By Chris Dimick
Since it was planted 30 years ago, the ICD-9 code set has grown roots deep into the healthcare system. Within individual organizations and enterprises, those roots can reach into nearly every department and function.
Upgrading to ICD-10 thus requires organizations deconstruct their business and clinical processes in order to identify the uses of coded data and transition each of these areas to the new code set. For this reason, the ICD-10 upgrade offers a unique opportunity to assess operations and seek improvements that can lead to improved care and more efficient workflows.
But that opportunity can only come when a healthcare organization is not rushing through the transition. Organizations that plan to reap additional benefits beyond a new code set should be well into their transitions this year.
Following are reports from three health systems that are. Each took on ICD-10 early and has made steady progress in their transition plans. Team members describe their progress and their objectives, stories they first shared in presentations at the AHIMA 2011 ICD-10 Summit in April 2011.
St. Mary’s Health System
Staff at St. Mary’s Health System wanted to get a jump on ICD-10 planning, so they called in help to get their program jumpstarted.
The health system, located in Lewiston, ME, includes a 233-bed acute care facility, a 210-bed long-term care and rehab facility, and a provider network of 115 physicians. The ICD-10 team partnered with a consulting firm, becoming a test site for a company looking to fine tune its ICD-10 services.
The consultants helped St. Mary’s get focused and under way by conducting an ICD-10 impact analysis and risk assessment that now serves as a guide for the transition, says Betsey Shew, JD, CPHQ, the director of performance improvement at St. Mary’s.
Tracking the status of the many departments affected by ICD-10 is a major challenge for all facilities. St. Mary’s is managing the task through the use of a readiness tracking tool created by its consultants. The tool uses periodic surveys to measure each department’s progress toward ICD-10 implementation.
Each department’s progress is tracked along a larger graph, which shows the milestones they need to reach in order to fully implement ICD-10 by the October 1, 2013, deadline. The tool also shows departments where they will be in the near future if they continue their current implementation pace.
The tool has been very valuable to St. Mary’s ICD-10 planning team, Shew says. They can see what areas of the system are on track with implementation and what areas should have additional resources applied to get on track. The surveys also keep ICD-10 in the forefront of people’s minds, a much-needed reminder in a time of many competing projects.
Such focused project organization helped bring a once seemingly overwhelming and panic-worthy implementation into focus, Shew says.
Educating the Organization on ICD-10
As in many organizations, not all departments at St. Mary’s saw their connection to the ICD-10 project. Much of St. Mary’s initial work involved educating departments on how the transition will affect them.
“When we first started going through the whole risk assessment, people said, ‘Well, we don’t code charts— this has nothing to do with us,’” Shew says. “Throughout the assessment process we had to do a lot of education.
“One of the lessons that we learned, if we were to do this all over again, is to start by doing some general coding training at a very high level for the organization,” she says.
St. Mary’s ICD-10 education to date has focused on the life of a patient record, from documentation of care all the way to receipt of payment for service. Clinicians and nursing units were a key audience.
“They just weren’t drawing the connection between the fact that this record is coded, and it is the information they were using to drive their operations,” Shew says.
Improving Documentation and Coding
St. Mary’s implementation plan has allowed the ICD-10 implementation team to look for ways to improve the organization’s overall operations through the transition.
“We are looking at where we are going to get the most bang for our buck,” Shew says. “We are at that phase now looking at how we can leverage all this, [asking] how can we tie all these things together.”
For example, St. Mary’s is connecting the dots in documentation improvement related to both ICD-10 and the health system’s transition to an electronic health record and computerized physician order entry. As a way to improve core measure compliance and its supporting documentation, staff members have discussed the use of pick lists in documentation. This feature could also aid the ICD-10 effort by improving documentation quality in certain instances.
Coding education is another aspect of operations under review. As it draws up its plan for coder ICD-10 education, St. Mary’s is considering requiring its coders to become certified or at least obtain comparative training as part of the ICD-10 transition. This strategic initiative to improve coder education will make transitioning to ICD-10 smoother, and it will likely improve coders’ ability to capture the organization’s quality of care and improve reimbursement, Shew says.
