By Shelley McDermott, PMP and Wendy Coplan-Gould, RHIA
ICD-10-CM/PCS (ICD-10) impacts every aspect of a healthcare provider’s organization. It is a universally recognized enterprise-wide initiative with multiple stakeholders, but is still competing with other high profile projects for IT resources and budget dollars. Virtually every hospital department is involved with achieving meaningful use of EHRs, complying with HITECH-HIPAA omnibus rules, and moving toward the pay-for-performance model under healthcare reform. With so many demands on human and financial resources, some providers see ICD-10 as an unavoidable exercise in regulatory compliance. Others, however, like the University of Washington (UW) Medicine Health System, have wisely positioned the move to ICD-10 as part of their overall strategic plan.
UW Medicine’s journey to ICD-10 readiness held a particular focus on the importance of comprehensive coding and documentation assessment and can serve as a case study on how to implement ICD-10 as the industry moves into final preparations.
Unique Strategy Brings Coding to the Forefront
UW Medicine is a four-hospital system with two academic medical centers and two community hospitals serving the greater Seattle, WA area. The health system also includes a network of nine neighborhood clinics, a physician practice plan, the UW School of Medicine, and Airlift Northwest-an air ambulance service. With over 645,000 combined admissions annually, 1.6 million outpatient and emergency room visits, and 25,000 employees, UW Medicine faced an extensive conversion to ICD-10. But rather than wait, the health organization focused on being an early adopter of ICD-10. Instead of treating the ICD-10 conversion as a compliance project, the move to ICD-10 was leveraged to support UW Medicine’s overall strategic goals and objectives.
The organization’s request for proposal to conduct an ICD-10 impact assessment was released in September 2011 and included teams that are often employed for a project of this scope: IT, revenue cycle, and finance. But UW Medicine took assessment one step further. They conducted an in-depth assessment of both clinical coding staff and clinical documentation as part of the initial evaluation phase. This was a unique request in the early days of ICD-10 readiness assessments.
Quick ICD-10 Implementation Tips
UW Medicine suggests following these tips for a smoother ICD-10-CM/PCS implementation:
- Focus physician, coder, and clinical documentation specialist training in order to reduce overall time requirements.
- Early identification of opportunities can allow for early remediation.
- Existing workflow, operational, and documentation challenges may be uncovered and addressed before they become a bigger issue in the world of ICD-10.
Two Vendors Tackle Impact Assessment
Two firms, OTB Solutions-based in Seattle, WA-and HRS-based in Baltimore, MD-joined forces to reply to UW Medicine’s request for proposal. The firms had met several months prior at the AHIMA ICD-10 Summit. Due to the large scope of the project, the firms decided the only way to met all of UW Medicine’s stated needs was to combine efforts. Their fully integrated proposal for IT, coding, clinical documentation, and awareness was selected and UW Medicine’s ICD-10 impact assessment began.
Within the first 60 days of engagement, OTB and HRS conducted 32 introductory workshops and over 170 director-level stakeholder interviews to raise awareness and garner support for the ICD-10 implementation project. The workshop objectives were to capture information about where and how diagnosis and procedure information was being used. Also, the workshops gave an overview of ICD-10 that helped socialize the program throughout the organization. Workshops included an overview of ICD-10, an opportunity for staff to share concerns and ask questions, an opportunity to capture and document impacted workflows, and an exercise designed to continually improve the efficacy of the workshops.
Stakeholder interviews were focused on eliciting information on the impact of ICD-10 on UW Medicine. The interview process was different from the workshops in that the workshops were designed to capture information and find out where and how diagnosis and procedure information is used. The interviews, on the other hand, served to identify how ICD-10 would impact the enterprise at a strategic level. Information collected during the interviews was used to identify risks and potential mitigation strategies, ascertain strategic opportunities and determine the priority of ICD-10 among other organizational initiatives.
Finally, impact and risk assessments were performed simultaneously across five key areas-IT, coding and the clinical documentation improvement program, revenue cycle and finance, clinical operations, and physician readiness. Vendor and payer readiness were identified as the largest areas of risk.
