By Mary Butler
Even the most well prepared health information management directors can anticipate a few restless nights between now and the October 1, 2014 ICD-10-CM/PCS (ICD-10) compliance date, but the best ones know this already and have factored fatigue into their to-do list.
Shiny George, MS, RHIA, CPHIMS, CCS, CCS-P, CMS, senior director of HIM at Thomas Jefferson University Hospitals, located in Philadelphia, PA, is overseeing the implementation of ICD-10 at her 1,000-bed hospital as well as the attestation process for the “meaningful use” EHR Incentive Program, and is even helping to implement a new electronic health record system.
“You can be tired, but you have to keep eating your Wheaties,” George says. “No implementation goes 100 percent smoothly. ICD-10 is not the only project we’re working on. There’s a lot of competing priorities, but this one will make or break our future,” she adds, underscoring the importance of meeting the Oct. 1, 2014 deadline.
With exactly one year to go, George and others have never ending checklists. For George and other HIM directors, items at the top of that list include getting documentation checks in place, starting or ramping up training programs for the whole enterprise, launching an ICD-10 communications plan for internal staff, testing claims submission with payers, and checking in regularly with vendors and external stakeholders.
The Documentation Piece
George says that from an HIM perspective, her top area of concern for her in the migration from ICD-9-CM to ICD-10 is the integrity of clinical documentation.
“If the clinical documentation is not sufficient for the coders to capture the ICD-10 code, all the efforts will be in vain,” George says.
Her hospital has completed numerous documentation impact analyses and just implemented a ICD-10 analytical tool system that will help identify the impact areas from a clinical documentation perspective.
George encourages HIM people to collect as much clinical documentation data as they can before they go talk to physicians. She recommends analyzing the charts of top admitting physicians and identifying areas that need improvement.
“You really need to speak their language. And what I mean by that is this, physicians are really interested in publically reported data, U.S. News and World Report rankings. If you don’t get the codes correct, you don’t get the quality of care data you want. You have to take it to that level,” George urges.
Kim Felix, CCS, a certified ICD-10 trainer who works for IOD, agrees that documentation specificity is crucial to a smooth transition. Her strategy for getting physicians on board is by catering to their specialty.
“You have to find something specialty specific or you’re going to lose them all,” Felix says. “If you can give them a couple overview courses, such as for a cardiologist, and then limit that time to an hour maximum. And don’t test them or quiz them. Do that during your documentation training.”
Felix says that by tailoring training and educational efforts to a physician’s specialty, they will appreciate the saved time. “Wasted time is something physicians hate more than anything,” Felix says.
Training and Education
Sarah Branish, RHIA, ICD-10 program director at Sisters of Charity Leavenworth Health System, based in Lakewood, CO, says that getting buy-in and engagement from all the stakeholders within her whole organization is the most difficult part of preparing for ICD-10.
“I think it’s because there’s so much conversation within healthcare markets, people are still saying ‘Oh, there will be another delay, or oh, the American Medical Association is going to stop this from happening.’ We’re still encountering people who feel like this isn’t going to happen,” Branish says. “And they think we’ll get another year or two years to work on this.”
She fears a rude awakening when—or if—a delay doesn’t come.
Branish and George both say the most resistance to ICD-10 comes from physicians. And both have plans for comprehensive internal communication campaigns.
George says education and training is a huge undertaking in her facility, and it is one of the major initiatives she’ll oversee as part of the ICD-10 transition. She said that every single department in her health system, except for foodservice and janitorial services, will need some form of training on ICD-10.
Felix says coding and compliance directors would need to sign their coders up with ICD-10 trainers as soon as possible to give them enough time to train adequately for the transition. And if they started training existing coders immediately, they would still need about two hours of training per week, every week, between now and October 2014, to be comfortable. She warns that the longer providers put off training, the more they risk cutting into coder productivity.
Training and education also includes reaching out to external stakeholders and third-party vendors. For George, this has been one of the hardest parts of the preparation process.
George says her HIM department has to “work with vendors to make sure they give us the data to make sure they will be ICD-10 ready. If the external stakeholders aren’t compliant, it will affect the hospital as well.”
This can be frustrating since hospitals have no oversight over their vendors. If there is any doubt that an important vendor may not be ICD-10 compliant by the deadline, she recommends “staying on their back.”
Coding Dry Runs
Lila Mayer, RHIA, director of coding and compliance, works with Branish at Sisters of Charity. She has the task of managing the workflow for all of the coders preparing for the ICD-10 transition. Branish and Mayer are taking part in a national testing program, and plan to do as much testing with payers as possible before the implementation date. But even much of that work comes down to prepping the coders, who, Mayer says, are already contending with a lot of changes right now.
They have had their hands full adjusting to a new EHR, computer-assisted coding, and auto suggested coding.
“However we can, we’re trying to do things in small portions,” Mayer says. “From their standpoint they don’t see it as small portions. These are major changes. All of this has moved their thought process and day-to-day workflow tremendously,” says Mayer, adding that change management will be a big part of her job this year.
Felix says the onus is on both payers and providers to start doing trial runs with ICD-10 codes prior to October 2014.
“If I were the HIM [director], I’d be calling Aetna or Blue Cross saying ‘Let’s do some practice.’ But as an insurer, you’d want to make sure you’re not losing all those practices, and all those hospitals,” Felix says. “It has to be mutual.”
After D-Day
While HIM departments should give themselves a well-deserved pat on the back come October 1, 2014, their work on ICD-10 will be far from over.
Branish says her key area of focus will be on monitoring the revenue cycle for tweaks and corrections after the implementation date. She also is expecting to see a big jump in the rate of claims denials. Both Branish and Mayer anticipate spending a lot more time at the photo copying and faxing records to appeal denials.
“You know, after the compliance date, we’re going to see a lot of people trying to ensure we’re reducing the use of unspecified codes, which today, in ICD-9 that’s very difficult. It’s going to be twice as hard with ICD-10,” Branish says.
Mayer and Branish said they were shocked when the Centers for Medicare and Medicaid Services announced they wouldn’t do any ICD-10 testing with providers.
“They’ve actually given us some good guidance on handling straddle patients—patients that straddle implementation date, but other than that, we were pretty disappointed. I guess we’ll see the other payers we can test with instead,” Branish says.
Felix recommends that providers measure data such as case mix index (CMI) before and after the transition.
“Measuring, this is what you have to do,” Felix says. “You want to compare CMIs, coding in ICD-9 and ICD-10, you can do that before October 2014, getting your CMI as equal as possible, getting your coders productivity and accuracy as close to ICD-9 standards as they’ll be in ICD-10. [It’s] not as easy a challenge,” Felix says.
Mary Butler (mary.butler@ahima.org) is the associate editor at the Journal of AHIMA.