Shew feels confident her organization is on track to a successful implementation. It is on pace to complete the phase-1 steps described in AHIMA’s “ICD-10 Preparation and Planning Checklist” by the recommended deadline of July 2011.
St. Mary’s in-house tracking tool also predicts that at the current pace it will accomplish the complete ICD-10 implementation by the October 1, 2013, deadline.
“We are starting to really develop a road map to tell us where we need to focus our energy, how we need to prioritize, and what structure is going to work for us to be successful,” Shew says.
Christiana Care Health System
If it wasn’t documented, it wasn’t done. This HIM truth has been a rallying call at Christiana Care Health System, emphasizing how important complete clinical documentation is to accurate health records and ultimately medical billing—both of which will change significantly with the transition to ICD-10.
Christiana Care has a goal to achieve positive transformation of clinical operations and clinical documentation through its ICD-10 transition.
Comprised of two hospitals and 47 primary care and specialty offices in New Castle County, DE, Christiana Care recognized early the opportunity the ICD-10 transition presents to improve its clinical operations, says Kathy Westhafer, RHIA, CHPS, Christiana’s program manager in clinical information, and Peggy Lynahan, ICD-10 program manager at Christiana.
Christiana launched its ICD-10 program in 2009—the year the deadline was announced—even though some felt it was too soon to begin. Westhafer and Lynahan, however, were among those with a clearer view of the work involved.
“We’ve had a pretty good sense that this wasn’t just a matter of swapping out coding systems—that this was really going to, in the long run, impact our MS-DRGs, impact how we are going to be reimbursed…, and impact our outcomes in terms of our score cards and how we look to the rest of the country,” Westhafer says.
Bringing Clinicians on Board
The ICD-10 planning team knew physician participation would be essential if Christiana wanted to improve clinical documentation and operations through the transition. After learning of the significance of the ICD-10 implementation, Christiana’s senior vice president of quality and patient safety became the chair of the organization’s ICD-10 steering committee.
Having a clinical representative in the lead role—a role often filled by a CFO or CIO—has given the project good exposure to clinicians and ensured the ICD-10 transition is centered on more than just reimbursement, Westhafer says.
In fact, 13 of the 19 members of the ICD-10 steering committee are clinicians, and they have become valuable resources in determining how to implement the code set. The clinicians advise on how to engage the clinical staff and offer insights on how the implementation will affect clinical practices.
“We have them right there in the room being able to tell us, ‘No, that won’t work’ or ‘Yeah, that is a great way to do it, and here is some guidance on how to go after it,’” Lynahan says.
Physicians respond best to the ICD-10 transition if the spin is not on the codes themselves but on the code set’s ability to provide better care through better documentation, Lynahan says.
Integrating with Incentive Programs
The ICD-10 transition is not an isolated event at Christiana. The implementation team has worked to integrate it into other current initiatives, seeking to group and leverage work where possible.
“We are seeing integration as key to how we are taking this forward,” Lynahan says. “We are looking at the way we are integrating with meaningful use and value-based purchasing and other healthcare reform elements to ensure that the end result we come up with—whether it is clinical documentation or coding services—is something that is meeting the needs for the patient and meeting the needs of all those initiatives.”
Advanced clinical documentation is one example of a requirement that crosses multiple initiatives at Christiana. More detailed documentation is necessary to support the greater specificity of the ICD-10 code set. It is also needed to meet quality measures required in the meaningful use EHR incentive program.
The ICD-10 implementation team has kept these meaningful use requirements in mind when developing its physician documentation education initiatives for ICD-10, as well as when developing meaningful use initiatives.
Other connections to the meaningful use program include the creation of coded problem lists in the EHR and the distribution of electronic discharge summaries. In both instances, the ICD-10 and meaningful use teams are in communication to ensure their work dovetails.
A unifying theme throughout all the efforts is accurate and complete documentation at the outset necessary to code in ICD-10, create accurate quality measures, determine correct severity of illness, and fully leverage reimbursement claims, Lynahan says.
“I think in healthcare there has been a lot of fixing it on the back end, and that is a lot of what has to change,” she says.
While large health systems may have more resources to commit to the ICD-10 transition, they also have more areas needing resources.
