Hospitals have more than two years to get ready for the switch from the ICD-9 to the ICD-10 diagnosis codes, which occurs on Oct. 1, 2013, but coding consultants are urging hospitals to already start preparing.
Some warnings about ICD-10 can sound almost apocalyptic. Eric Mueller, services president of WPC Services in Brentwood, Tenn., states, "The scope of this change is the biggest thing that healthcare has seen." Ray Desrochers of HealthEdge Software in Burlington, Mass., says, "This will be the Y2K of healthcare." Of course, the dire warnings in 1999 about Y2K bringing the economy to its knees never materialized, but Mr. Desrochers argues this was because banks and other institutions took the problem very seriously. He advises hospitals to do the same for ICD-10.
How much on the mark are these warnings? Here consultants and other coding experts explain the ICD-10 system and how it would affect hospitals and other providers.
What the change means
The number of diagnostic codes will rise from 13,000 under the current system to 68,000 and two more digits will be added to the code, moving it from five to seven characters. This will allow for more precise billing information, according to the American Academy of Professional Coders. In fracture care, for example, each particular ICD-10 code differentiates an encounter for an initial fracture, follow-up of fracture healing normally, follow-up with fracture in malunion or nonunion or follow-up for late effects of a fracture, AAPC said.
Very exact information will help hospitals and others mine claims data and improve care delivery, according to ICD-10 Watch, an online coding advisor. "Deeper coding creates an opportunity to have a much sophisticated payment platform with more reliable information coming out," ICD-10 Watch said. "The result is much more reliable information on outcomes."
But to provide precise billing information, coders will have to study the chart much more extensively and will no longer be able to approximate diagnoses, says Janice Jacobs, director of the regulatory compliance practice at IMA Consulting in Chadds Ford, Pa. Under ICD-10, they can't use unspecified codes to fill in gaps in the chart, as they can do under ICD-9, where there are codes such as "abdominal pain, unspecified quadrant," she says. The quadrant will have to be specified.
Because ICD-10 codes have to be so granular, AAPC predicts they will slow down the process of documentation, entering new codes and communicating with payors. Coding experts say this will mean lower coder productivity and initially more coding errors and more days in A/R, which they say could last for several years at many hospitals.
Changes for coders
Except for physicians, coders will be the most affected by ICD-10. The new system is more than just an updated version of ICD-9; it represents a whole new coding language, Ms. Jacobs says. "It's a complete change for coders," she says. "In ICD-9, when codes were added it was just sequential. This is completely different."
Even when coders master the new ICD-10 language, they will never be as efficient as before because they will need to spend more time on each chart, Ms. Jacobs adds. To determine the exact code, "coders will have to read the whole chart," she says. "They will never hit the same level of productivity again. If they were doing 50 charts a day, they won't reach that level again."
According to TM Floyd, a coding software company in Columbia, S.C., implementation of ICD-10 in other countries caused an initial 50 percent reduction in coder productivity. Due to lower coder productivity as well as more coding mistakes, "days in A/R will initially go up, and even double in some instances," Mr. Mueller at WPC Services says.
Moreover, to be able to find the exact clinical information in the chart, "the coder is going to need a much more in-depth knowledge of anatomy, physiology and the disease process," Ms. Jacobs says. All of this means extensive training for coders over many months. "But I would not recommend training coders now, because they'll forget what they've learned," she says. "Train them when you get closer to the 2013 implementation date." Identifying the right timing for training will be "a delicate juggling act," she concedes. "I foresee a lot of headaches with it. ICD-9 has been around forever. Coders have to stop cold-turkey and go to ICD-10."
Changes for physicians
Physicians play a pivotal role in the transition to ICD-10. For coders to retrieve exact information from the chart, physicians have to enter the needed information. "The coding is only as good as the chart," says Marcel Handler, CFO for Millin Associates, a coding consultancy in Cedarhurst, N.Y. "The chart is more than just a clinical record," he says. "It is also a billing record. Physicians have to learn what needs to be put there for billing purposes. This is already a problem in ICD-9 and it will be a greater problem for ICD-10."
