ICD-10: Back to the Future?
Will Oct. 1, 2013, be Y2K for physician practices and hospitals? That's the deadline for making the transition from ICD-9-CM (clinical modification) codes to ICD-10-CM and ICD-10-PCS (procedural coding system) codes.
Like the Y2K bug, ICD-10 will require analysis and changes to a range of computer systems. Both transitions also had hard deadlines—currently, CMS has no intentions of postponing its Oct. 1, 2013, date for activation of ICD-10. However, the similarities may end there.
Y2K was a relatively simple problem in IT terms, and involved a two-to four-digit reset. Solving the problem that thick with worry and thin on substance was vital, but it was also relatively easy to assess and then accomplish. In contrast, ICD-10 contains nearly nine times more codes than ICD-9. The ICD-10 codes will have different code compositions—seven digits, higher levels of detail and structure, and will expand the number of ICD-9 codes from almost 17,000 to approximately 155,000. In addition, ICD-10 is divided into procedural and diagnostic code sets. ICD-10-CM will jump to 68,000-plus diagnostic codes from the current 14,000.
The new procedural codes, which will be integrated into the hospital setting but not independent practices, will increase from the current 3,824 designations to 72,589. That large increase in codes will require increased clinical documentation, training, and hardware and software changes. Providers will need to build their budgets accordingly. As the source for ICD-10 codes entering the system, physicians have a critical part in a smooth ICD-10 transition, so they must be involved early on in the education and adoption process.
Because the current ICD-9 codes do not accommodate various disease states or recent medical advances, coders cannot add proper specificity to medical claims. With ICD-10, coders will have greater granularity and laterality at their fingertips, and thus can include a higher degree of specificity in claims. For example, in ICD-9, there is a single code used for the repair of an artery. In ICD-10, that number jumps to 195—with 65 different arteries and three approaches to repair from which to identify and select, offers Kathy DeVault, a certified coding specialist and manager of professional practice resources at American Health Information Management Association (AHIMA).
If implemented and used properly, ICD-10 will enable more claims to be processed without rejection, saving time and speeding reimbursement. But with competing IT projects on the roster at most facilities, this is a big "if." Stakeholders may agree that the new codes are necessary, and that successful implementation will begin at the point of care. Many organizations, however, have not begun a preliminary assessment of what the transition will require, which could negatively impact their bottom line (see sidebar, right).
For many providers, the transition to ICD-10 has taken a back seat to meaningful use, EHR implementation and other health IT issues. For example, during a February webinar presented by Ernst & Young, providers were asked where their organizations were in the process of implementing ICD-10. The answers were sobering:
Those poll results may actually represent an improvement over survey findings published in the September 2010 issue of the Journal of AHIMA. Of the 838 AHIMA members surveyed, 59 percent said they had not yet begun either Version 5010 (an update to insure the new codes conform to HIPAA compliance) or ICD-10 implementation; 20 percent said that they would not begin preparing to make the switch for another six months. Only 6 percent said they were almost finished with implementation, while 10 percent said they were half done.
Before facilities can make the conversion to ICD-10, they must first transition from HIPAA 4010/4010A1 to X12 Version 5010 of the HIPAA transaction standards no later than Jan. 1, 2012. This will allow their systems to accept various differences between the new and old codes including the alphanumeric, seven-character system in ICD-10 vs. the five-numeric character ICD-9 standard.
Based on the AHIMA survey, 77 percent of facilities have either not started or just begun to determine what needs to be done for the 5010 conversion—despite the fact that AHIMA had recommended implementation planning teams be in place by September 2009.
Two advisory groups—the North Carolina Healthcare Information and Communications Alliance and the Workgroup for Electronic Data Interchange—estimated that the complete ICD-10 conversion process will take providers 966 days to complete. This means that facilities should have started the planning process Jan. 18, 2010, to comply with the Oct. 1, 2013, deadline.
"ICD-10 is the biggest thing to hit healthcare in a very long time and everyone needs to start preparing now to ensure a smooth transition as the compliance deadline rapidly approaches," says Kim Charland, vice president of consulting at MedLearn, a medical coding, compliance and reimbursement education firm and consultancy in St. Paul, Minn.
Providers need to focus on processes because most facilities don't know what they don't know. However, they also can't implement ICD-10 in a vacuum—organizations that take a holistic approach and work with vendors and payors on medical documentation, coding and disease management are most likely to succeed, according to the Ernst and Young webinar.
An important first step in ICD-10 implementation is building a team of physicians, representatives of coding, billing and finance, IT staff, business associates, and vendors—and performing a practice impact analysis. "You will first need to identify all the places in the practice that ICD-10 conversion will impact," says Charland.
"We started talking about [ICD-10 conversion] two years ago," says Paula. "People in the documentation department get the credit because they hired a documentation specialist who was working in Europe and was familiar with ICD-10. She had been working with ICD-10 for a couple of years, she knew the system and had used it before."
ICD-10 transition was already on Tampa General's radar screen at the time the organization was looking into implementing a systemwide EHR to replace approximately 35 disparate information systems, none of which were actual EHRs, says Paula. When Tampa was in the process of choosing its EHR system (Epic), "we asked what their preparations were for ICD-10," says Paula, who notes this should be a question that every healthcare facility asks its EHR, hospital information system, office practice management or other vendors—and early in the process.
"First, ask about meaningful use, then 'what are your preparations for ICD-10?' Especially if you're making purchasing decisions," he says. Encouraging a relationship of coders and physicians is equally important.
Tampa General has worked with Epic using a vendor-guided effort to drive the process, according to Paula. The facility is now creating templates for physician documentation. "I wanted to improve the relationship that coders have with physicians. Part of the [ICD-10 transition] team is the coding team: Developing that relationship with the coders allows them to participate in creation of templates. The docs know if they want the hospital to get paid for the care provided, this is the best way to go about it."
