Questions for Compliance Officers Preparing for ICD-10

Time is running out before the changeover to ICD-10 on October 1^st 2015. Although it is the responsibility of program managers to implement the change, the Compliance Officer should play an active supporting role in the efforts and not just sit on the sidelines waiting for problems to occur.  However, if problems do occur, it will definitely have an impact on compliance. At a minimum, Compliance Officers should question the transition preparation progress in advance of the deadline. This task falls under the umbrella of “ongoing auditing” by ensuring that program managers are meeting their obligations in keeping abreast of changes in regulations and payment standards; in providing written guidance (policies/procedures) for staff; in training staff on written guidance; and in ensuring that staff is following guidance correctly.

A weak transition can prove to be very costly and affect coverage determinations, payment determinations, medical review policies, plan structures, statistical reporting, actuarial projections, fraud and abuse monitoring, and quality measurement. Providers can expect: (a) increased claims denials due to misinterpretation of new policies or rules; (b) delays in claims processing; (c) requests for additional medical records related to specific claims; and (d) more aggressive Center for Medicare & Medicaid Services (CMS) contractor action and government use of administrative sanctions and penalties. CMS identified 5 major steps that are needed for the transition, including: (1) making a plan; (2) training the staff; (3) updating the processes; (4) talking with vendors and health plans; and (5) testing the systems and processes.

Questions Compliance Officers Should Ask

1. Who has been assigned as the project manager to oversee the transition to resolve issues, train staff and external vendors to ensure that all coding is consistent with the new standards?

2. Have all the risks associated with the changeover been identified and addressed?

3. Does the implementation plan address: (a) software upgrades; (b) hardware procurement; (c) staff training; (d) form revisions; (e) work flow changes during and after implementation; and (f) risk mitigation strategies?

4. Have policies governing coding been updated?

5. Have updated code books and other technical resources been obtained for the new system?

6. Is there a plan developed to audit claim submittals (both pre-payment and post-payment) to recognize and address incorrect coding?

7. Have all phases of project planning being documented with milestone benchmarks?

8. Has the impact of a potential reduction in coding accuracy and production been evaluated?

9. Are implementation plans between providers, payors, and vendors being communicated?

10. Has a clearinghouse been engaged to assist in identifying problems and the types of claims that will be rejected under the new system?

11. Was there an assessment of those needing training on ICD-10 and have they received it?

12. Were all hard-copy and electronic forms (e.g. superbills, CMS 1500 forms) updated?

13. Have all the clinical documentation captured key new coding concepts?

14. Have all documentation gaps identified been resolved?

15. Has an operational assessment been performed to assess the business processes affected by changes implemented for ICD-10 transition?

16. Has there been a review of all existing contracts with third-party payors to ensure that their diagnosis-related groups system lines up with your organization?

17. Is there focused training on the top ten DRGs that payors most likely face errors with?

18. Has there has been claim submission testing with carriers?

19. Have case managers and finance ensured pre-authorization for procedures that will be performed on or after October 1?

20. Has there been testing to determine whether current cases can be coded properly according to the ICD-10 standards with adequate documentation to support the claims?

21. Have there been metrics and dashboards developed to keep informed of how well the roll out of ICD-10 is working?

22. Has financial management found a way to assess the consequences of the changeover to ICD-10 and to measure performance?

23. Has financial management developed a cash reserve to bridge problems, rejection of claims, interruption of payment, and possible penalties?

24. Has the staff been tested on coding correctly using ICD-10 to ensure proper preparation?

25. In anticipation of the complications and unexpected problems that may arise, has there been a plan for extra temporary coders to assist in submitting claims accurately after October 1st?

26. Has the organization’s system been tested with those vendors, clearinghouses, and health plans with whom most business is conducted?

27. Have back-up systems been developed, and tested?

28. Have payors been asked about how ICD-10 changes may affect current contracts, payment schedules, and reimbursements?

29. In anticipation of startup problems, is there an established help desk staffed with individuals who have full understanding of issues and ready to assist anyone experiencing problems?

30. Has a logging system been developed to keep track of problems to identify weaknesses, common issues, trending analysis, and ensuring timely closure of identified issues?

31. Have insurance company contacts been established that can quickly resolve potential glitches or problems?

32. Has a disaster recovery plan been implemented in case of electronic system failure?

33. Are there plans to deal with those patients who begin treatment under ICD-9 but discharged after ICD-10 implementation?

34. Have all the vendors, health plans, clearinghouses, and third party billing services with whom the organization deals been contacted to confirm their readiness for ICD-10?

35. Has IT evidenced review of the technology to understand affected areas and communicated how affected areas will be addressed by the systems?

36. Has IT been contacted to run tests on the systems?

If there are problems with the answers to any of these questions, the time to raise them is now, not after implementation. This month, CMS has moved ahead in establishing and staffing their ICD-10 Coordination Center to not only manage and triage issues but to ensure timely communication with the provider community. Dr. William Rogers, M.D. was named the agency’s “official ICD-10 ombudsman” to investigate and address stakeholder complaints regarding the code switchover. CMS continues to encourage taking advantage of the CMS ICD-10 resources, guides, and tools. Further, CMS encourages providers to participate in acknowledgement testing available to Medicare submitters through September 30, 2015, whereby providers can confirm that claims are successfully submitted with ICD-10 codes.