But unlike ICD-10 training for coders, training for physicians can start right away, because physicians don't actually use the new codes; they just have to provide exact information for them, Mr. Handler says. However, he has found that many physicians don't take ICD-10 seriously yet. Even when a hospital has a certified ICD-10 instructor on staff, he says many physicians are not interested in learning. "My biggest concern is whether physicians will react in a timely manner," he says. "My concern is that they will start looking into it at the last minute."
In helping physicians prepare for ICD-10, hospitals face the familiar problem of trying to persuade mainly independent practitioners to embrace a new system. "There has got to be a 'what's in it for me?' " says Ms. Jacobs of IMA Consulting. "The hospital may have to pay to train physicians, because it would be a good investment." She also recommends phased-in training, which involves identifying physicians who are slow learners and giving them more focused sessions. The hospital could also carry out mini-audits of charts to see which physicians still need more instruction, she says.
Changes in IT systems
To prepare for ICD-10, IT vendors will have to upgrade their systems from the current 4010A1 standard to HIPAA 5010 by Jan. 1, 2012. With that date fast approaching, 48 percent of hospital executives identified implementing ICD-10 as the top financial IT priority for 2011, according to the HIMSS Annual Leadership Survey.
However, "many vendors are not yet up to speed on HIPAA 5100, and they will need to be by January," Mr. Handler says. "Some vendors will make it, but some won't." Hospitals whose vendors don't meet the deadline will have to purchase other systems that do, he says. Likewise, some IT vendors for payors also will have trouble upgrading their systems, Mr. Desrochers of HealthEdge reports. This may impair their ability to process claims, he says.
Changes for hospitals in general
While coders, physicians and IT systems will have the most to do with ICD-10, it will also impact the rest of the organization, Mr. Mueller says. "This new system will affect the workflow and cadences of the entire organization," he says. "Everyone in the revenue cycle, from scheduling through bad debt and collections, is going to experience a huge impact." For example, schedulers who contact the insurer for preauthorization must make sure they are using the right code, he says. If the wrong code was used, the patient might not be covered. To convey a sense of the new system, he recommends much shorter training sessions for these staff than coders will need.
Ms. Jacobs adds that every paper or digital form in the hospital that will have to be updated for ICD-10. For example, hospital charge tickets and physician practices' encounter forms tend to be quite short, perhaps a page or two, front and back, listing the common codes used. But with ICD-10 vastly expanding the number of codes, the short format will no longer work. "I can't see a physician flipping through a five-page form," Ms. Jacobs says. She thinks hospitals and practices could switch to electronic forms that accommodate more codes by organizing them in a decision tree, for example.
Longer-term implications
Mr. Mueller of WPC Services predicts it will take a few years for hospitals and payors, including Medicare, to get used to ICD-10. "Look at ICD-9," he says. "CMS is still fine-tuning the business rules around code sets and it's now more than 20 years after the implementation."
He also predicts that fraud and abuse allegations against hospitals will rise. "History tells us that whenever there is a new dataset, the number of fraud and abuse cases go up," he says. "Everyone will make mistakes: the payor, the provider, the clearinghouse. It will take a couple of years to work out the kinks."
Increased errors under ICD-10 would also draw the attention for recovery audit contractors, Mr. Desrochers says. "RACs could have a field day here," he says. To guard against this, ICD-10 Watch, a respected coding blog, advised hospitals to perform a "RAC data-diving exercise." This involves focusing on highly utilized code sets and determining what kinds of documentation specificity those codes will need. "Once you know your numbers, so to speak, associated with ICD-10, you can drive greater documentation clarity," ICD-10 Watch recommended.
Related Articles on ICD-10:
What You Should be Doing to Prepare for ICD-10: 3 Strategies
ICD-10 Specificity to Impact Nurse Workflows
4 Predictions on the Switch to ICD-10