Come Oct. 1, 2013, the healthcare landscape will be bidding adieu to a friend that has been around for more than 40 years: ICD-9.
Replacing it is ICD-10, which will become the new procedural, diagnostic, coding and billing default of the healthcare landscape for the start of the 2014 fiscal year, much to the displeasure of several groups. The American Medical Association stated in Nov. 2011 that it will "work vigorously to stop implementation of ICD-10," but CMS has repeatedly said that ICD-10 — which has been postponed for more than a decade already — will not be delayed any more.
In anticipation of ICD-9 heading out the door, here are nine things hospitals and health organizations ought to be doing right now to prepare for ICD-10.
1. Clear the Version 5010 hurdle. Currently, all HIPAA-covered entities must be compliant with the Version 5010 transaction standards, but CMS will not initiate enforcement of the standards until March 31, 2012. However, Version 5010 is like the training wheels on a bicycle. If hospitals want to have any success with their ICD-10 implementation, they must first get through Version 5010, which is an essential administrative and technological precursor, says Paul Spencer, compliance officer for Fi-Med Management.
The main reason for this switch to Version 5010 is due to the longer length of the ICD-10 codes. "Right now, ICD-9 stops at five characters, but with ICD-10, depending on the type of code, it can be four to seven characters in length," Mr. Spencer says. "It's important to build billing standards to accommodate that."
2. Align ICD-10 efforts with electronic health record initiatives. ICD-10 will impact a hospital or health system's operations in several areas, including technology, billing, coding and clinical documentation. Since ICD-10 requires certain technological advancements, providers should consider ICD-10 changes in concert with meaningful use and EHR initiatives, which are also required of hospitals and physician practices. For example, it would be futile for providers to upgrade their billing software for ICD-10 without ensuring their EHR is also fully transitioned. There needs to be interoperability between the two. "The bigger EHR vendors have been working on ICD-10 updates for years," Mr. Spencer says. "But there are still a number of physicians who have their EHR and billing separate. You have to look into integration."
The fusion of ICD-10 and EHR software is important beyond meaningful use, as well. Hospitals, in an effort to move toward accountable care organizations or a similar model, are affiliating with and purchasing physician practices at a rapid pace. Transitioning to an ACO-like model will be easier if hospitals and physician practices align their ICD-10 and EHR efforts. "Especially now when dealing with ACOs and hospitals acquiring physician's practices, what they really need to do is look at all of billing systems they have," he adds. "If you're picking up a physician's practice with its own billing system, that in and of itself could create a headache."
3. Conduct risk and coding assessments. There are two types of areas in which hospitals should evaluate themselves in preparation of ICD-10: risk and coding. Lori Jayne, director of health information management and privacy officer at The Lahey Clinic, a teaching hospital of Tufts University School of Medicine in Burlington, Mass., says her organization has conducted several risk assessments to see where their coding and technology might be vulnerable in the wake of a tidal wave of new codes.
The Lahey Clinic had a third party assess which specialties involved the most risk of coding, billing or other ICD-10-related issues. In this case, those areas included neurosurgery, cardiovascular, radiology and orthopedics due to their high coding error rates and new and more specific codes. As The Lahey Clinic makes the transition to ICD-10, the HIM team will pay extra attention to those "risk" groups that will be heavily affected by ICD-10. "We did this risk assessment just so we're not chasing a needle in haystack," Ms. Jayne says. "We have significant volume and complex patients. We identified those critical areas not just because the codes have just expanded but because the technology and approaches to the procedures have changed as well. We don't want our coders to be overwhelmed with all the new coding requirements for all patient types."
Hospitals must also perform a coding assessment. Gloryanne Bryant, regional managing health information management director at Northern California Kaiser Hospitals, said in a recent webinar that hospitals must see where their coders actually stand in their basic knowledge of the four core competencies of coding: medical terminology, anatomy, physiology and pharmacology. This initial assessment of 50 to 150 questions on the basic four competencies should have multiple choice and true/false answers while not allowing resources. This can give a healthcare organization an idea of what type of training and education needs to be provided for the nuts and bolts work of ICD-10. Several organizations, ranging from AHIMA to AAPC, offer those types of coding assessment solutions.
