At the Margins

ICD-10 from the inside: Why SSM Healthcare stopped sweating the small stuff


This is part of a series of weekly posts from the frontlines of the ICD-10 transition. Each blog post will recap interviews with Advisory Board members who talk to us about the transition at their organization. Make sure you're subscribed to our blog so you don't miss out.

While ICD-10 has not been the juggernaut everyone expected, few organizations are coming away completely unscathed. For an industry not known for efficiency or adaptability, there is the danger that small-scale coding and billing hiccups could exact a cumulative toll on the productivity of health care organizations. But larger concerns are also starting to take center stage.

We spoke with Carole McEwan, ICD-10 Project Manager for SSM Healthcare, to learn her take on the road ahead. In charge of the ICD-10 response for a major health system covering most of the Midwest, Carole was understandably hesitant to call ICD-10 a non-event. Yet rather than sweat the small stuff, Carole recommends focusing on larger, and arguably more realistic, concerns: payer denials and physician practice coding.

The hidden (for now) denial threat

When narrowing down where to focus her team, Carole is sure about one thing. Insurers will continue to be the most significant and unpredictable challenge for health care providers. As a result, she is not getting too distracted by little ICD-10 hiccups. The game plan is simple. Let billing and coding continue to manage the incoming ICD-10 issues unless they start to struggle. Those departments are within the organization’s span of control whereas the more significant threat facing SSM is external. Carole’s primary focus is getting ahead of patterns in how payers are responding to their claims.

"Payers haven’t created denial codes for ICD-10 specificity. Right now we are trying to figure out how to data mine our denials to see what they are really denying. [I doubt] payers will give us helpful information to make it easy for us to create a pool of data to use for preventing denials. Don’t expect them to change. We’re trying hard to figure out what denials tell us about where we are having problems—and then answering what to do once we find them," said McEwan.

While denials are hardly a new threat, what makes them such a challenging ICD-10 problem is the high degree of unpredictability. It takes significant work effort to diagnose issues, communicate results to the appropriate teams, and educate on course corrections. This causes a drain on billing teams who must make sense of what they get back from payers or why claims are not making it out the door. After you take into account the existing array of minor ICD-10 issues already being managed, denials represent both a productivity cost as well as the threat of lost reimbursement.

Carole believes the answer is proactively uncovering patterns in denials so they can be prevented. Together with SSM’s data team, remits and payer communication are watched closely. "If we can find a trend early enough, it becomes an advanced warning so we can catch potential denials from other payers," said McEwan.

In the meantime, she added, "I fully expect denials will continue to expand."

Trouble outside the four walls of the hospital

Further removed from the hospital span of control, Physician practices represent the other looming challenge area for Carole and SSM. Coding struggles in the practice environment can significantly impact documentation, quality, and reimbursement. Even worse, it can be extremely difficult to course correct engrained or existing problems across so many disparate sites and different stakeholders.

"It’s not our hospital coding we are concerned about, but rather practice coding, the 1,500 claims, and how complex this area is," said McEwan. With several thousand physicians (both affiliated and non-affiliated), this is a more significant threat to SSM’s post-ICD-10 response than the myriad of minor coding or billing issues.

Our ICD-10 research indicates that only highly progressive organizations had the resources to establish broad physician practice ICD-10 preparations. As a result, we believe Carole’s concerns over physician practice coding may be more acute for other organizations even if they have fewer sites.

With non-employed physicians, it is arguably even more difficult. According to Carole, the practices may only provide code information or faxed orders with limited information, which means SSM’s team loses time and expends resources to get what they need.

Paying close attention and asking the right questions

Like many others, Carole and her SSM team were certain the ICD-10 transition was going to result in many more issues than they have seen to date. "I went into ICD-10 prepared to be on the lookout for which HIPAA exempt payers would not accept ICD-10, and I fully expected to see them. But it didn’t happen. So that makes me wonder what is the next thing I might have missed that we’re going to see come to pass," said McEwan.

A former Baldridge Award-winning organization, SSM has a long tradition of diligently measuring performance—and they are not ready to call ICD-10 a complete success. Carole plans to monitor trends closely until at least the close of January numbers. "I think there’s going to be a lot of issues arise [and because] we don’t necessarily see them often enough, they won’t rise to the surface. But when we have enough claim volume, we can see those patterns emerge," said McEwan. Until they do emerge, we are confident Carole’s top notch team will continue their principled effort looking to their data for both questions and answers.

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