ICD-10 Time Management: One Year, Many Goals

Deborah Grider has been waiting longer than most of us for ICD-10. As one of the top ICD-10 consultants in the country, she started studying ICD-10 years ago in preparation for what she felt would be a game changer in healthcare reimbursement. Last March, she had a schedule full of ICD-10 consulting projects ahead when word reached her while on a training assignment in the Virgin Islands about Congress’s vote to delay the implementation again.

“Quite honestly, I have been involved with several implementation projects and, when they announced the delay, everyone stopped. They redirected their efforts to Meaningful Use Stage Two. A lot of them are getting back on track now but the momentum is gone,” Grider said. Grider is a healthcare consultant at Karen Zupko and Associates.

Lost ICD-10 momentum is lurking in the back of the mind of any healthcare professional whose job involves seeing an organization safely through this transition. Getting momentum back may be tough, acknowledges Grider, but there is no shortage of tasks to complete by the new implementation date, October 15, 2015.

“You have to become a cheerleader,” Grider said. “And you have to give them the best and the worst situation and the worst situation is, if you are not ready, you don’t get paid.”

ICD-10 cheerleaders have been working the “financial impact is likely” angle hard for good reason.

“The top risk across the industry is the potential of financial risk. Even with the goal of “financial neutrality” in the revenue cycle there are other potential financial impacts to healthcare organizations. These vary in each organization but may include the cost to implement system upgrades, training and loss of productivity for physicians, clinical documentation specialists and coders. An increase in coding, billing and payment errors will result in a higher rate of rejections and extend accounts receivables,” states the Workgroup for Electronic Data Interchange (WEDI) White Paper on ICD-10 Critical Metrics.

Grider broke down the productivity impact into some specific challenges she has seen in both her research in other countries’ ICD-10 implementations and in her many ICD-10 impact assessments aimed at forecasting what ICD-10 implementation will look like in our complex multi-payer, multi-information system environment.

For coders, it is a massive upheaval in deeply ingrained coding patterns from basic keystroke patterns to documentation review for coding assignment. Coders currently coding with ICD-9, a mostly numeric coding system, position their fingers in the tight numeric box of the computer keyboard. ICD-10 codes are alphanumeric and coders will now reach for a letter each time a code is entered. Further, many coders rely on memory for the most frequently-billed codes. Going from 17,000 ICD-9 codes to the 155,000 ICD-10 codes means a more limited reliance on memorization. While coders, in time, will once again have a memory bank of highly utilized codes, even those codes may have specificity variables which slow down coding assignment.

“What we found is in most countries including Australia, including Canada, including Europe, they had a fifty percent reduction in productivity for the six month period (after ICD-10 implementation),” said Grider.

In order to prepare, most organizations have a plan to dual code a certain number of claims for practice and clinical documentation review. For example, Kettering Healthcare and Beacon Partners recently hosted an ICD-10 webinar to share ICD-10 project management tips. According to the presentation, Kettering had a initial plan to dual code 25% of their claims and gradually increase the percentage until reaching 100 percent of claim. However, due to the year’s delay in implementation, they revised the dual coding plan. Under the current plan, coders are currently coding one claim per day in both ICD-9 and ICD-10. They plan to increase dual coding to 25% of claims closer to the implementation date but not go any higher in the percentage of claims to be dual coded.

Clinical staff, too, face productivity issues centered on the need for more specificity in the clinical documentation. They must learn to document to the level of specificity required under ICD-10. To this end, technology is trying to provide a piece of the answer to this challenge. However, technology implementation is not always the turn-key solutions that healthcare organizations hope for.

“They need to document smarter, not more but smarter, and get that specificity within their assessment and plan-of-care. That will take time,” Grider. “In order for computer-assisted coding to work effectively, the clinical documentation has to be there.”

Kettering also states they rolled out their computer-assisted coding tool with too little internal training. They advise organizations to take a close look at developing internal resources both in the coding staff, known at Kettering as “superusers” and within the information systems staff and to also to involve their vendor in this onsite training effort.

“Assess your vendor team and demand an onsite presence as much as possible so that they really understand the dynamics of your organization and staff and get as consistent a resource as possible from that vendor,” Hasley said in the recent presentation.

Hasley explain that, as Kettering implemented CAC, they would work with extremely knowledgeable vendor staff at one phase of a project when other parts of the implementation would be supported by less knowledgeable staff who were not as familiar with Kettering’s specific needs.

And for those organizations who are depending on their electronic medical record for ICD-10 prompts and features, Grider states that many electronic templates will need to be rewritten as a prerequisite for any clinical documentation improvement. There are many ICD-10 implementation tasks which healthcare organizations could have stayed the course with despite the implementation delay and Grider expressed disappointment that more organizations have not continued work in this area since actual documentation improvement initiatives can be implemented ahead of the code set implementation

Kettering also has found that the scope of ICD-10 impact is easy to underestimate. For example, Kettering shared that their training efforts were well underway when they missed a key area of impact which required focused documentation training.

“There was a huge impact that we had not identified. We missed the fact that our surgical and ER nurses were entering orders and needed to understand the specificity in the EPIC tool,” explained Kristen Halsey, ICD-10 Project Manager for Kettering Healthcare.

Taining scheduling is likely one top tasks many organizations are evaluating at this time and, with the uncertainly surrounding implementation, there may be a temptation to put off scheduling training and see what develops in 2015. Grider says waiting too late hampers many other facets of ICD-10 preparation.

“Get your coders properly trained and don’t wait until the last minute,” state Grider. “Make sure they have enough time to get training, get retrained and maybe have a refresher course.”

Grider explains that early training makes possible many of the ICD-10 implementation success strategies such as dual coding, team coding and auditing for ICD-10 clinical data elements. Rewriting the clinical documentation templates and all other clinical documentation improvement initiatives require indepth code set familiarity.

Grider also keeps a careful eye on payer ICD-10 implementation. Her article written more than a year ago recommending that providers carefully review managed care contracts for ICD-10 language was one of the first to actually cite specific “budget neutrality” and appeal limitations related to ICD-10 implementation.

Grider said some managed care contracts attempt to define budget neutrality in terms of an overall percentage of reimbursement change rather than allowing providers to contest case-by-case reimbursement shifts. Further, some contracts prohibit a provider from initiating a review of the payment impact for four months from the implementation date. Because of the potential affect of these contract terms, Grider recommends securing legal advice for contract negotiations.

“With the disruption of cash flow, with the impact of ICD-10 and the fact that ICD-10 will impact us financially, there has to be some real careful planning to review the risk,” she said.

Grider also recommends getting testing dates on the calendar with top payers. If key payers are not planning to open testing to all providers, Grider advises sending a certified letter asking for the specifics regarding testing dates, who participated in testing and what the test results were, including percent of failed claims.

“You want some validation of how many claims were tested, the error rate and what were the error codes,” she said.

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