Firm deadline? Or not?
Presuming CMS allows ICD-10 to happen as scheduled, it won't be from a lack of congressional attempts to intervene. During May and June alone, the U.S. House of Representatives floated three ICD-10 bills that called for either a "transition period," a "grace period" or stopping ICD-10 implementation altogether.

The most dramatic bill for ICD-10 stoppage is similar to a 2013 proposal prohibiting HHS from replacing ICD-9 with ICD-10, which died before reaching committee. Observers expect the 2015 measure to meet a similar fate, though the transition and grace period bills could find support.

The transition bill, HR 2247, known as the "Increasing Clarity for Doctors by Transitioning Effectively Now Act" – yes, that's "ICD-TEN" – would require HHS to provide "transparent testing to assess the transition … from ICD-9 to ICD-10."

It would not, however, delay the Oct. 1 deadline and would not call for CMS to accept dual 9 and 10 coding. What it calls for is "comprehensive, end-to-end testing" to assess whether Medicare fee-for-service claims in ICD-10 is fully functional. CMS would then report to Congress on the results. During an 18-month transition period and any ensuing extensions, no reimbursement claim submitted to Medicare could be denied due solely to the "use of an unspecified or inaccurate subcode," according to the bill.

The grace period legislation, HR 2652, titled "Protecting Patients and Physicians Against Coding Act of 2015," came out in early June and seeks to create a two-year grace period where healthcare providers' ICD-10-based claims submitted to Medicare and Medicaid would not be denied due to coding errors. Implementing this grace period would ensure physicians are not negatively impacted while ICD-10 is "fully implemented within the healthcare system."

The American Health Information Management Association has come out against all the measures, saying that they would only create unnecessary complications and delay of the inevitable. CMS' existing payment policies to grant advance payments for physicians experiencing cash flow disruption and financial difficulties should be adequate, said AHIMA CEO Lynne Thomas Gordon. Moreover, she says the grace period could potentially lead to inaccurate coding, improper payments and potential medical billing fraud.

Collaboration is key
Christian Omba, ICD-10 program director for UNC Healthcare System in Chapel Hill, N.C., says he is "cautiously optimistic" about making the deadline, so he does not want to see another delay.

"We want it to hold," he said. "We have spent an inordinate amount of time and resources to prepare. We are ready and want no further disruption."

Omba calls proposals for a grace period or transition delays "ridiculous," because "it's like the kids in high school who refuse to do their homework. Congress' involvement is analogous to a school maintenance worker canceling final exams because someone might pull a fire alarm."

With a professional background in the banking and finance industry, Omba has headed up his health system's ICD-10 efforts and methodically followed the blueprint.

"My first reaction upon taking this assignment was that the industry seemed to running around chaotically like headless chickens," he said. "Our effort has been very progressive and deliberate and our executives have been very supportive. Our pilot testing was then appropriated by HIMSS for national pilot testing. We've been dedicated to preparing, sharing best practices and offering lessons learned."

The key to the process, Omba says, has been collaboration from everyone in the organization and within the healthcare continuum.

"We followed the requirements and built a plan with checkpoints along the way," he said. "Collaboratively you can get there as an industry. It results in better patient care when everyone is engaged. That needs to happen. When the deadline comes, we expect some outliers but we don't anticipate any adverse impact."

'Niners' vs. 'Tenners'
One consequence of the multiple ICD-10 delays has been the uncertain status of coding personnel – both the current ICD-9 workers and new coders trained exclusively in ICD-10.

AHIMA estimates that there are some 25,000 students with certification from health information management associate and baccalaureate educational programs who are waiting to be hired. In particular, last year's deadline extension raised questions for hospitals on the verge of hiring "tenners" to replace the "niners," many of whom are expected to leave their coding jobs rather than learn the much more complex new system.

While there are no absolutes in describing the typical demographic profile of either coding faction, "niners" tend to be women in their 50s and 60s, while "tenners" are younger women in their 20s and 30s.

Yet Zack Wilson, president of Jacksonville, Fla.-based CSI Healthcare IT, says it should be noted that while the occupation is predominantly women, there are men who work in the field and that there are younger "niners" in their 30s and 40s who will make the transition to ICD-10. In the meantime, it is limbo for hospitals and both coding staff factions, Wilson said.

"A lot of 'niners' are keeping at it currently, even though they might leave when ICD-10 arrives," he said. "The hospitals have spent a lot of money on training to get their staffs up and running on 10 and it's adding up to double the cash because of last year's delay. And now we're seeing a delay in re-training in case I gets delayed again."

There is an army of new "tenners" who are anxious to start working but because they have no actual coding experience, are stuck in a long line to replace outgoing "niners" if and when they leave, added Kyle Johnston, regional sales director for CSI, which provides staffing and coding services. For the past few years, students have been signing up for ICD-10 coding training because they believe it offers job security, solid pay and – because 98 percent work at home – work-life flexibility.