Coding and CDI Assessment
Great benefits can be realized by including coding and clinical documentation in the initial assessment, according to Sarah Lucas, MHA, ICD-10 program director at UW Medicine. “Understanding the state of current documentation and coding is critical information to focus training efforts, and facilitate early remediation opportunities where available,” she says.
To understand the current knowledge base and skill set of the UW Medicine coding and CDI teams, 166 coders and clinical documentation specialists were assessed by HRS experts, including hospital and professional fee coders. A series of e-mail communications and webinars were conducted to inform coding staff of the assessment process and explain the logistics of taking and scoring ICD-10 tests.
Online exams were used to measure the skill sets and knowledge levels of existing coders in four areas-anatomy and physiology, medical terminology, path-physiology, and pharmacology.
Over 97 percent of the coders participated during a two week period with 99 percent completing all four tests. Based on exam results, baseline knowledge was defined and individual education plans (IEPs) were generated. The coders received eight AHIMA CEUs for completing all four assessments, which helped make the entire effort a win-win for staff and UW Medicine’s ICD-10 team.
Instead of training every coder in all aspects of biomedical education, UW Medicine was able to focus their coder training efforts. HIM directors were able to use individual assessments and IEPs to supplement staff in areas of weakness while also making the most of each coder’s strengths.
Other benefits were realized through this process. Specialized coding assignments could be utilized to maximize efficiency and mitigate productivity loss associated with ICD-10. Once staff is proficient in one clinical area, they can be cross-trained to provide broader support in other areas as well. For example, some record types that are easily coded in ICD-9-CM (i.e., obstetrics) will be more difficult to code in ICD-10 requiring more specialized coder skills.
Benefits of Individual IEPs
The benefits of creating an IEP for each coder are significant and should be carefully considered as part of an overall ICD-10 assessment project. Well-developed IEPs offer the following benefits:
- Identify and map unique strengths and weaknesses of each coder
- Limit remedial education time and costs only to areas of need/weakness for the coder, hospital, and system level
- Minimize loss of coder productivity since fewer training hours are required
- Maximize knowledge and skill sets of each coder in ICD-10
- The opportunity to deploy coders where they are most skilled and talented
- The opportunity to facilitate specialty coding assignments for maximum coder efficiency in ICD-10
- The opportunity to mitigate coder productivity loss in ICD-10
How Do the Coders Feel?
After the assessment was completed, UW Medicine embarked on parallel training paths. The general coder population began bio-medical education to address any issues identified during the assessments. Additionally, the organization worked with AHIMA to provide internal training to 25 high-performing coders who became AHIMA-approved ICD-10-CM/PCS trainers. By training coders in ICD-10 early, UW Medicine found a higher rate of staff satisfaction.
“Feedback from the coders that trained early and are now coding in ICD-10 has been very positive,” Lucas says. “Staff indicate they have enjoyed the opportunity to learn a new tool and to become early adopters of ICD-10. Their enthusiasm has also reduced general anxiety among their peers around learning the new ICD-10 code set.”
Although there has been industry concern that if trained early staff may leave to take more lucrative positions, this has not been observed at UW Medicine. On October 2014, when most everyone is trained on ICD-10, retention issues may arise. But early training has led to increased coder satisfaction and retention, Lucas says.
Other benefits of early ICD-10 training and dual coding identified by UW Medicine include:
- An ability to conduct DRG shift analysis early in collaboration with payers
- The opportunity to review specialty and sub-specialty documentation for improved analysis
- In-house, internal expertise allows for quick remediation of impacted areas or problems
Review Clinical Documentation
In addition to coding assessments, consultants conducted an analysis of UW Medicine’s existing clinical documentation. The consultants met with individual coders and clinical documentation staff to identify potential risk based on current operations, and sample charts were selected for review and coding in ICD-10.