Take for example Banner Health, one of the largest nonprofit healthcare companies in the US, which must manage the ICD-10 transition across 23 acute care facilities in seven states. But Banner views ICD-10 as an opportunity, not a burden.
With that mind set, Banner got started quickly. Its HIM department, IT department, and project management office launched the ICD-10 initiative in 2009, developing a comprehensive implementation plan that it could use organization-wide.
That early planning has put Banner on track to complete phase 1 of AHIMA’s preparation and planning checklist by the recommended deadline of July 2011, according to Jaime James, MHA, RHIA, Banner’s senior director of health information management services, and Linda Martin, MA, PMP, IT project management senior consultant at Banner Health, headquartered in Phoenix, AZ.
Assessing the Impact
One of Banner’s first steps was developing an ICD-10 impact assessment reaching across 14 business units that reviewed applications, interfaces, and report extracts for ICD codes or data derived from the codes. The assessment provided more than just a look at ICD-10 impact, it also gave the enterprise a new and more integrated perspective of its system-wide operations, Martin says.
That perspective helped Banner’s ICD-10 team identify opportunities to leverage the project for strategic advantage. Objectives include:
- Decreasing diagnosis-related billing denials
- Improving registration processes and protocols in the revenue cycle
- Implementing computer-assisted coding tools
- Gaining more appropriate reimbursement due to higher specificity of coded clinical data
- Leveraging ICD-10 for the meaningful use program
- Integrating ICD-10 with the accountable care organization program
- Standardizing processes across the enterprise to increase efficiency
Following its formation in 2000 from the merger of two health systems, Banner Health underwent a large standardization initiative that looked across its operations to find opportunities to reduce the number of disparate systems and processes in use. This standardization and simplification of operations has aided the ICD-10 transition, specifically preventing the need to upgrade a variety of different billing systems.
The ICD-10 impact assessment gave Banner another chance to look at how billing practices are handled system-wide, including practices in its growing number of clinic facilities. These conversations with outlying partners have allowed Banner to “continue our march to standardization,” Martin says.
The revenue cycle is also a point of focus for strategic ICD-10 initiatives. In addition to reviewing the changes needed in the revenue cycle due to ICD-10—from registration to payment—Banner is also reviewing each section of the revenue cycle to identify gaps and areas in need of improvement, Martin says.
Many healthcare providers are uncertain how the ICD-10 transition will affect the way they work with payers. Banner has a unique insight, since the system includes a payer. This has become an invaluable resource, because Banner’s ICD-10 team can test, in-house, the entire cycle of an ICD-10 code, from documentation, to code assignment, to submitting billing, to receiving reimbursement.
“It will help us understand what other payers are going through and thinking,” James says.
Revising, Renewing to Keep Moving
Though there have been several early successes, the ICD-10 transition has also come with several challenges. In the first years of the initiative the team has found it difficult to move forward at times due to lack of adequate recognition and attention for the project, resource constraints, project unknowns, communication issues, and issues with managing a large and diverse core implementation team.
Maintaining momentum on a project that spans years is a challenge for any organization. Banner’s ICD-10 team has attempted to keep people engaged by breaking down the transition into chunks and celebrating when each piece is accomplished.
“It is that constant renewal and planning,” Martin says. “And I think revisiting and doing lessons learned regularly—that helps people feel like they have a say in this huge thing.”
Some things are outside of Banner’s control. The team is waiting on various system application vendors to revamp their products for ICD-10, something several won’t have complete until 2012.
“We would have loved to have wrapped up our impact analysis in 2010, but the reality is that there are external factors outside of our control,” Martin says.
Dependence on external entities such as vendors and payers can make a project manager miss sleep. In those instances, the best an organization can do is focus on the risks and opportunities and stay connected to what is happening in the industry so any necessary response plan can be drawn up, Martin says.
Banner, Christiana, and St. Mary’s owe their progress to an early start and concise and collaborative organizational planning. A similar outlook has motivated each organization. The transition to ICD-10 is more than a regulatory requirement. It can be used to improve many aspects of healthcare.
“We are still using codes that don’t necessarily reflect the work that we do, and I think [ICD-10] is going to really be able to help us finally do that,” Shew says. “This is going to have a wide-reaching impact—everything from making operations decisions to making finance decisions to making quality decisions.”