MGMA Protests Decision Not To Test ICD-10 With Medicare

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The Medical Group Management Association (MGMA), representing 13,200 organizations that include 280,000 physicians, has sent a letter to Kathleen Sebelius, the Secretary of Health and Human Services, protesting the decision of Medicare not to do end-to-end testing of ICD-10 claims submissions from healthcare providers to Medicare contractors.

The American Hospital Association also has concerns about this policy, although the AHA doesn't believe it has been finalized yet, association officials told InformationWeek Healthcare.

MGMA's letter said that it is "extremely concerned with the Medicare announcement that it will not be conducting ICD-10 end-to-end testing with external trading partners, including physician practices … This action would increase the potential of a catastrophic backlog of Medicare claims following the Oct. 1, 2014 compliance date. Failure to [test] could result in significant cash flow disruption for physicians and their practices, and serious access to care issues for Medicare patients."

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Noting the extremely complicated nature of the transition to the ICD-10 diagnostic code set, MGMA said, "End-to-end testing between trading partners is absolutely critical to measure operational predictability and readiness, and also to identify any roadblocks well in advance of the compliance date."

Moreover, the association said, commercial health plans tend to take their lead from Medicare. If Medicare decides that end-to-end testing is unnecessary, many of these private insurers will also decline to do testing. "Again, this could result in practitioners not being paid for their services and disruption to healthcare service delivery," the letter said.

MGMA cited several inconsistencies between this decision and other policies of the Centers for Medicare and Medicaid Services (CMS):

-- Medicare conducted end-to-end testing with providers for the industry-wide transition from the HIPAA 4010 transaction set to the 5010 set well in advance of the compliance date.

-- Last fall, CMS contracted with National Government Services (NGS), a Medicare contractor, to develop a checklist for testing of ICD-10 and other standards required by the government. NGS recommended that providers test ICD-10 with Medicare.

-- CMS is requiring all state Medicaid agencies to test with their external trading partners, including providers. Robert Tennant, MGMA's senior policy advisor, told InformationWeek Healthcare that CMS officials confirmed Medicare's non-testing policy at a meeting of the National Committee on Vital Health Statistics (NCVHS). An agency official also referred to it July 15 at a "listening session" that included representatives of key stakeholders, he said. But CMS never announced the decision publicly, and it declined an InformationWeek request for comment on the MGMA letter.

Speaking at the NCVHS meeting, CMS official Denise Beunning explained that the decision not to test was "a business decision that Medicare fee for service has made." Based on the internal testing that the Medicare division has done, she said, "They feel that is going to be adequate for them to process claims with ICD-10 and have them go through the system smoothly."

Nevertheless, she added that after receiving feedback from NCVHS' standards subcommittee, "I think they [Medicare officials] left here with the intention of perhaps … having some discussions among themselves as to whether it would be prudent to conduct end-to-end testing with providers, and if so, what that might look like. I think that based on industry feedback and feedback from the subcommittee, that they are now open to that discussion."

Tennant said he hadn't yet received any official CMS response to the MGMA letter, other than that it was being circulated in the agency. "Their argument is that they're focused on internal readiness and that should be sufficient," he said. In addition, he noted, the agency believes that because Medicare contractors can accept 5010 claims transactions and most providers are now using 5010, "there should be no problem with ICD-10. We don't share that opinion."

MGMA wants Medicare contractors to test ICD-10 claims submission with a subset of both providers and electronic clearinghouses. If that is done, Tennant said, "They can identify problems and disseminate that information out the industry. That's really the goal, so providers know where the potential pitfalls and problems are and can correct them prior to the compliance date."

The majority of MGMA members submit Medicare claims through clearinghouses, Tennant observed. But clearinghouses can't fix ICD-10 claims the way they solved problems with 5010 transactions. For example, he noted, "they can't arbitrarily assign an ICD-10 code to a claim and convert a ICD-9 code to an ICD-10 code without having more information from the practice, which can be problematic."

AHA officials said they still weren't sure whether CMS had finalized its decision on testing. George Arges, senior director of AHA's health data management group, said that he'd been told CMS would make an announcement about this in the near future, probably in September.

Added Chantal Worzala, the association's director of policy, "AHA has voiced concern with CMS that hospitals need the ICD-10 testing to be adequate. We are still working with CMS to fully understand the extent of testing that they plan to do. Our opinion is that the minimum necessary is testing that will allow hospitals and Medicare contractors to validate DRG assignments."