For hospitals and health systems, adopting ICD-10 is a lot like painting a house. Before painting can begin, there must be some type of analysis to know how the costs of painting will impact a family's budget. Next, all of the essential supplies and tools are needed. Then, a family can finally begin the long, steady painting process.
However, all of that doesn't mean a whole lot if no one knows how to paint properly.
Coders and other frontline staff — one group of painters — play a vital role in a hospital's ICD-10 transition, but many within the industry say the most important stakeholders are one level deeper: physicians.
Hospital CFOs will be quick to realize this, as poor documentation in ICD-10 will equal a major hit to the bottom line — be it undercoding, rises in accounts receivable days or other adverse financial consequences.
"The reality is ICD-10 will require physicians to document things they've never had to document before," Mr. Hock says. "If they don't start documenting these new concepts, three things will happen: A claim will be coded lower than it should have and will be reimbursed less than it should have; the claim can be submitted and billed but eventually will be denied; or you don't end up billing it and query the physicians, which is fine, but it slows down the process significantly."
Mr. Hock says ultimately, a hospital can have coders, health information management professionals and information systems personnel at the top of their games, but a failed ICD-10 initiative can still occur if physicians are not more specific with their diagnoses and treatments.
"The CFO is dependent on this documentation for every metric in their revenue cycle," Mr. Hock says. "This is despite having a diligent HIM director, a CIO that upgraded the systems, trained coders and the other initial pieces of ICD-10 that most people have already tackled."
1. Identify codes and procedures that have low and high risks. Before people can solve a problem, they have to know where to start. For hospitals, this involves knowing which codes need better documentation. While this sounds straightforward, it's not.
"When most groups start tackling this, they'd likely look at high-volume and high-revenue codes and procedures within the organization," Mr. Hock says. "The challenge is that high-volume and high-revenue codes aren't necessarily the riskiest ones when it comes to ICD-10."
For example, hospitals and physicians may reasonably look at codes for congestive heart failure, which is a high-volume, high-revenue diagnosis for most organizations. However, Mr. Hock says the number of codes affecting CHF will not really differ from ICD-9 to ICD-10, meaning documentation will not have to change drastically to keep claims clean.
Instead, he says there are many other procedures and diagnoses lurking that have more significant implications. For instance, malignant neoplasms are well out of the top 10 for hospitals in terms of coding frequency, but the number of MN codes will more than double from ICD-9 to ICD-10. "There are tons of new documentation concepts with this," Mr. Hock says. "And if physicians don't get those concepts right, there will be significantly lower reimbursements or significant amounts of denials."
2. Break down coding changes into clinical concepts. Once hospitals know the high-risk areas that need more specific physician documentation, they can help physicians understand the magnitude of the change — in physicians' terms.
Mr. Hock gives the example of ICD-10 codes for orthopedics. It's one of the most dramatic examples of increased codes, as orthopedic codes will swell from 33 in ICD-9 to roughly 1,800 in ICD-10. That certainly seems daunting, but Mr. Hock says that major increase stems from specificity. ICD-10 codes involve more description. A physician dealing with a patient that has a fractured radial bone doesn't need to write a novel — they just have to describe four specific areas of the diagnosis and treatment.
"There are only four new clinical concepts that drive that entire change: laterality, joint involvement, encounter and healing," Mr. Hock says. "It's a totally different conversation to have with a physician if they just pay attention to those four clinical concepts. And most physicians would recognize that as important, or at least medically thoughtful."
Hospital executives who help physicians understand the ICD-10 transition more will be able to improve the ICD-10 implementation as well as the hospital-physician alignment strategy. "It feels like you're staring at a brick wall, and you ask yourself where's the most important place to start?" Mr. Hock says. "Make it simple for the physician, and it at least becomes manageable."
However, all of that doesn't mean a whole lot if no one knows how to paint properly.
Coders and other frontline staff — one group of painters — play a vital role in a hospital's ICD-10 transition, but many within the industry say the most important stakeholders are one level deeper: physicians.
