ICD-10: Act Now
Regardless of
EXECUTIVE SUMMARY
Although the Department of Heath and Human Services has not announced any additional information regarding a delay in the ICD-10 implementation date, the industry should proceed with assessment and implementation efforts now. The benefits associated with ICD-10 assessment and planning greatly outweigh the reasons for delay. In our experience working with early adopters, we have learned that the collaborative enterprise-wide work necessary to implement ICD-10, particularly the assessments, system inventory, communication and project management plans, are practices that immediately benefit the entire organization. In the following pages, we will outline and discuss steps an organization should undertake today to improve overall organizational efficiency while at the same time preparing their organization for ICD-10.
3 ORGANIZATIONAL CHANGE
Because ICD-10 is an organization-wide issue, the work an organization needs to do to prepare for ICD-10 is really about organizational change management. Organizational change management is a challenging process that requires flex-ibility and continuous evaluation of interdisciplinary initiatives to reach enterprise-wide success. Throughout the process it will be imperative to create a balance between internal and external resources. In reality, no organization is perfect, so it will take time to understand your organization’s unique needs and strengths. To assure ownership of the change, it is important to first utilize internal resources as much as possible, and then, if necessary, obtain external resources. While external resources, when paired correctly, can provide strength and guidance to assist where the organization lacks, they can increase the overall risk of the project. One of the keys to successful change management is to have great collaboration between in-ternal and exin-ternal resources that
complement one another. While implementing this process, keep in mind that change can be posi-tive; be prepared for tweaks along the way and strive to be the best organization you can be.
It is imperative to identify all key stakeholders within the organi-zation. Initiate regular sessions with these stakeholders to drive awareness and drive home the importance of organization-wide engagement based on inter- disciplinary (corporate and department specific) roles. In these sessions, as committees are developed, discussions should en-compass organizational priorities, strategy and implementation plans. As the group begins to derive a plan, it is important to prioritize based on past experiences and real data, such as the implementation of National Provider Identifier (NPI), 5010, the Outpatient Prospective Payment System changes with Ambulatory Payment Classifications (APCs), rather than on a perceived relief from a delay in implemen-tation date.
It is important to become PROCESS-ORIENTED in your approach. Get out of the silos and the aura of being “due date” focused. It is imperative to integrate all regulatory changes—electronic medical records, computer-assisted-coding, and electronic coding solutions, for example. Think HOLISTICALLY. It’s not only that ICD-10 will require a holistic approach, but also that the same approach can provide your organization with an opportunity to learn to work as a strategic team to improve performance and foster stronger organizational community with stronger communication, processes and practices.
Evaluate your organization by conducting a comprehensive review of current processes and practices to identify gaps and prioritize. Key takeaways should include a clear understanding of process vulnerabilities and opportunities, risk mitigation and resource efficiencies, which are crucial to understand as the planning and implementation phases commence.
CDI IT Education Payer Relations Vendor Management Reimbursement Organizational Change to ICD-10
CLINICAL DOCUMENTATION IMPROVEMENT
All providers should engage in continuous Clinical Documentation Improvement (CDI) practices. ICD-10 both underscores and elevates the importance of CDI work, as does the implementation of the electronic medical record (EMR), high denial and re-bill rates, and the focus of Recovery Audit Contractors (RACs) and other investigative organizations. A well-executed CDI program serves multiple internal operational purposes, including strengthening the relationship between coding and physicians (and the EMR) to improve overall awareness of how documentation drives reimbursement, ensuring and enhancing compliance with quality and reim-bursement claims processing regulations, and giving health care providers a better understanding of their patient mix and clinical outcomes.
As the industry has begun to prepare for ICD-10, the increased focus on clinical documentation improvement has built momentum—a momentum that should not slow down based on a change in implementation date. All improvement efforts in documentation and audit can serve, in general, to identify under-and over-coding issues. Specifically, the following are best practice work tasks that are immediately beneficial for an organization to perform regardless of implementation date.
■ Provider practices and specialty departments should examine their patient
population in terms of diagnostic conditions, specifically those that are: • Most utilized;
• Implicated in the highest reimbursement;
• Of the type that lead to the highest denial, physician query and re-bill rates; and
• Target areas for quality reporting and published RAC reviews.
