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Q&A: A vendor's perspective on HIPAA 5010 and ICD-10

Government Health IT Editor Tom Sullivan spoke recently with Ana Croxton, NextGen Healthcare’s vice president of EDI products and services, about its 5010 efforts and what lies ahead on the road to ICD-10 – including a service that's not yet released but is in the design phase to help users understand ICD-10 codes.

Q: What’s your sense for how prepared health entities are right now for HIPAA 5010?

[See also: ICD-10 is much more than a coding issue]

A: I think they know what they need to do, however, they’re certainly procrastinating. Last week I attended some conferences with AMA and HIMSS, and a lot of payers were there, and that’s pretty widespread. I don’t know what they’re waiting for; it’s not going away. What’s going to happen is there will be a big pileup.

Q: What will NextGen provide its customers in preparation for HIPAA 5010? How does that all work?

A: We follow the same thing we’ve done for other major industry changes, like 4010 and then also NPI, which was another major change very similar in nature to 5010. So we go through a period of internal and external focus groups for preparing and planning. That’s what we’re doing right now with ICD-10. For 5010, we’re full-force. It’s in the current version of our general release of our application. So we do ask clients to upgrade but our clients are not charged for the upgrade. It’s simply a question of getting the inclusion of the changes into the application far enough in advance that clients can plan for their upgrade and generally the rule of thumb is about a year to allow them time to test and then, subsequently, upgrade in their production environment. We’ve done that now with 5010.

And then we go through a series of educational forums that we provide for our clients at no cost. For 5010 it’s a series of white papers, knowledge-based articles, and monthly billing calls focused on 5010 that are primarily affecting the billing operations of an organization. We will increase the frequency as we get closer to the deadline date, knowing that many clients have put off either testing or the upgrade. Right now they’re monthly, in November we’ll go to weekly and possibly more than weekly. That’s when they’re actively engaged in the transition. The value of these conference calls is that, because the nature of the data is transitional, meaning things change as the payers update, adapt, and enforce, actually do their implementation. So there might be slightly different information as things shake out. With ICD-10 there’s a significant change in that you’re not just dealing with the billing people but also with the physician force.

[See also: ICD10 and HIPAA 5010 - Game Changers]

Q: Are you also involved in testing for 5010?

A: Absolutely, we work our partner clearinghouses and have joint WebEx’s with, say, Navicure to say, "This is what customers need to do in the application to meet the requirements’ and ‘this is how this particular clearinghouse will handle it." Maybe you’ll send 5010 to all payers and those that are not ready will handle it. Maybe they’ll want two separate files; it depends on the clearinghouse. But we do joint communications with each of our partner clearinghouses.

Q: One of your customers told me the ICD-10 updates would come in version 5.8, when can customers expect that?


A: They should expect that late 20102 or early 2013. We try to do that about a year ahead of time. So we would like to have it out by the fall, but the exact date is not set. The trick with ICD-10 is having clients understand the mapping relationship and the decision-making that will have to be involved because the changing codes are taking them to a greater level of specificity. Part of what we’re planning and discussing internally is potentially having an online kind of sandbox, if you will, so that they can upload a current file and see what it would look like with ICD-10 and what kind of decisions they’ll need to make based on my business environment and the types of specialties that I perform, procedures that I do, typical diagnoses, so that they start getting a feel for it.

Q: Is that something you’d anticipate them using on an ongoing basis like a service or to use more as a one-off trial?

A: I’d expect them to use that prior to the general release of the application so they can get a sense of, "Hey, what does this mean to me?" because I don’t think there’s a very good sense of that. It’s just an abstract move from 17,000 codes to 70,000 codes. "What does that level of specificity mean to me and my practice?" The only way they’ll get a sense of that is to learn what they have to do now and what that will look like later, in my opinion. So we’re in the design phase of this tool that we thought could be a good way to familiarize themselves with the changes not in a 700-page document but in a real-world example.

Q: Despite the overwhelming spike in pure numbers of codes, a lot of physicians, specialists in particular, will primarily use a subset of ICD-10 on a regular basis and they have to learn that subset rather than all the new codes…


A: Exactly. That’s why you have to give them real-world examples on how they really practice to reduce anxiety and to prepare them for the types of decisions they’re going to face with regard to specificity so they can start thinking about it. There’s laterality, there’s sequencing, all kinds of stuff that’s fairly obvious. And then the other question is what happens when one of these codes is used inappropriately? How do we know that this is not a broken leg as a result of a skiing accident because someone hit a tree or would they pay any differently because it’s just a broken leg? Or will they deny that claim? And the answer is I don’t know. Those are the financial questions that no one has answered yet. Payers don’t know how systems are going to ultimately adjudicate based on those rules or if in fact that systems will be mapped to ICD-9 codes. Maybe you have to send it but that doesn’t mean they have to use it. I suspect you’ll see a little bit of that.

Q: One of the things that’s come up lately is people saying providers may have already budgeted for ICD-10 implementation within competing health IT projects, most notably meaningful use … are you seeing that among your customers as well, or is that pie-in-the-sky?


A: A lot of the steps to get to meaningful use will help them, the applications upgrades and so forth, a lot of the vendors will be rolling all this functionality into the same releases. For us, 5010 and meaningful use stage 1 were in the same release. Once meaningful use Stage 2 is decided, potentially that will make it into our release that includes ICD-10 but I’m not saying that will happen because some of things have not been fully decided yet. So I don’t think they’re necessarily connected but by virtue of the timing they may well be.

Q: That would certainly be advantageous to providers to do both but with stage 2 potentially being pushed back to 2014, I’m a bit skeptical…


A: That’s a lot of changes in a very short period of time. We have some breathing room between the other regulatory changes and now we’re dealing with a whole different audience. ICD-10 truly impacts everything. This is not only a clinical shift, it’s also a financial shift because it ultimately could very well determine the amount of reimbursement. So in addition to coding for ICD-10, we have to provide tools with retrospective information so clients can see how they are impacted by particular changes because it’s nuanced and it’s not as simple as "I’m not getting paid anymore, did I make a mistake selecting and including proper code or did the payer make a mistake in the way it was adjudicated based on the new level of specificity?" That’s going to be tough.

Q: We discussed what you’re doing for customers in terms of HIPAA 5010. With ICD-10, there’s the software upgrade piece, what else can customers expect?


A: Educational materials similar to 5010. We are working toward having a Web-based tool so they can feel the difference, not just read about the difference.

Q: And that’s the sandbox, just to clarify, that you mentioned before? 


A: That’s the sandbox. I don’t have an exact date for that, but it’s certainly a priority. It’s in the design phase. Right now we’re talking about how to make that available because it’s something that will be meaningful. Based on the reception we’ve had so far I think we might be onto something

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