prior to Oct 1, 2013 will have to have his/her claims coded in ICD-9 if discharge is before Oct 1, in ICD-10 if discharge is after Oct 1. This may be somewhat confusing for documentation.

HHS also stated that the final coding guidelines would be published by the end of January. As of today (Jan 27) I could not find them on either the CMS or NCHS web site.

The ICD-10 project will be a massive change for health plans and providers. Those entities looking at the 2013 date and saying "we've got plenty of time" should remember the HIPAA 1 and NPI experiences. The industry faced major hurdles on the compliance dates for those requirments. ICD-10 is much bigger, as it impacts both clinical systems (that store documentation, results, and codes) and the administrative systems. Starting the assessment process now would be a critical first step. And, for those who don't think they are aware of all of the business processes that will be impacted, give me a call. I've got lots to tell you.

Review of the Final Transactions Version Update Rule

I spent some time over the weekend reviewing the details of the rule published on Friday. Congrats to CMS on getting this rule out, and on listening to industry concerns regarding timing and testing. This rule adds a new wrinkle to the implementation process, allowing entities to begin using the newly adopted standards before the compliance date if both trading partners agree. This is accomplished by adopting both the old and the new versions as standards for the period between the effective date of the rule and the compliance date for the new versions.

Let's look at the basics of the new rule, both items adopted and those not part of the final rule.




First, the X12 5010 TR3s were adopted as new HIPAA standards. CMS indicated that some changes in the TR3s were requested by some commentors (e.g. anesthesia minutes vs units). CMS suggested that these changes be taken up with X12 and the DSMOs for inclusion in the next round of updates.

NCPDP Version D.0, and the NCPDP Medicaid Subrogation Version 3.0, were adopted as standards; no technical changes were requested (Good job NCPDP).

Both the NCPDP transaction and the X12 transaction are allowed to be used for billing retail pharmacy supplies and services. Presumably, health plans will set the standard to be used for billing them, based on current practice.

Also, the suggested changes in the definitions of the transactions to specify senders and receivers were adopted. This is primarily a clarification and should not have a significant impact on operations.

Now, the compliance dates:

New compliance dates:

• Versions 5010 and D.0—January 1,

2012.

• Version 3.0 for all covered entities

except small health plans—January 1,

2012.

• Version 3.0 for small health plans—

January 1, 2013.

Pretty much as the industry requested - three years to full compliance. Now the wrinkle (quoted from the Federal Register)

"During the Level 1 and Level 2 testing

periods, either version of the standards

may be used in production mode—

Version 4010/4010A and/or Version

5010, as well as Version 5.1 and/or

Version D.0—as agreed to by trading

partners. Covered entities should be

prepared to meet Level 1 compliance by

December 31, 2010, and Level 2

compliance by December 31, 2011. After

December 31, 2011, covered entities

may not use Versions 4010/4010A and

5.1. On January 1, 2012, all covered

entities will have reached Level 2

compliance, and must be fully

compliant in using Versions 5010 and

D.0 exclusively.

While we have authorized contingency

plans in the past, we do not intend to

do so in this case, as such an action

would likely adversely impact ICD–10

implementation activities."

Very nice allowance for testing and implementation of the new versions (which are much improved over the old versions) prior to the compliance date. The preamble states that the move to the newer versions prior to the compliance date is by "trading partner agreement".

However, the exact regulatory language is:

§ 162.925 Additional requirements for
health plans.
(a) * * *
(6) During the period from March 17,
2009 through December 31, 2011, a
health plan may not delay or reject a
standard transaction, or attempt to
adversely affect the other entity or the
transaction, on the basis that it does not
comply with another adopted standard
for the same period.


Now, my friend Dr. Kepa Zubeldia of Ingenix Corp has pointed out that the regulatory language (which is binding, the preamble is not) seems to require a health plan not reject a 5010 transaction after March 17 even if they are not ready to accept it. This apparent contradiction will need to be clarified by CMS, or will require health plans to quickly have a "5010 to 4010A1" translation capability pretty quickly. It would have been better to put the trading partner clause in the regulatory language to avoid any arguments.

CMS also stated clearly that they do not intend to allow contingency plans for the version upgrades. Let's all hope the industry gets the message and meets the due date, especially since it was the due date that the industry said that they could meet.

Some other responses to comments that indicate CMS intentions or suggestions for the industry:

They recognized the value of pilot testing, and suggested that SDOs get some volunteers to do pilot testing before proposing new standards to NCVHS.