Brian Junghans, partner at Cumberland Consulting Group, agrees that hospitals need to provide refreshers on medical science, anatomy and physiology because the ICD-10 codes require a more specific anatomical reference.
4. Provide foundational and prerequisite education. Completing technological and assessment goals is the vital groundwork of ICD-10 projects, but eventually, hospitals simply have to train and re-educate their staff, particularly their coders and HIM professionals. Ms. Jayne says hospitals should hold 10-week courses that retrain staff members specifically in anatomy and physiology, two of the main core competencies.
Ms. Bryant says an organization should already have performed the coding assessment, and formal training on ICD-10 technology, codes and all other nuances should formally begin by Jan. 2013 at the latest.
5. Experiment with computer-assisted coding. Roughly one year ago, during the infancy of ICD-10 adoption for many hospitals, Ms. Jayne says The Lahey Clinic implemented computer-assisted coding into their coding business process. This technology essentially takes an abstract of rich-text documents, and instead of a coder manually reading a chart, the computer suggests codes, diagnoses and procedures through natural language processing to save coders time. "It takes a good 30 to 45 minutes to do a full coding record cycle, and with the expansion of ICD-10, it could double that time," Ms. Jayne says.
She adds that CAC could help the relationship between coders and clinicians. CAC and its related autosuggestions could prompt coders and physicians to double-check and correctly identify all intended diagnoses and procedures. "Improving your current documentation today is making it more efficient for your providers and coders," Ms. Jayne says. "It's a baby step, but it'll make it so much easier with training and implementation later on."
6. Enhance physician documentation. While coders and frontline staff undoubtedly play an integral role in the implementation of ICD-10, physicians and other clinicians also are a big part of the success and seamless transition to ICD-10.
Educating physicians on ICD-10 may not be the easiest of endeavors, especially as their schedules greatly vary from day to day. However, hospital staff must be dedicated to lay down a "gradual learning" approach for physicians and must understand that not all physicians and clinicians are technologically savvy. Additionally, ICD-10 will most likely affect the daily workflow of physicians and clinicians when the deadline hits, making it all the more important to improve their documentation now. "Clinical documentation is not as obvious a change straightaway, but how people document clinical content and what they need to collect differently to support the more complex code set is pervasive," Mr. Junghans says.
7. Consider installing a reporting and tracking system. Coders and providers each have their own separate challenges, but the two groups can help each other out during the ICD-10 process. Ms. Jayne says her hospitals installed a reporting and tracking technology system that interactively keeps track of a claim from documentation to billing.
Along the way, coders input information, clinical documentation improvement specialists track the information and a physician reviewer monitors the process from the clinician's point of view. Any one of the groups is therefore able to add its input in case there is a coding discrepancy. "In the event where we are questioned by auditors, instead of re-coding or re-evaluating a chart, we can look at all of the dialogue between the coder and provider," Ms. Jayne says.
8. Test functionality with vendors, payors and clearinghouses. Hospitals are expending a lot of energy to prepare internally for ICD-10, but a factor that cannot be left unattended is the testing of ICD-10 compatibility with health IT vendors, payors and clearinghouses, Mr. Junghans says.
Similar to Version 5010 risk mitigation strategies, hospitals should communicate with vendors and trading partners regularly, reach out to a clearinghouse for assistance, establish a line of credit to help cover potential cash flow disruptions from delayed reimbursement claims and take advantage of available ICD-10 testing resources offered by CMS.
9. Understand how ICD-10 will impact a hospital's bottom line. Hospital CFOs are well-aware of the technological challenges ICD-10 presents, and as hospitals wrap up their strategic planning phases, they also know the pending costs. ICD-10 could cost anywhere from a couple million dollars to as much as $100 million for very large, integrated health systems, but if the upfront costs are not swallowed, the future costs due to lost reimbursement and a lagging revenue cycle could be even greater. "The cost [of ICD-10] is going to overwhelming, but it's the cost of doing business," Ms. Jayne says.
Mr. Junghans agrees, adding hospitals must work under the assumption that there will be no more federal delaying of ICD-10. "In order to take full advantage of ICD-10 and to keep a steady state of operations and revenue collection, the sooner hospitals start education and the deeper they get the education entrenched, the better prepared for this transition hospitals will be," Mr. Junghans says.
