Four lessons learned on smoothing the transition from ICD-9.
Change. Few relish it. Some abhor it. Sometimes change is optional. Sometimes it's not. For hospital executives and physician practice leaders, changing from ICD-9 to ICD-10 is mandatory. Oct. 1, 2014 is the deadline. And it's fast approaching.
With only nine months remaining, it's time healthcare leadership gets past the doom-and-gloom attitudes of naysayers and focuses on expediting the change. After all, time is short — and rapidly growing shorter.
5 Realities to face
ICD-10, or the International Classification of Diseases, 10th Revision, is a much more complex system of codes than ICD-9. Supporters say ICD-10 will allow providers to keep better track of patient care and aggregate data to perform quality-improvement analyses. There are certain realities that one must accept when discussing the change:
- We are stuck with the deadline for ICD-10 implementation of Oct. 1, 2014. After two previous postponements, this date is not moving. Much of the world switched to ICD-10 long ago.
- Many hospitals and physician practices are woefully behind in preparing for the transition, although it’s difficult to quantify exactly how many are how far behind, because determining readiness is subjective.
- Best practitioners are well into forensic efforts for dual coding, and they already have a good understanding of the challenges, pinpointing their top areas and service lines for revenue concerns. They are looking downstream at physician documentation and coding. They are looking upstream at revenue recognition changes.
- Dual coding is underway. (That's the good news.)
- Many have postponed physician training. (That's the bad news.
Having been actively involved in ICD-10 since 2010 and helping hundreds of hospitals resolve clinical coding issues, here are four lessons learned for smoothing the transition from ICD-9 to ICD-10.
Lesson learned #1: Holding physician training last is a mistake
Conventional wisdom was to save physician training for the end of the process. In fact, the industry instructed providers to hold off on physician training until six months prior to ICD-10 go-live. So hospitals invested, instead, in coder and CDI specialist training. But what we've learned in hindsight is that some physician training should have been conducted prior to dual coding.
As coders are dual coding, they are sending physicians many more queries than before. The relationship is becoming adversarial right out of the gate, and ICD-10 is getting blamed. It’s difficult for coding departments to engage in coding unless physicians have engaged in basic training. This can create a toxic environment, and is a bad start to physician-coder relationships.
Dual coding should be the driver for scheduling physician training. Holding physician education until last is a mistake.
Best practices have become much clearer. We suggest teaching physicians by exception. Teach them only what they don’t already know and focus only on specific areas, diagnoses, procedures and/or services that represent your greatest financial risk. Use multiple modalities for training.
Conduct a forensic review of physician documentation (use a sample of known high-risk cases), exercising due diligence to understand their specialty and case mix, and then educate physicians in these target areas. Dual code these high-risk cases by specialty. Provide physicians with feedback by specialty.
Lesson #2: CAC technology will help, but impact still too new to determine
The market doesn't have high enough penetration of computer-assisted coding systems to know yet if this technology will prove itself out as a "savior" for ICD-10. It is an immensely valuable technology, but exact productivity impact is not yet measured. CAC is more difficult in an inpatient environment than outpatient services. Once the CAC adoption rate increases, we’ll be able to more closely determine its impact.
Lesson #3: More hospitals should be contingency planning
We’re not hearing about as much post-ICD-10 planning as we should. Most hospitals are looking at contingency staffing, but there is much more to consider.
ICD-10 is the perfect storm and will likely include productivity drops, reimbursement glitches and audit spikes. Faulty — or nonexistent — contingency plans will exacerbate these problems. There simply is not enough contingency planning underway because everyone is focused on getting ready for ICD-10.
For example, what will recovery audit contractors do post-ICD-10? Will they become more aggressive predators? What if interfaces don't work between providers/clearinghouses/payers? What problems will end-to-end testing efforts fail to uncover? These will be difficult challenges to manage over the next 18-24 months.
Lesson #4: Staffing demands require out-of-the-box thinking
There is a desperate search for staff from both providers and vendors. Unless there is work for that staff (read “coders”) to do, it is financially difficult to bring that staff on ahead of time. Hospital executives should be more open minded and consider the following backup options:
- Remote coding, if not already implemented, is essential. If you are a facility that doesn't have a remote-coding operation underway, you're in trouble. If you're demanding coders be onsite, keep in mind that there are dozens of other hospitals and vendors vying to recruit their resources remotely. The IT effort required is also a stumbling block. Along with meaningful-use requests and adoption of new technology, ICD-10 will become a high priority when coders leave to work remotely.
- Embrace a blended staffing model for coding. Offshore coding can be utilized for some cases, with the domestic component responsible for quality control, compliance and inpatient coding. Offshore companies are doing better; they will be a lifesaver for U.S. coding companies and hospitals. Interest has never been this high in outsourced and offshore coding. Where there is no staff to be found, offshore will be the only option.
- So, in order to be as prepared as possible for the ICD-10 transition, train your physicians, utilize CAC technology, plan for contingencies after go-live and consider backup options for staffing. It’s going to be a very interesting nine months on both sides of the ICD-10 deadline.