Health Information Management

ICD-10 two-year game plan

JustCoding News: Inpatient, August 29, 2012

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Retain. Train. Assess. Investigate. Analyze.

HIM professionals have undoubtedly come across action verbs like these since HHS announced January 15, 2009, the final regulation to replace the ICD-9-CM code set with the more advanced ­ICD-10-CM code set currently used in other nations.
HHS called for an October 1, 2013, compliance date. Recently it finalized a one year delay of ICD-10-CM/PCS until October 1, 2014.
Why the holdup? HHS wanted to address concerns among provider groups about meeting the compliance date and to give them more time to "prepare and fully test their systems to ensure a smooth and ­coordinated transition to these new code sets," according to its April 9 press release.
Does your HIM department have reason to be ­concerned about meeting the compliance date? If you have not completed an ­ICD-10 impact assessment by now, it might, says Mark Jahn, vice president of healthcare practice at Atrilogy Solutions Group in Irvine, Calif.
"You should have finished your impact assessment by now," says Jahn, who started the Minnesota ICD-10 Collaborative, a collection of health plans and healthcare providers focused on producing best practices for ICD-10 preparation, in October 2010. "However, we still see quite a few organizations that have not done that."
This assessment is essential for HIM managers and directors to ­conduct, he says. With the proposed ICD-10 compliance date just over two years away, now is the time to check for any missing items in training, clinical documentation, staff retention and resources, and technology. 
If you haven't already done so, conduct a detailed analysis of your coding work flow, says Luisa ­Dileso, RHIA, MS, CCS, manager of coding education services at MRA Health Information Services in Quincy, Mass. Dileso suggests including the coders in this process ­because they "are closest to the work."
Through your analysis, gather a list of functions ­coders perform each day. Document every step, then highlight those that slow down productivity. "While your coders may still complete a few of these tasks, going forward you may find some that can be ­assigned to a data analyst, another department, or ­clerical staff," ­says Dileso.
For example, certain data regarding restraints, anesthesia, consultants, etc., could be collected at the point of service.
Analyze your business impact
If you think you're behind, take an inventory of all your business processes, Jahn says. Identify which business processes will be affected by ICD-10 and to what degree. "There's certainly an opportunity to clean up your business practices and eliminate unnecessary steps," he says.
For example, ask yourself the following questions:
  • Does your HIM staff have all the right resources to ­complete their tasks?
  • Are there steps that can you can eliminate?
  • Do you have the right people executing processes?
  • Is your staff appropriately using technology to ensure their processes are as efficient as possible?
"It's amazing to me how many HIM departments out there determine their processes on Excel® spreadsheets," Jahn says. "You want your HIM department to be ­operating as efficiently and effectively as ­possible. They've evolved over the years, and [department l­eaders] haven't had the time to effectively manage their processes."
Squeeze out waste and inefficiency now in order to make things less difficult once ICD-10 comes, he adds.
Test your technology
Inventory and evaluate all your hospital's software for ICD-10 compatibility and, upon its updating, ­complete your final tests no less than 90 days from the compliance date, says James S. Kennedy, MD, CCS, CDIP, ­managing director of FTI Healthcare in Brentwood, Tenn.
"All software should be tested and in place at least three months prior to whatever implementation date we have in place," Kennedy says. "The issue is you don't want to fall into a [HIPAA] 5010 trap where not all the carriers from 5010 were able to carry all the codes. All the testing should be started, at the very latest, six months out and finished three months away from the compliance date. Develop test files and run things through these test files."
HIM directors must be engaged in discussions with both IT professionals and decision support staff. "Not everything goes to IT," Kennedy says.
Take inventory of your software and start planning ­upgrades to handle ICD-10 codes, he suggests. "With the expansion of codes, you've got to make certain all of the software you've got can handle up to 8-digit codes (7-digit codes plus one for POA [present on admission] status with diagnosis codes)," Kennedy says. "Right now the maximum length of a [ICD-9-CM] diagnosis code is five digits, and the maximum length of a procedure code is four."
Take inventory of every piece of software in every department that interfaces with codes, Kennedy says, "and look at what it's going to take to upgrade or change software in order to handle [ICD-10] codes."
A scanned or electronic record that is thoughtfully indexed and mapped better supports the coder as well as the clinician, improving the productivity of each, Dileso says.
"And often there are system features [that were] not initially implemented that can help your cause. So take another in-depth look at your systems," she says. "Identify features you may not be using and work with IT to make them operational."
Kick training into gear in 2013
When training your staff for ICD-10, think outside the typical classroom setting, Jahn says.
"There are many different ways and many different ICD-10 education solutions out there, and a lot of them are technology-based," he says. "No longer are we classroom-based."
Start with anatomy and physiology and never pass up an opportunity to reward your staff.
"One HIM department I worked with during Christmas time gave all their coders a present-an ICD-10 coding book," Jahn says. "Coders are not used to getting anything, and they were so thankful. They went into the HIM director's office to tell her it was the greatest thing they received for Christmas."
Understand that coders' learning styles differ, and make sure the education and training you provide adequately meets the needs of your staff, Jahn adds.