■ Once target areas have been established, internal investigations and analysis
should focus on looking at example cases to understand the relationship between what is captured in the encounter documentation, what is coded, how the claim is processed and paid, and other compliance/quality issues.
■ Findings should be communicated to all staff involved in the process, including
the clinician, the coder, IT and vendor personnel who manage the encounter screens and forms, and reimbursement staff. The key elements of communica-tion include:
• The importance of CDI to the entire organization (be specific— e.g., reimbursement, patient care);
• What is expected from a reimbursement and compliance perspective (provide access to published rules and underscore the risk of
non-compliance); and
• How each team member can improve their specific practices (best established with their feedback).
Clinical documentation improvement best practices provide accurate coding and clinical data, and accurate data will allow us to data-mine to better understand our patients, where they are in their disease management, and which treatments lead to better outcomes. Clinical documentation is the first step in reaching the ultimate goal of better disease and risk management.
In our experience, one of the biggest CDI challenges involves vocabulary. The terminology that the clinician uses in the medical record to describe a patient condi-tion, the language of the diagnosis coding system, and the wording of the regulatory requirements can differ significantly. ICD-10-CM uses a much richer and descriptive vocabulary, which should mitigate some of this disparity in terminol-ogy, but providers can and should start to run translations now.
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AHIMA has published exceptional resources regarding the ICD-10 coder training plan, so we will try not to repeat the experts. Instead, let’s imagine that you are ready to educate staff around a specific issue. As you design that training, consider how to ensure that your training is:
• On-going and focused on the highest risk areas specific to your organization. Hit the top five this quarter, the next top five will emerge for your attention next quarter.
• Job role-specific rather than one-size fits all. Doctors and coders learn differently, and your plan should respect this learning process.
• Task-related not just conceptual. Provide specific “what to do” train-ing in the software and systems available to each staff member. • Evidence-based and referenced,
to give staff reasons to “buy in.” Provide statistical data about patient outcomes, financial facts about impact to reimbursement, and/or specific risk to the organization (likelihood of audit, remediation) if best practices aren’t followed.
• Assessment-based. Understand what each staff member already knows by performing a knowledge gap assessment, and teach according to their “gaps.” • Respectful. You’ve got a great
team of very smart and capable professionals who want to learn. Assume they can and give them the opportunity to provide feed-back on the process.
• Transparent. Avoid forming teams who are the knowledge keepers. Once you have completed training on an issue, allow your staff to take ownership for staying up-to-date by providing them with access to payer and Medicare policies.
EDUCATION
A key focus with ICD-10 implementation guidance published in the industry is
coder and clinician education. As discussed in the CDI section, education must be
done for ICD-10 readiness. CMS has urged that ICD-10 specific coder training be done closer to the implementation date, but there are a number of training and education tasks that can and should start now.
■ It is never too soon to perform coder knowledge gap assessments to determine
the educational needs of your coders. By now, you’ve seen the recommendation that ICD-10 will require a better understanding of the following areas, which you should include in your assessment:
• Anatomy & physiology • Pathophysiology • Medical terminology • Pharmacology
■ Improving coder’s vocabulary in these areas will result in benefits immediately,
and will be useful for ICD-9 or ICD-10 coding, so there is no reason to procrasti-nate. Many education vendors include pre- and post-assessment tests along with their curriculum; therefore, you might consider purchasing an “all-access pass” to content and establish a process for each coder to self-assess and begin learning the modules that are required.
■ When performing focused clinical documentation improvement education, it
is important to include access to ICD-10 coding tools so that all staff can visualize how the ICD-9, ICD-10, CPT and ICD-10-PCS systems each describe similar concepts.
■ When training reimbursement staff, link coding to current and predicted
Medicare payment logic for APCs and Medicare Severity Diagnosis-Related Groups (MS-DRGs). Turn to this staff to shed light on target areas that are going to require greater specificity, are more complex under ICD-10, or are currently frustrating. There is minimal risk in having staff start documenting for the specificity of ICD-10, even though that information is not needed to properly ICD-9 code.
■ For inpatient coders, the Procedure Coding System (PCS) system provides
exceptional definitions of root operations, body systems and parts, and medical devices and the like. You may consider holding off learning how to build a seven-character PCS code, but it is not too soon to start studying the vocabulary of PCS and relating that to current CPT descriptions.