They will consider concerns about having to adopt the claims attachment standard during the version upgrade and ICD-10 implementation process. This may mean the final rule will be delayed even more, or that the compliance date will be far into the future (well after the ICD-10 compliance date of Oct 1, 2013.)

They did not adopt the X12 acknowledgment transactions as HIPAA standards, but recognized that there is no prohibition against using them to help the implementation process.

They acknowledged the need to assist Medicaid plans in meeting the compliance deadlines, and for coordination between Medicare and Medicaid.

They also acknowledged the need for comprehensive industry outreach, and their intent to work together with industry organizations to meet that need.

Not bad - for this, looks like CMS listened to the comments and responded accordingly. The industry got what they asked for. Now it is up to the industry to meet their obligations and reach compliance by the Jan 1, 2012 date.

Next post will discuss the ICD-10 final rule. That one is a little dicier - not sure CMS gave the industry all that they asked for.

The Regs Are Published!

The Final Rules for HIPAA 2 - X12/NCPDP upgrades, and ICD-10 were published in the Federal Register today!

I will review the rules this weekend and post a more complete analysis, but the key points:

X12 5010/ NCPDP Compliance Date - Jan 1, 2012, but folks can begin using the transactions in production as early as March 17 of this year and still be considered in compliance. This means we have about 3 years to get into compliance. Not bad.

ICD-10 Compliance Date - Services on and after Oct 1, 2013. Approximately 4.5 years to compliance. Longer than originally proposed, longer than AHIMA suggested, but shorter than others suggested. This is going to a bear to implement, and we really need to get it right.


I will be interested in seeing the CMS rationale for their final decisions. Kudos to them for getting the rule published, and agreeing with most industry comment on the transaction version upgrades. The jury is still out on ICD-10.

ICD-10

Final Regs Cleared by OMB - And So It Begins

The final regulations that set the compliance dates and policy issues regarding the adoption of ICD-10, X12 version 5010, and NCPDP version D.0 were cleared by OMB yesterday. I would expect final rules to be on display this week at the Federal Register web site, with publication a couple of days later.

It will be interesting to see how CMS has modified the proposed rules based on the comments they received, and their justification for making or not making changes. Industry reaction is expected to be swift. If CMS has extended the due dates per most of the comments, I would guess there will be support and the beginning of the implementation movement. If dates were not changed, look for opposition and protests to the new Adminstration and to Congress. Let's hope that CMS has listened to comments and has set reasonable compliance dates and associated policies. We need to move forward on 5010 and D.O to assure better information flow for providers and health plans.

Privacy Impacts of ICD-10 and 5010?

Haven't heard much about this, but I did do an audiocast last month (see Dennis Melamed's Audiocast Site) which discussed the increased amount of information ICD-10 will include, and the impact on privacy. With more specificity in the diagnosis, we have increased information in the hands of the health plans. Do staff who currently deal with diagnoses codes need all that information? What about the customer service folks?

Also impacts on the "de-identification" issue. Since we have more codes, we will have smaller cells when summarizing results by diagnosis codes. Will some of the cells be too small?

An example of the increased specificity and the implications. Now, we have one sports injury code. Under ICD-10-CM, there are 24 codes for injury, broken down by the sport and the type of injury. All of a sudden, we will be getting statiistics on injury by sport. Who needs to know this, and should it be kept from certain eyes. Don't know, but what if the "anti-lacrosse" folks get a hold of data showing more injuries in lacrosse than in other sports. Do they try and get lacrosse banned?

This is an innocuous example, but it gets more serious as we look at more serious diseases.

Rush to Publish Regs?

There was a story yesterday about the administration’s rush to publish final rules. See http://www.msnbc.msn.com/id/27312289/ ... While this is an Interior Department rule, I would guess that HHS is looking to get out the final rules on ICD-10 and 5010/D.0 before the end of the year.

The major concern with this is that they will not adequately address public comments, and will rush out something that is unworkable. Hopefully, our friends in Baltimore and Washington will do their best to create a workable solution.

You can see the public comments on the NPRMs at http://www.regulations.gov/fdmspublic/component/main?main=DocketDetail&d=CMS-2008-0101 for the X12/NCPCP rule and http://www.regulations.gov/fdmspublic/component/main?main=DocketDetail&d=CMS-2008-0096 for the ICD-10 rule.


Let’s watch and see what CMS does.