He suggests getting some of your staff certified, ­depending on your budget and staff size.
Determine HIM's place in documentation improvement
HIM directors must have a say in a facility's ­clinical documentation assessment, and that should be completed this year. A HIM director's involvement in this ­arena typically includes pulling random charts and assessing them along with certain subset of charts.
"Come back with an assessment of where you are today and where you need to be," Jahn says. "Know where you need to be supported in ICD-10 from a CDI [clinical documentation improvement] perspective and put in a program to get physicians to document at an ­appropriate level."
A physician liaison between HIM and clinical staff may be your best option, Jahn says, adding that the liason can "represent the voice of HIM" and should be able to interact effectively with the two groups.
Be certain the CDI process establishes a strong ­partnership between the coder and the provider, Kennedy says. If you don't have a strong CDI process, consider ­developing one. ( for information on HCPro, Inc.'s CDI association.)
"If clinically relevant documentation is being missed today, it will be more glaring with ICD-10," Kennedy says.
Keep coders engaged, on board
Reports that say ICD-10 will require 25%-40% more HIM department coders can be scary. That's why you must keep coders happy-and not terrified of the ICD-10 transition, Jahn says.
And if you are hiring extra coders, "Where are you going to put them?" Jahn asks. "Will you allow them to work from home? How do you make that happen? The sooner you start thinking about this, the better."
Keep your coders happy with pats on the back when you can, and be in constant communication.
"Bring them into important meetings and let them know they're valued," Jahn says. "All those soft ­touches go a long way. Let them work from home if that's a ­viable option, and give them an opportunity to be trained."
Take inventory in these ICD-10 target areas
As the ICD-10 transition approaches, there are ­plenty of areas on which to focus to help you and your HIM staff effectively prepare. The following are some target areas and tips:
  • Use ICD-9-CM to help ICD-10 efforts. "The best way to perform well in ICD-10 is to first do ICD-9-CM ­correctly and then negotiate the differences," says Kennedy. ICD-10 allows for increased specificity. If your current ICD-9 records contain ­coding and documentation errors , your problems will not automatically be fixed in ICD-10. Having a physician liason or advisor in place may be your first step to getting your current coding and documentation practices right. "If one does not have a concurrent review process and/or physician advisor to coding, they should consider ­developing one," Kennedy says.
  • Analyze severity and risk-adjustment factors. As ­facilities implement EMRs, they should look closely at what ICD-10 documentation elements essential to ­severity and risk adjustment should be programmed for physician consideration, Kennedy says. When planning your EMR deployment, don't ignore the coding or CDI departments, says Kennedy. Instead, why not go ahead and ask for documentation elements essential to ICD-10? This is especially true if the documentation ­affects an MS-DRG, which goes back to getting your CDI program in place. "Let the EMR be a tool," Kennedy says.
  • Consider computer-assisted coding (CAC), if it's right for your budget. Facilities should be investigating whether the cost of CAC will lessen the approximate 25% loss of coding productivity expected with ICD-10. Productivity loss estimates vary, however. "Nobody ­really knows for sure how much productivity will be lost in ­ICD-10," Kennedy says. "However, computer-assisted ­coding is promoting itself as a way for mitigating that loss, especially as more hospitals develop EMRs. It is a technology that HIM departments at least need to look at."
While looking at these systems, be sure to budget for tight EHR and encoder integration, says Deliso.
"There are often inefficient interfaces between clinical and financial systems that may impede coder productivity," Dileso says.
Ideally, HIM needs to ensure that the end users (coders) have up-front input in EHR clinical/financial interfaces and systems design, Dileso says. Their interfaces for accessing clinical documentation needed for code ­assignment should flow naturally to abstracting/billing screens.
HIM also needs to document and quantify system-based barriers to productivity. "A perfect example is when coders have to access ­multiple electronic clinical modules/locations to review and piece together the clinical picture and information required for inpatient code assignment," Dileso says. "In other words, the electronic information is not integrated or streamlined in any way that promotes productivity."
  • Keep abreast of medical necessity ­requirements. Facilities should stay up to date on how insurance companies plan to transition outpatient medical necessity requirements to the ICD-10 environment. Right now, certain ICD-9-CM diagnosis codes allow a claim to be paid. But will other payers besides CMS be publishing new lists of ICD-10 codes supporting medical necessity? The answer isn't yet clear. HIM directors must encourage their outpatient revenue cycle department to learn which codes in ICD-10 meet these medical necessity requirements. It may be a question of entering into contracts, with language such as the following suggested by Kennedy: "We need to know in ICD-10 which documentation we need to support a claim."
Finally, while you budget and prepare for the transition to ICD-10, you must also prepare for the unknown, says Jahn. "A lot of people don't plan for contingency," Jahn says. "For ICD-10, I recommend at least a 25% contingency budget and time. If people aren't giving that, they're making a huge mistake. You're not planning appropriately. You need to take that into consideration because there are going to be many unknowns."
Editor’s note: This article originally appeared in the September issue of Briefings on Coding Compliance Strategies. Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at

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