"Here at [redacted] we've decided to wait until next year to do anything more about ICD-10," my friend and former colleague wrote in an email the other day. "The thinking is, why should we keep training people now? They'll forget what they learned, and we'll have to do it again anyway."
My friend's simple equation — ICD-10 implementation means "training" — betrays a common misunderstanding. Of course, ICD-10 implementation does involve training. But the most important success factors are changes in the organization's attitudes, beliefs and behaviors. Training is not what is needed to ensure that everyone works together to capture the clinical documentation needed to "code out" in ICD-10. Coders who aren't keen thinkers are going to be leaving their employers' money on the table after Oct. 1, 2015, regardless of how much coder training they have. Training isn't the answer to ensuring that the revenue cycle as a whole is strong enough to flourish after the shock of a revolutionary change with no transition period. Clinical documentation improvement training won't take hold if physicians don't see the need for it.
If we look at ICD-10 implementation as a change management initiative rather than a training exercise, we see that the delay in implementation might actually be more helpful than harmful. Old habits die hard, and culture change takes time. Here are some aspects of organizational culture and capabilities that may need to change because of ICD-10, and some ways to make the changes, taking advantage of the extra time Congress gave us.
- A collaborative culture. ICD-10 will test your organization's ability to work closely and cooperatively across departmental lines. For example, internal clinical information flows need to be re-engineered with the participation and cooperation of everyone from triage nurses and admitting staff to coders and billers. The goals are to capture ICD-10-level specificity wherever it can be most efficiently collected and to make the more detailed data available wherever needed to optimize care and reimbursement. Further, the IT department must support the documentation agenda and carry it into its interactions with vendors. And revenue cycle managers must support the agenda and carry it forward in working with payers and clearinghouses.
Does your organization have collaboration embedded in its cultural DNA, or are you working with silos? If the latter, leadership needs to (a) start calling out and praising team-oriented behavior in staff meetings, with awards, etc.; (b) start privately reprimanding the "me-firsters"; (c) financially reward the team players to the extent policies and resources permit; and (d) ensure they have an empowered and accountable body in place to deal with crosscutting issues including, but not limited to, ICD-10. This body can be your ICD-10 steering committee, if it has been active and effective. - Coder capability. Seventy-three percent of ICD-9 codes have no 1:1 analog in ICD-10; in most cases, it's a one-to-many situation that requires the coder to apply keen inductive and deductive reasoning to arrive at the correct code. My experience is that being a superb ICD-9 coder doesn't guarantee that one will be an excellent ICD-10 coder, but being a poor ICD-9 coder does guarantee that one will be a poor ICD-10 coder.
So, starting now, you may want to be sure that your coder quality assurance program focuses not only on whether codes are correct based on the documentation in the chart but also on whether the coding is optimal — that is, whether the coder has ensured the medical record includes the specifics needed to maximize reimbursement and capture the disease burden of your population correctly (querying the physician as necessary). One or more ICD-9 coders who rise to the top under this evaluation should be trained and tested in ICD-10 and used for dual coding and systems testing.
- Robust processes. Unless Congress intervenes to delay implementation again, no claims submitted in ICD-9 after Sept. 30, 2015 will be paid, and no "live"" claims in ICD-10 will be accepted before Oct. 1, 2015. That means everything has to work perfectly at go live — and we know how likely that is, no matter how much testing we might do beforehand. Coding experts are predicting as much as a 50 percent short-term drop in inpatient coder productivity, and CMS and others advise the industry to have six months' cash on hand to deal with slowdowns, backlogs and denials.
But thanks to Congress, we have time to minimize the impact. You can make sure your coding and billing and receivables processes are as automated and as stress-resistant as possible. You can evaluate the return on investment of computer-assisted coding and computer-assisted documentation software. As noted above, you can start dual coding with ICD-10-trained coders (your best). You can keep pace with your IT vendor's ICD-10 schedule by testing each new release internally as soon as it is released. The sooner you start tuning up your processes, the more time you will have to get everybody used to the changes, and the less traumatic going live will be. - Physician buy-in. Before the delay, some hospitals and health systems were gaining community physician cooperation by offering free documentation training and help with encounter forms, using the Oct. 1, 2014 date as leverage. Without that leverage, this kind of physician training and practice assistance may be a much tougher sell — at least until about this time next year. However, that doesn't mean that you should do nothing now to encourage better clinical documentation. It may make sense to use the delay to integrate CDI into your overall initiatives to align with physicians around population management. The virtues of having much more detailed and accurate information about how patients presented and were treated should be evident to employed physicians, physician partners in accountable care organizations and practices participating with you in risk- and gain-sharing programs.
To sum up, anybody who has tried to change organizational culture knows that it takes planning, resources and time. Thanks to Congress, we have considerably more time for changing attitudes, beliefs and behaviors than we thought. Whether we do the planning and invest the resources will determine whether we've used the time wisely. Good luck!
Philip Nathanson has been a senior manager at CMS, two hospital systems, Aetna, and the National Committee for Quality Assurance. His consulting clients have included hospitals, integrated delivery systems, insurers, health information management firms, pharmaceutical and biotechnology firms, and physician group practices.
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