Why physicians are ICD-10 cornerstones
Ed Hock, a senior director at The Advisory Board Company, says physicians are the foundational pieces of a successful ICD-10 implementation because ICD-10 is a documentation issue as much as it is a coding issue. Documentation falls on the laps of physicians, who must learn to be more specific in their diagnoses so coders can appropriately choose the right code among the 140,000 within ICD-10.Hospital CFOs will be quick to realize this, as poor documentation in ICD-10 will equal a major hit to the bottom line — be it undercoding, rises in accounts receivable days or other adverse financial consequences.
"The reality is ICD-10 will require physicians to document things they've never had to document before," Mr. Hock says. "If they don't start documenting these new concepts, three things will happen: A claim will be coded lower than it should have and will be reimbursed less than it should have; the claim can be submitted and billed but eventually will be denied; or you don't end up billing it and query the physicians, which is fine, but it slows down the process significantly."
Mr. Hock says ultimately, a hospital can have coders, health information management professionals and information systems personnel at the top of their games, but a failed ICD-10 initiative can still occur if physicians are not more specific with their diagnoses and treatments.
"The CFO is dependent on this documentation for every metric in their revenue cycle," Mr. Hock says. "This is despite having a diligent HIM director, a CIO that upgraded the systems, trained coders and the other initial pieces of ICD-10 that most people have already tackled."
How to improve physician documentation
Mr. Hock says there are two important things hospitals can do to help physicians improve their documentation.1. Identify codes and procedures that have low and high risks. Before people can solve a problem, they have to know where to start. For hospitals, this involves knowing which codes need better documentation. While this sounds straightforward, it's not.
"When most groups start tackling this, they'd likely look at high-volume and high-revenue codes and procedures within the organization," Mr. Hock says. "The challenge is that high-volume and high-revenue codes aren't necessarily the riskiest ones when it comes to ICD-10."
For example, hospitals and physicians may reasonably look at codes for congestive heart failure, which is a high-volume, high-revenue diagnosis for most organizations. However, Mr. Hock says the number of codes affecting CHF will not really differ from ICD-9 to ICD-10, meaning documentation will not have to change drastically to keep claims clean.
Instead, he says there are many other procedures and diagnoses lurking that have more significant implications. For instance, malignant neoplasms are well out of the top 10 for hospitals in terms of coding frequency, but the number of MN codes will more than double from ICD-9 to ICD-10. "There are tons of new documentation concepts with this," Mr. Hock says. "And if physicians don't get those concepts right, there will be significantly lower reimbursements or significant amounts of denials."
2. Break down coding changes into clinical concepts. Once hospitals know the high-risk areas that need more specific physician documentation, they can help physicians understand the magnitude of the change — in physicians' terms.
Mr. Hock gives the example of ICD-10 codes for orthopedics. It's one of the most dramatic examples of increased codes, as orthopedic codes will swell from 33 in ICD-9 to roughly 1,800 in ICD-10. That certainly seems daunting, but Mr. Hock says that major increase stems from specificity. ICD-10 codes involve more description. A physician dealing with a patient that has a fractured radial bone doesn't need to write a novel — they just have to describe four specific areas of the diagnosis and treatment.
"There are only four new clinical concepts that drive that entire change: laterality, joint involvement, encounter and healing," Mr. Hock says. "It's a totally different conversation to have with a physician if they just pay attention to those four clinical concepts. And most physicians would recognize that as important, or at least medically thoughtful."
Hospital executives who help physicians understand the ICD-10 transition more will be able to improve the ICD-10 implementation as well as the hospital-physician alignment strategy. "It feels like you're staring at a brick wall, and you ask yourself where's the most important place to start?" Mr. Hock says. "Make it simple for the physician, and it at least becomes manageable."
More Articles on ICD-10:
On the Coding Radar: 3 Reasons Why Hospital CEOs Must Pay Attention to ICD-10
ICD-10 or ICD-11? The Dilemma Behind Both Coding Systems