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Behavioral health providers unprepared for ICD-10 transition

Thin profit margins will make it harder for behavior health providers to weather the ICD-10 transition

Tammy Worth, Contributor

When there were changes last year to CPT codes, Lisette Wright saw revenue cycle shifts disruptive enough to put behavioral health organizations she worked with out of business.

Wright, executive director of Behavioral Health Solutions, said many behavioral health providers have thin enough profit margins that they just subsist from month to month. When insurers weren’t prepared for the changes, claims didn’t get paid on time and the cash reserves weren’t enough to pay the bills.

Wright worries that behavioral health organizations are also not prepared for similar changes – those coming courtesy of ICD-10 – and the disruptions could again cause significant problems for providers.

“I am very worried about the revenue cycle impact to behavioral health and substance-abuse facilities,” she said. “They think this has nothing to do with them or think their EHR vendor or practice management software will deal with it for them – but this is not a computer issue.”

Although IDC-10 changes were recently postponed until October 2015 at the earliest, it is not the time for behavioral health organizations to stop preparation. If anything, the change will just give providers the time to work out the kinks, particularly since they are simultaneously dealing with changeover to the newest version of the Diagnostic and Statistical Manual of Mental Disorders.

“A new wrench has been thrown into the works with the delay of implementation,” said Nina Marshall, director of public policy at the National Council for Behavioral Health. “A lot of providers are asking questions about whether they need to continue to focus on it now and asking what it does for DSM 5 implementation.”

Marshall said the changes with the DSM are only further complicating issues for behavioral health organizations. It was recommended that groups change to the DSM 5 in January 2014, but many are waiting to tie implementation to the ICD-10 changes. What may end up happening is that providers and insurers are working simultaneously on a mix of DSM 4, DSM 5, ICD-9 and ICD-10.

“For those that are closer and were ready, it’s frustrating,” Marshall said. “They are left with question marks about when to use which code sets – you can have one organization that is using both (DSM) 4 and (DSM) 5 and how confusing is that?”

Because of the potential variation among insurers, Marshall said one of the first steps organizations need to take to prepare for the change is understand where each payer is in the process and what their timeline is for the changeover. And the only way to do that is to call and ask. 

Marshall said each provider needs to be creating a project plan for implementation that includes ensuring that people across the organization – from the front desk to clinicians – understand the implications of the changes to both code sets.

Wright said it is particularly important to get clinicians involved. Many think that electronic medical records will take care of the changes, but that isn’t the case. Vendors will be updating systems to accommodate for the differences, but physicians will have to pick the diagnoses, which are more detailed under the new code set.

Many providers like to use unspecified codes, which will no longer work with auditors, Wright said. If someone is treating a patient for major depression, but only documents it as general depression, they could be subject to audits and paybacks. And Wright said in the DSM 5, Aspberger’s is no longer a diagnosis, but is part of autism spectrum disorder. It is, however, still in ICD-10.

Wright said groups need to begin going through the readiness process at least seven months prior to implementation. Larger organizations should be preparing right now. Providers should be doing readiness assessments, leadership education, creating a transition team, systems inventory, a financial impact analysis, gap assessment and training. She recommends having the entire transition process complete by no later than four months prior to the go-live date.

“They have to know where they stand and how prepared they are for a financial hit,” she said.

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