Consultants looked at cases from each system hospital separately, creating individual reports for feedback and presentation. Gaps in clinical documentation between ICD-9-CM and ICD-10 were identified and risk stratified. This information helped identify strategies for focused and impactful physician training.
Secure Help with ICD-10
Many hospitals do not have the financial resources to pull in outside partners for their ICD-10 journey. For these organizations, the above lessons learned and peer advice is particularly important. However, for hospitals that can afford external support, selecting partners with significant ICD-10 experience is crucial.
Several questions to ask potential ICD-10 consultants or vendors include:
- How many ICD-10 assessments have you performed?
- Do you provide IEPs for each coder based on assessment findings?
- May we call your customer references?
- Do you have an existing spreadsheet of vendor readiness by software application and release level?
- Have you participated in any end-to-end testing initiatives with payers (i.e., HIMSS/WEDI ICD-10 National Pilot Program)?
- Can you provide a demo of Clinical Foundation Assessments to determine user friendliness?
Every small step taken toward a successful ICD-10 transition is valuable. HIM professionals should not wait until every IT system or payer is ready. Progress is made and insights are gained even with small, manual projects. Once needs are identified for every staffing level and IT inventory across the organization, modifications in technology, coding, and documentation can occur. ICD-10 readiness should be accomplished in small increments, with all changes complete across the entire organization by October 2014.
Consultants Share Key Lessons Learned from ICD-10 Implementation
Working with UW Medicine and other healthcare provider organizations on ICD-10 assessments and readiness, OTB and HRS have learned five key lessons:
ICD-10 concerns don’t stop at coding and clinical documentation. HRS and OTB note two key problems observed in IT and revenue areas:
- ICD-10 initially cuts coder productivity by 50 percent. Practice over time gains back 10 percent and the use of computer-assisted coding may boost productivity an additional 20 percent. Ultimately, more coders will be needed once ICD-10 is required.
- All hospitals are looking for coding talent. Secure outsourced coding partners early while resources are still available.
- Coders trained on ICD-10 and given the opportunity to code real, live cases every day become energized, and employer loyalty is strengthened.
- Undertake coder assessments to determine exactly what training is required. There are many training options to consider and published guidelines are inadequate in the real-world.
- Once unique strengths and weaknesses of each coder are identified, specialty coding assignments can be aligned accordingly. Specialty coding is recommended during the initial six months of ICD-10 go-live to ensure coding and revenue accuracy.
- Vendor readiness for IT systems is extremely difficult to nail down. Push vendors for demonstrations of their ICD-10-compliant versions and system capabilities. Ask the hard questions and demand deadlines.
- Revenue cycles need an immediate tune-up. Hospitals are not preparing for ICD-10 with an eye on accounts receivables. HIM professionals are encouraged to work hand-in-hand with revenue cycle teams to clean-up accounts receivable now, reduce discharged not final billed prior to ICD-10, and set aside cash reserves for slower claims payment, reduced productivity, and increased denials. Some payers are ready, but many are not.
Test Now: No Time to Wait
If there is one resounding lesson learned by UW Medicine and other early adopters of ICD-10, it is that the waters must be tested now. There is no time to wait and see what peers are going to do. Organizations that take steps towards awareness, assessments, training, documentation modifications, and end-to-end payer testing will be well-prepared and way-ahead in 2014. Even if end-to-end testing with trading partners relies on manual dual coding and paper-based claims, it should begin now.
Knowing what and where DRG shifts and potential losses lie in ICD-10 is the key to a smooth transition and maintained cash flow. UW Medicine determined that ICD-10 success will not be measured as much by the volume of denials, but rather in how quickly staff can remediate them.
Shelley McDermott (firstname.lastname@example.org) is ICD-10 practice lead with OTB Solutions, and Wendy Coplan-Gould (email@example.com) is president at HRS.
McDermott, Shelley; Coplan-Gould, Wendy.
"Path to ICD-10-CM/PCS Preparedness—Case Study: A Consultant-Guided Journey to ICD-10"
Journal of AHIMA