"There has been a lot of buzz about it: Word has gotten out that this could be an awesome job," Johnston said. "It is a younger generation who sees this as an opportunity and just like with the occupational and physical therapists, there still won't be enough to fill the need."

As the hiring stalemate lingers, it is fair to wonder about what impact another potential deadline disruption would mean.

"I don't even want to think about it," Wilson said. "I would venture that it won't (happen), but if it (does) I agree with others who say we might as well wait and adopt ICD-11 in 2017."

Payer perspective
Contrary to what some providers might think, payers are rooting for their success as the go-live deadline approaches. What payers don't want, says George Vancore, senior manager with Florida Blue, is a heavy squall of denials due to non-compliance.

As a result, the health plan has emphasized awareness, education and training – especially for physicians, who compose the bulk of not-ready-for-primetime providers.

"The large health systems will be fine – they may experience some anomalies, but they will submit their claims without incident," Vancore said. "The individual physicians have a different situation: Their financial risk is non-existent in this space because the individual practice bills with HCPCS codes (and) aren't changing with ICD-10. But the rub is that the diagnosis codes are ICD-10, so they need to know those."

With more than 170,000 codes in ICD-10, Vancore realizes that such a dynamic expansion is intimidating to the physician community, so much so that many have become paralyzed with confusion, indecision and fear. Yet he maintains that there is no reason to fear the new format and that the "noise" surrounding ICD-10 is more of a distraction than anything else. What physicians need to focus on, Vancore says, is the codes that are most relevant to their practice.

"They have to determine how many they will actually use," he said. "If you are a specialist, learn the codes that relate to your specialty. If you are a family practitioner, concentrate on the ones that most accurately represent the codes you use today."

Florida Blue has been prepared for ICD-10 since 2013, Vancore contends. "I can flip the switch on tomorrow with 12 hours' notice," he says.

In the two years since then, Florida Blue has used that time to conduct tests with "any willing provider" who wants it, along with holding seminars, roundtables and "lunch and learn" sessions for those who need to be brought up to speed.

In order to discover how prepared the provider community is for ICD-10, Vancore and his team conducted a short survey of 600 physicians earlier this year and the results confirmed his suspicions: Nearly 35 percent of respondents said they haven't done anything, don't know where to start and have no idea how to proceed.

Converting to ICD-10, "is not that hard," Vancore insists. "I will work with them, get them to attend my training sessions and get them converted in two weeks. They have to make sure their clinical documentation is prepared. Anyone who sends me an ICD-9 claim on Oct. 1 will be identified as non-compliant and become a named entity in my action plan for CMS. If they can't send me an ICD-10 enabled claim, I can't pay them."

Lacking bandwidth
The physician sector definitely has more challenges in adopting ICD-10, but at the same time they also have some advantages, says Larry Allen, vice president of information technology and CIO of Healthcare Network of Southwest Florida, which operates 15 centers across the state.

As a fairly large clinical enterprise, Healthcare Network is in good shape to start ICD-10 and was ready at the time of the last delay. Yet Allen acknowledges that a lot of independent practices are woefully behind due to a lack of bandwidth and resources.

"They are not afforded the luxury of having staff and bringing themselves up to speed," he said. "They are entirely vendor dependent. They need vendors to guide them through the process and learn the format based on their denials."

There are two negative impacts that physicians will feel from not being ready, Allen says – noncompliant coding will prevent them from collecting revenues that are rightfully there and missing co-morbidities associated with chronic diseases, such as diabetes and hypertension.

"This will hurt because the margins are already slim in primary care," he said. "They don't have anywhere to go for help."

Even so, Allen believes that physicians are in better shape than unprepared health systems because they are smaller, don't have the baggage of a bureaucracy and are therefore more nimble in responding to the situation.

"Ultimately, physicians will do better than hospitals because their learning curve is not as steep," he said. "They can respond quickly because it is in their best interest to do so."

Anticipation, not urgency
MedAssets counts a significant number of small and mid-sized hospitals among its client base and representatives say in light of successful tests conducted throughout the year, they should be in good shape at the deadline. Of the approximately 2,800 hospitals who tested their ICD-10 readiness in January and April, the results were higher than 99 percent acceptance rates for everyone, including small hospitals, and Amick expected similar results for a third test in July.

"We see customer readiness," she said.

"With the delay that happened last year, it has served some organizations well – especially the smaller ones," Amick said. "The smaller they are, the more challenged they are, so the extra time has helped. We've seen the conversations change greatly over the last six months, from when people hadn't started to now talking about finishing touches on testing and how to think about the disruption we will endure."

The post-deadline period is being dissected into 30-day time frames as a measuring stick on progress, Amick said, with each marker serving as its own finish line.

Preparation is what transforms a sense of "urgency" into a sense of "anticipation," Davis said, with providers having a sense of how things will go and have mitigation plans in place to make the transition as smooth as possible.

If there is a sense of urgency, "it is in the readiness of the staff and how to approach the extra time it will take during the transition," Amick said. "Some hospitals have prohibited vacations and limited time off immediately following the deadline. They need to make sure they have as much capacity as possible."