Replacing it is ICD-10, which will become the new procedural, diagnostic, coding and billing default of the healthcare landscape for the start of the 2014 fiscal year, much to the displeasure of several groups. The American Medical Association stated in Nov. 2011 that it will "work vigorously to stop implementation of ICD-10," but CMS has repeatedly said that ICD-10 — which has been postponed for more than a decade already — will not be delayed any more.
In anticipation of ICD-9 heading out the door, here are nine things hospitals and health organizations ought to be doing right now to prepare for ICD-10.
1. Clear the Version 5010 hurdle. Currently, all HIPAA-covered entities must be compliant with the Version 5010 transaction standards, but CMS will not initiate enforcement of the standards until March 31, 2012. However, Version 5010 is like the training wheels on a bicycle. If hospitals want to have any success with their ICD-10 implementation, they must first get through Version 5010, which is an essential administrative and technological precursor, says Paul Spencer, compliance officer for Fi-Med Management.
The main reason for this switch to Version 5010 is due to the longer length of the ICD-10 codes. "Right now, ICD-9 stops at five characters, but with ICD-10, depending on the type of code, it can be four to seven characters in length," Mr. Spencer says. "It's important to build billing standards to accommodate that."
2. Align ICD-10 efforts with electronic health record initiatives. ICD-10 will impact a hospital or health system's operations in several areas, including technology, billing, coding and clinical documentation. Since ICD-10 requires certain technological advancements, providers should consider ICD-10 changes in concert with meaningful use and EHR initiatives, which are also required of hospitals and physician practices. For example, it would be futile for providers to upgrade their billing software for ICD-10 without ensuring their EHR is also fully transitioned. There needs to be interoperability between the two. "The bigger EHR vendors have been working on ICD-10 updates for years," Mr. Spencer says. "But there are still a number of physicians who have their EHR and billing separate. You have to look into integration."
The fusion of ICD-10 and EHR software is important beyond meaningful use, as well. Hospitals, in an effort to move toward accountable care organizations or a similar model, are affiliating with and purchasing physician practices at a rapid pace. Transitioning to an ACO-like model will be easier if hospitals and physician practices align their ICD-10 and EHR efforts. "Especially now when dealing with ACOs and hospitals acquiring physician's practices, what they really need to do is look at all of billing systems they have," he adds. "If you're picking up a physician's practice with its own billing system, that in and of itself could create a headache."
3. Conduct risk and coding assessments. There are two types of areas in which hospitals should evaluate themselves in preparation of ICD-10: risk and coding. Lori Jayne, director of health information management and privacy officer at The Lahey Clinic, a teaching hospital of Tufts University School of Medicine in Burlington, Mass., says her organization has conducted several risk assessments to see where their coding and technology might be vulnerable in the wake of a tidal wave of new codes.
The Lahey Clinic had a third party assess which specialties involved the most risk of coding, billing or other ICD-10-related issues. In this case, those areas included neurosurgery, cardiovascular, radiology and orthopedics due to their high coding error rates and new and more specific codes. As The Lahey Clinic makes the transition to ICD-10, the HIM team will pay extra attention to those "risk" groups that will be heavily affected by ICD-10. "We did this risk assessment just so we're not chasing a needle in haystack," Ms. Jayne says. "We have significant volume and complex patients. We identified those critical areas not just because the codes have just expanded but because the technology and approaches to the procedures have changed as well. We don't want our coders to be overwhelmed with all the new coding requirements for all patient types."
Hospitals must also perform a coding assessment. Gloryanne Bryant, regional managing health information management director at Northern California Kaiser Hospitals, said in a recent webinar that hospitals must see where their coders actually stand in their basic knowledge of the four core competencies of coding: medical terminology, anatomy, physiology and pharmacology. This initial assessment of 50 to 150 questions on the basic four competencies should have multiple choice and true/false answers while not allowing resources. This can give a healthcare organization an idea of what type of training and education needs to be provided for the nuts and bolts work of ICD-10. Several organizations, ranging from AHIMA to AAPC, offer those types of coding assessment solutions.
Brian Junghans, partner at Cumberland Consulting Group, agrees that hospitals need to provide refreshers on medical science, anatomy and physiology because the ICD-10 codes require a more specific anatomical reference.