REIMBURSEMENT
For inpatient reimbursement, an impact analysis related to ICD-10 readiness is actually quite similar to the reimbursement work related to MS-DRG validation reviews being done by the RACs and Medicaid Integrity Contractors (MICs). We believe organizations should proceed full steam ahead.
The following is an outline of a typical MS-DRG audit as well as a few additional elements to address ICD-10 readiness:
• Determine the highest risk areas for your organization. This includes the focus areas your RAC has published, your top paid DRGs, your top utilized DRGs, and cases associated with medical necessity and/or other denial/re-bill issues. • For each of the risk areas, pull historical claims data and compare them to the
medical records for those cases.
• Perform a self-assessment that is in line with a complex review typical of the RAC.
— Confirm that the documentation supports the ICD-9 coding. — Validate that the principal diagnosis was appropriately assigned. — Confirm that the CC/MCC secondary diagnoses are well documented. — Review Present On Admission coding and documentation as part of
• Natively assign codes in ICD-10 as if it is post-implementation. This is an excel-lent exercise for your coding and audit staff to underscore areas where current documentation is lacking. Next, confirm the ICD-10 to MS-DRG grouping logic to assess if payment is consistent.
• To validate and understand the limits and value of the General Equivalency Maps (GEMs) published by CMS, translate the ICD-9 codes from claim to ICD-10, to determine if the results match what was assigned by natively coding in ICD-10.
Reviews of this type provide the basis to help organizations understand current performance under ICD-9 and provide specific information about what is required to prepare for ICD-10. In a single review, you can glean important lessons regarding medical necessity, coding, documentation, DRG validation and other audit issues. Reimbursement and clinical documentation improvement efforts, tackled together, will work to cease the inevitable increase in accounts receivable. As part of the process, it will be important to also address the following key reimbursement risks:
• Coder and Physician productivity issues, including coder’s learning curve and physician documentation issues.
• Increase in rework due to claims adjudication and rejections. • Unfamiliarity with adjusted medical review policies which increases
the chance for denials.
• Risk of RAC and MIC take-backs post implementation date.
While there may be a delay with CMS, a possible reality is that commercial payers move forward with the original October 1, 2013 implementation date. This potential scenario underscores the imperative that organizations (1) assure that their managed care contracts are performing, (2) have defensible fee schedules, and (3) have better front end registration processes and protocols.
PAYER RELATIONSHIPS
A complete payer contract review assists in identifying areas where contracts require risk remediation. Even if ICD-10 is delayed, this exercise should be performed with a focus on stop loss and carve-outs, new payment models (e.g., paid-for-performance, bundles) to maximize revenues through renegotiating contract terms.
As an organization begins to create an inventory of all existing contracts, it may be prudent to consider an online solution to efficiently and effectively manage contract information. The ability to manage contracts and relationships allow for a
risk management and compliance program to organize and manage all
contrac-tual and arms-length relationships in your organization from a single location. A one-stop compliance program management tool makes it easy for organizations to closely monitor and track critical relationship activity and maintain detailed records that meet regulatory requirements.
7 IT SYSTEM
Most providers perceive ICD-10 as an issue that must be solved by primarily coding and IT departments. Many may think that with the delay, the IT teams can relax. On the contrary, we believe that utilizing the extra time to analyze the IT system changes required for this major change will turn a requirement into a hidden benefit of system-wide improvements. What we’ve learned from early adopter organizations is that health care IT is usually complex, poorly integrated and quite de-centralized. Making a single change is like pulling a thread that exposes vulnera-bilities throughout the system. A comprehensive, integrated and strategic approach is necessary for ICD-10 implementation, and the delay actually gives us hope that we can be ready on time. The following are some things any organization should consider regardless of a delay:
• Your organization should have a solid understanding of all internal IT systems, collated into an “IT Systems Inventory.” Initially, the inventory assessment should include the “mainframe” or “corporate” system-wide platforms and databases of which core IT department staff are familiar. Denote system dependencies so that it is clear when changes need to be made and that the changes are prioritized. Next, you will need to extend the assessment to include applications, processes, databases, special reports and the like that are “home grown” in other facilities, departments, or even on individual work stations. To accomplish this, our recommendation is that you should share your internal IT inventory with all department heads and locations within your organization and ask open-ended questions.
