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Impact of ICD-10 on Small Provider EHR Use, Reimbursement

By Kyle Murphy, PhD

- Healthcare providers of all sizes are stuck playing the waiting game following the ICD-10 transition on October 1 relative to reimbursement.

ICD-10 impacts EHR use, reimbursement

As family practitioner Linda Girgis, MD, FAAFP, tells EHRIntelligence.com, the true indication of a successful ICD-10 transition depends on how one public payer handles ICD-10 claims for Medicare and Medicaid reimbursement.

"For the commercial payers, everything has gone through smoothly and we're getting paid for that," says Girgis. "We still haven't received anything back from Medicare or Medicaid. We're still not sure about that, but all those claims were accepted into their systems to be processed. Nothing was rejected, so that's a good sign. With the commercials, everything has been reimbursed the way it's supposed to be."

The Centers for Medicare & Medicaid Services have 30 days to respond but has done little to inspire confidence based on the experience of the family physician's practice in attempting to get clarification from the federal agency.

"They are still within that timeframe, but really they should have been the ones first prepared because they are the ones pushing to roll it out," Girgis explains. "My biller tries to call every day. Since October 1, they have messaged that they are down due to technical difficulties so it's impossible to get through to any person there."

READ MORE: Physician EHR Use Increases, Health Data Exchange Still Lags

For a small practice with 30 percent of its reimbursements coming by way of CMS, any setbacks in getting paid could have serious consequences for the business.

"Big organizations, hospitals, and groups can go a few months without 30 percent of their reimbursement coming in. But for small practices, that can be devastating," argues Girgis.

The technical challenge of ICD-10

Because ICD-10 has both a clinical and financial purpose, it is also presents challenges for physicians which may not have been apparent in the build-up to October 1.

While the ICD-10 transition has been relatively smooth for the Girgis practice, it has not been without flaws, one of which resides in its EHR technology.

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"For one thing, in our EHR we have our problem lists and when it updated to ICD-10 it left all the problem lists in the ICD-9 format. Now we have to go back and re-change them all one by one," Girgis reveals.

The result is manual work by the two clinicians in the practice, Girgis and her husband, between patient encounters and beyond.

"The doctors are doing it right now," she says. "I'm doing it as I come across different patients, but definitely it's adding time on to the workday."

That extra work extends to billers who must spend more time completing their tasks and adapting to the new code set the size of which is hard to cut down because of the nature of the practice. "I'm sure specialists have a much smaller list," adds Girgis.

Another issue is the result of the referral system the Girgis practice relies on to get reimbursed.

READ MORE: Improving Physician EHR Use Key to HL7/ONC C-CDA Challenge

"We had some problem initially doing referrals because the software at the insurance company was not accepting ICD-10, so that was a problem. A lot of the problems now are being smoothed out," Girgis describes.

Resolving those problems required identifying the breakdown in how claims moved between parts of the reimbursement puzzle.

"One of the biggest problems is that our claims go from us to the clearinghouse and then to the insurance company," says Girgis. "Even though each one of those people were prepared, the process of mapping it from this place to this place didn't always line up."

According to the family practitioner, both sets of problems are present despite the amount of time the practice put into being ready on time. Others may not be so fortunate.

"We tried to be prepared pretty early," Girgis asserts. "All along we were sending test claims and trying to keep up with it. But I know many practices were not so well prepared and had to catch up in the last month, and they are having more difficulty."

Trying to appreciate the benefits of ICD-10 is a difficult one for the family physician given that less than a month has passed in the ICD-10 era and plenty of work remains outside of reimbursement.

"In the end, everything is going to be smooth, but I also don't know that it was a necessary change other than just adding another mandate on to us. If you think about it, we have meaningful use and now these other criteria. It's really burdensome to small practices trying to keep up with all these mandates," she concludes.

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