4. Provide foundational and prerequisite education. Completing technological and assessment goals is the vital groundwork of ICD-10 projects, but eventually, hospitals simply have to train and re-educate their staff, particularly their coders and HIM professionals. Ms. Jayne says hospitals should hold 10-week courses that retrain staff members specifically in anatomy and physiology, two of the main core competencies.
Ms. Bryant says an organization should already have performed the coding assessment, and formal training on ICD-10 technology, codes and all other nuances should formally begin by Jan. 2013 at the latest.
5. Experiment with computer-assisted coding. Roughly one year ago, during the infancy of ICD-10 adoption for many hospitals, Ms. Jayne says The Lahey Clinic implemented computer-assisted coding into their coding business process. This technology essentially takes an abstract of rich-text documents, and instead of a coder manually reading a chart, the computer suggests codes, diagnoses and procedures through natural language processing to save coders time. "It takes a good 30 to 45 minutes to do a full coding record cycle, and with the expansion of ICD-10, it could double that time," Ms. Jayne says.
She adds that CAC could help the relationship between coders and clinicians. CAC and its related autosuggestions could prompt coders and physicians to double-check and correctly identify all intended diagnoses and procedures. "Improving your current documentation today is making it more efficient for your providers and coders," Ms. Jayne says. "It's a baby step, but it'll make it so much easier with training and implementation later on."
6. Enhance physician documentation. While coders and frontline staff undoubtedly play an integral role in the implementation of ICD-10, physicians and other clinicians also are a big part of the success and seamless transition to ICD-10.
Educating physicians on ICD-10 may not be the easiest of endeavors, especially as their schedules greatly vary from day to day. However, hospital staff must be dedicated to lay down a "gradual learning" approach for physicians and must understand that not all physicians and clinicians are technologically savvy. Additionally, ICD-10 will most likely affect the daily workflow of physicians and clinicians when the deadline hits, making it all the more important to improve their documentation now. "Clinical documentation is not as obvious a change straightaway, but how people document clinical content and what they need to collect differently to support the more complex code set is pervasive," Mr. Junghans says.
7. Consider installing a reporting and tracking system. Coders and providers each have their own separate challenges, but the two groups can help each other out during the ICD-10 process. Ms. Jayne says her hospitals installed a reporting and tracking technology system that interactively keeps track of a claim from documentation to billing.
Along the way, coders input information, clinical documentation improvement specialists track the information and a physician reviewer monitors the process from the clinician's point of view. Any one of the groups is therefore able to add its input in case there is a coding discrepancy. "In the event where we are questioned by auditors, instead of re-coding or re-evaluating a chart, we can look at all of the dialogue between the coder and provider," Ms. Jayne says.
8. Test functionality with vendors, payors and clearinghouses. Hospitals are expending a lot of energy to prepare internally for ICD-10, but a factor that cannot be left unattended is the testing of ICD-10 compatibility with health IT vendors, payors and clearinghouses, Mr. Junghans says.
Similar to Version 5010 risk mitigation strategies, hospitals should communicate with vendors and trading partners regularly, reach out to a clearinghouse for assistance, establish a line of credit to help cover potential cash flow disruptions from delayed reimbursement claims and take advantage of available ICD-10 testing resources offered by CMS.
9. Understand how ICD-10 will impact a hospital's bottom line. Hospital CFOs are well-aware of the technological challenges ICD-10 presents, and as hospitals wrap up their strategic planning phases, they also know the pending costs. ICD-10 could cost anywhere from a couple million dollars to as much as $100 million for very large, integrated health systems, but if the upfront costs are not swallowed, the future costs due to lost reimbursement and a lagging revenue cycle could be even greater. "The cost [of ICD-10] is going to overwhelming, but it's the cost of doing business," Ms. Jayne says.
Mr. Junghans agrees, adding hospitals must work under the assumption that there will be no more federal delaying of ICD-10. "In order to take full advantage of ICD-10 and to keep a steady state of operations and revenue collection, the sooner hospitals start education and the deeper they get the education entrenched, the better prepared for this transition hospitals will be," Mr. Junghans says.
Related Articles on ICD-10:
ICD-10: Insight on Project Planning and Financial Implications
5 Reasons to Take ICD-10 Seriously Today
ICD-10: Will It Kill a Hospital's Productivity?