• Once there is a clear understanding of internal IT systems, it is prudent to extend the assessment to include any places where internal and external systems connect; specifically, payer interfaces and vendor tools. Please note that AHIMA published a suggested list of systems to consider. Additionally, CMS recommends that one way to accomplish this is to create a “Data Flow Map” that shows how information about a patient flows through the various systems from registration to clinical encounter to payment, reporting and audit. It becomes important to have a core team create the map, but don’t forget to disseminate it to departments for review and revision. We recom-mend that now is a great time to consider places where your current solutions have gaps, redundancies or just time- consuming work steps that can be improved. It’s also a good time to consider whether the current vendor solutions you have are the best available and for the right price.
• IT systems are dynamic, and with or without ICD-10, changes are required almost daily. Your organization should create and publish an IT system “Change Management Process” that is transparent and strictly enforced. In many organizations, the core IT staff already does this, but may not have looped in ancillary departments or forced small local solutions to follow the same process. As software developers, we believe that any complex system should be managed using software that facilitates bug/issue reporting, tracking and follow up. Work with your education team to disseminate the process to all staff and provide on-going reminders to keep then entire organization on board.
VENDOR RELATIONSHIPS
Most health care organizations operate with a combination of internal and vendor solutions. Preparing for ICD-10 requires not only that providers understand vendor readiness, including testing dates, but also work to understand who their vendors are. This process is beneficial regardless of an implementation deadline. We recom-mend that you proceed with these Phase 1 Assessment tasks:
• Create a consolidated database to track all vendors and their contracts. Consider using an online solution (such as the Contracts & Relationships
• Be sure that your inventory accounts for anticipated contract changes due to major regulatory changes such as 5010, Meaningful Use and ICD-10. • Establish a clear understanding with your IT team about how vendor
systems integrate with your own internal systems. • Establish a timeline for when vendor contracts renew.
• Schedule time before the renewal date to perform due diligence in reviewing each solution to ensure that it is the best available and that you have negotiated the best price possible.
• Ask vendors for a clear delineation of what is included, what enhancements are expected (any additional fees included), and how staff training is done. During Phase 2 of implementation, establish a working relationship with each vendor to stay on top of training, testing and go live work.
OUR WORKFLOW SOLUTIONS
To help our clients and partners with the transition to ICD-10, Wolters Kluwer Law & Business has created solutions that address this issue from two different perspectives: Coding and Compliance.
For coding, we’ve integrated ICD-10 and MS-DRG coding and payment resources that specifically address the critical tasks to be performed by coders and reim-bursement professionals into our Coding Suite™ and Compliance Suite™. This
includes ICD-10-CM and ICD-10-PCS electronic codebooks, an ICD-10 explorer tool that simultaneously allows you to natively code in ICD-9 or ICD-10 and map codes using GEMs, and an MS-DRG ICD-10 pilot grouper that connects to our provider-specific MS-DRG Calculator.
During the initial analysis phase of ICD-10 readiness, these tools can be used to understand and visualize the greater specificity of ICD-10 and analyze the reimbursement impact of the changed grouper logic. As we move closer to implementation, these tools are exceptional for training and education. Once the industry goes “live” with ICD-10, these tools will be fully integrated with medical necessity, claims edit and other coding tools.
For compliance, we’ve created an ICD-10 readiness assessment and dashboard tool that allows any organization and/or provider to self-assess their readiness, plan and implement the changes required, view progress, and provide reference resources to their ICD-10 task force team members. The majority of the Phase 1 assessment questions and work plan tasks outlined in this solution align with the mission- critical processes outlined within this paper.
SUMMARY
Understanding that ICD-10 is an enterprise-wide initiative that requires great collaboration amongst many entities throughout an organization, it is our belief that most of the ICD-10 assessment and planning tasks are beneficial exercises for an organization regardless of a potential implementation delay. All stakeholders in your organization must understand that the transition to ICD-10 will impact every aspect of claims processing, reimbursement, clinical documentation, payer relations and coding. We encourage providers to use the extra time wisely. Efficiently and effectively manage the daunting task of ICD-10 preparation and implementation—from re-educating your staff and updating your systems and tools to understanding the reimbursement consequences of this complex new coding vocabulary—with powerful solutions from Wolters Kluwer Law & Business.
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