Despite the recent news of a delay in the implantation date, ICD-10 remains a priority for healthcare, and those hospital executives who aren't concerned about clinical coder productivity declines may need a wake-up call. Coding productivity will undoubtedly take a hit before, during and after the implementation of ICD-10.
No hospital can afford to cut corners when it comes to budgeting for these crucial staff members who are the lifeline of an organization's revenue stream, regardless of the coding system used. Inadequate coder staffing negatively affects an organization's revenue and DNFB.
According to the ICD-10 National Pilot Program, coders using ICD-10 averaged two or fewer medical records per hour. This is compared to the three to four records per hour they were able to code in ICD-9. Experts have speculated this decrease will likely never improve completely to pre-ICD-10 levels in the long-term. HRS' own experience with coding in ICD-10 reveals similar results.
This article presents six concerns with coder staffing healthcare provider executives should acknowledge, understand and prepare for based on HRS' real-world experience with ICD-10 coding.
The reality
Nineteen out of 20 records in a pre-defined sample set took longer to code when using ICD-10. More specifically, it took HRS staff members an average of 16.5 additional minutes to code these records. Some records, including those pertaining to DRGs 202 and 203 (bronchitis and asthma with CC/MCC and without CC/MCC, respectively), took an additional 35 minutes to code. Why?
Asthma diagnoses are just one of the many areas that have been expanded in ICD-10. Coders must specify whether the asthma is mild intermittent, mild persistent, moderate persistent or severe persistent. They must also specify whether the asthma is uncomplicated, with acute exacerbation or with status asthmaticus. If this documentation is absent, they are forced to query the physician — resulting in billing delay, increased DNFB and additional medical staff frustration.
The added clinical specificity in diagnoses such as asthma and others is only one reason why ICD-10 makes coders' jobs more complex. ICD-10-PCS, which captures inpatient procedures, will be particularly draining on productivity. That's because surgical coding in ICD-10 requires coders to review documentation with a level of detail and thoroughness that simply wasn't necessary in the past. They must also build a code, selecting each character in the code separately based on the specific documentation, rather than assigning a code from a tabular list of procedure codes.
Computer-assisted coding can help to offset some of these productivity losses, but it certainly cannot be used to entirely circumvent staffing concerns, especially as they relate to ICD-10 transition planning. CAC will not allow organizations to decrease staffing budgets or avoid having to set aside additional money for training. Instead, hospital executives should consider the following six questions when determining a staffing budget for 2014 and beyond.
1. Given the delay in implementation, do I need to worry about coders continuing to practice ICD-10 now? If so, what should I consider when budgeting for necessary ICD-10 coding practice time? Most coders have received technical training by now, and in order to ensure competency, they must be allowed to practice assigning the new codes. ICD-10 is a whole new language for coders. If they don't use it, they will lose it.
Native hard-coding of cases in ICD-10 is the best way to ensure knowledge retention, provide hands-on practice and achieve return on investment for training dollars already spent. Coders should continue to use the ICD-10 coding knowledge they have achieved in order to maintain and continue to build understanding and proficiency with the new code set.
Executives should budget for someone to cover the day-to-day coding function while each in-house coder spends at least several hours per week coding solely in ICD-10. Since most organizations do not have the ability to provide backfill for this effort internally, contract coding staff will be necessary to maintain the routine coding effort for the hours that coders are continuing to practice their ICD-10 coding each month. Securing a strong relationship with a coding service partner now, even if only for a small amount of work per week, is a critical step to ensure your organization will remain staffed during the year ahead.
Note that there are also coding management costs associated with the required quality review of the hard-coded records in order to provide feedback, and deliver supportive education.
2. How many additional coders may be necessary after the ICD-10 transition date? If coders experience the 50 percent decrease as anticipated, organizations may need to double their coding staff resources in the short term. For example, if each coder is able to code 24 charts per day in ICD-9-CM but only 12 in ICD-10, who will code those remaining 12 charts? An additional full-time equivalent (or more) may be necessary. How much will these additional required FTEs cost the organization?
To determine exact costs, dual coding and time studies are necessary. Every coding entity is somewhat unique, depending on the knowledge, ability, and experience of its staff members. However, the above productivity impact during ICD-10's first ninety days is a commonly-used national benchmark.
3. How long will my organization need to retain additional staff? The first six months after ICD-10 implementation will be the most difficult. During this time, coder staffing must be a major priority for every organization. Costs directly tied to staff salaries will be most intense during this timeframe, and budgets must be established to accommodate this temporary increase. Staffing costs will likely decrease over time; however, it's too soon to determine when this will occur, and the timeframe will likely vary for each organization.
4. Should my organization offer retention or recruitment bonuses? Organizations have invested significant funding and resources to train coders in ICD-10, so ensuring a return on their investment is crucial. Offering retention bonuses may be a wise long-term investment. Some organizations may also want to consider offering recruitment bonuses to attract highly-skilled coders now and avoid scrambling later when there will likely be even more of a coder shortage and increased competition for those coders with established ICD-10 skills.
5. Can my budget accommodate the "unknowns"? Every staffing budget should be flexible enough to accommodate needs as they arise. For example, some staff members may require additional training after the ICD-10 go-live. How will the organization handle this? Not only will there be costs associated with that training, but the organization may also need to hire additional staff members to backfill the coding function.
Denials are another unknown. If claims are denied due to invalid codes, unspecified codes, technical problems, etc., organizations must be able to hire additional staff members to assist with the denial review and responses. If the organization's budget cannot accommodate this, the DNFB will likely rise and be compounded by a lack of incoming revenue. During the timeframe immediately following the transition, it will be critical to rapidly identify, reconcile and correct denied claims.
6. Must my organization hire any other HIM-related staff? Many organizations have committed to using the additional time before the ICD-10 transition to expand their documentation improvement efforts. Organizations are budgeting for extra CDI professionals or hiring an individual whose sole purpose is to manage and increase the efficiency of the query process. Asserting documentation improvement efforts now can help the organization tailor the query process to ICD-10 earlier, so that they can offset the expected 40 percent increase expected due to the inherent specificity in ICD-10.
In addition to streamlining the query process, ongoing coder and physician education must also be a priority. Some organizations have opted to hire an internal coding educator. Adding such a position obviously requires careful budgeting and planning. Such a position may be well worth the investment because this individual can help ensure coding and claims compliance, thereby reducing costly denials and further straining coder productivity.
Productivity drops: A long-term concern
According to Canadian HIM professionals, coder productivity with ICD-10 never completely returned to ICD-9 levels. While the 50 percent drop experienced by HRS and predicted by industry experts did improve over time, coders were never as productive in ICD-10 as they were in ICD-9. Regardless of the fact that the implementation date for the U.S. has been delayed by the recent congressional action, executives should brace themselves for the long road ahead in increased coder staffing budgets, stronger outsourced coding service partnerships and ongoing education as we all continue to contend with the ICD-10 learning curve.
Barbara Hinkle-Azzara, RHIA, applies her strong background in both hospital HIM leadership and vendor/client relationships to lead client development, coordination and management for HRS. Prior to joining HRS, Barbara served as the VP of HIM Solution Strategy for Meta Health Technology and director of HIM at several major teaching facilities in New York City.
Kim Carr brings nearly 30 years of health information management experience to HRS. Before joining HRS, Kim worked as a consultant for 3M Health Information Systems, KPMG and, most recently, Precyse Solutions. On the provider side, Kim has worked as a clinical documentation improvement manager and an HIM Coding Educator for Erlanger Health Systems, Cleveland Community Hospital and Bradley Memorial Hospital.
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