The goal is to make the process as transparent as possible to physicians, so that when go-live occurs, their workflows are not disrupted. However, physicians need to know that "some of these key phrases and the way templates are structured will have a dramatic effect on our organization," he says.
When it comes to those key phrases, Tampa General also is interested in the work being done by Nuance on computer-assisted physician documentation that has clinical language understanding, says Paula. The documentation uses algorithms to search for keywords used to explain a condition, then can "take those words out, and map them in whatever fashion is necessary" for proper coding of diagnosis. Looking at text itself in context has great potential to streamline processes, he says.
"In transcription and dictation, really looking at the text itself, you're going to see more and more the ability for computers to extract out of physician documentation the key phrases that are necessary and then have physicians sign off, with spot editing to make sure they're mapped out properly," he says.
In addition to enabling proper coding for ICD-10 at the point of care—thus increasing the likelihood of prompt claim payment—computer-assisted documentation may get organizations closer to automated clinical decision support, he adds.
For nursing documentation, Tampa General is working with Epic and is contracting with Clinical Practice Model Resource Center (Elsevier). While not involved in the move to ICD-10, they will similarly increase the details of nursing documentation. Hopefully, linking to standard codes including SNOMED-CT inside EPIC will be completed by 2013, Paula says.
He sees the use of augmented reality as a potential streamlining technology during the transition: "If you could somehow superimpose an algorithm on top of what you're viewing, you can apply the same thing to ICD-10. If you can have a clinical documentation that somehow operates in the background that can extract what is valuable and necessary, I think that is what is going to start to happen."
Tampa plans to complete its transition to ICD-10 during the summer of 2013, with time to test and refine systems before the Oct. 1, 2013, deadline, Paula says.
The benefits of staying ahead of the ICD-10 and HIPAA 5010 transitions clearly outweigh any headaches along the way, particularly because there is no getting around their implementation. At the very least, according to AHIMA, facilities should establish steering committees to oversee implementation, hold regular meetings to educate key stakeholders, begin an impact assessment for all systems applications and databases using ICD-9-CM codes and identify all systems changes that will need to be made.
The consequences of not doing so will result in unpredictable timelines and ever-ballooning budgets as facilities will inevitably wind up scrambling to make the transition in a haphazard manner. In other words, do your homework now or pay later.
It appears that more providers are starting to do that. The Ernst and Young webinar drew an audience of 1,700, and ICD-10 was a major topic of discussion at February's HIMSS 2011 conference. Panelists in one HIMSS educational session were asked what their Davies Award-winning health organization was doing to prepare for ICD-10. "I have a simple plan for ICD-10: I'll be retiring," quipped one panelist. Although it was a joke, his comment reflects some of the trepidation that's out there as facilities look toward Oct. 1, 2013.
Like the Y2K bug, ICD-10 will require analysis and changes to a range of computer systems. Both transitions also had hard deadlines—currently, CMS has no intentions of postponing its Oct. 1, 2013, date for activation of ICD-10. However, the similarities may end there.
Y2K was a relatively simple problem in IT terms, and involved a two-to four-digit reset. Solving the problem that thick with worry and thin on substance was vital, but it was also relatively easy to assess and then accomplish. In contrast, ICD-10 contains nearly nine times more codes than ICD-9. The ICD-10 codes will have different code compositions—seven digits, higher levels of detail and structure, and will expand the number of ICD-9 codes from almost 17,000 to approximately 155,000. In addition, ICD-10 is divided into procedural and diagnostic code sets. ICD-10-CM will jump to 68,000-plus diagnostic codes from the current 14,000.
The new procedural codes, which will be integrated into the hospital setting but not independent practices, will increase from the current 3,824 designations to 72,589. That large increase in codes will require increased clinical documentation, training, and hardware and software changes. Providers will need to build their budgets accordingly. As the source for ICD-10 codes entering the system, physicians have a critical part in a smooth ICD-10 transition, so they must be involved early on in the education and adoption process.
| The Clock Is Ticking…Louder |
The first interim milestones for ICD-10 and Version 5010 are behind you, according to the CMS. For Version 5010, the interim milestones include:
For ICD-10, the interim milestone was to begin compliance activities (gap analysis, design, development, internal testing) by January 2011. Transactions not meeting the standards by the deadline dates—Jan. 1, 2012, for Version 5010 and Oct. 1, 2013, for ICD-10—will be rejected. |
If implemented and used properly, ICD-10 will enable more claims to be processed without rejection, saving time and speeding reimbursement. But with competing IT projects on the roster at most facilities, this is a big "if." Stakeholders may agree that the new codes are necessary, and that successful implementation will begin at the point of care. Many organizations, however, have not begun a preliminary assessment of what the transition will require, which could negatively impact their bottom line (see sidebar, right).
For many providers, the transition to ICD-10 has taken a back seat to meaningful use, EHR implementation and other health IT issues. For example, during a February webinar presented by Ernst & Young, providers were asked where their organizations were in the process of implementing ICD-10. The answers were sobering:
- 78 percent of provider respondents said their facility has not formed a committee to inventory IT systems.
- 20 percent of organizations have started a committee for inventorying IT systems.
- Of those organizations, 9 percent have completed a gap analysis to find transition trouble spots.
- Among payors, in contrast, the poll revealed that 73 percent have at least started the analysis process.
Those poll results may actually represent an improvement over survey findings published in the September 2010 issue of the Journal of AHIMA. Of the 838 AHIMA members surveyed, 59 percent said they had not yet begun either Version 5010 (an update to insure the new codes conform to HIPAA compliance) or ICD-10 implementation; 20 percent said that they would not begin preparing to make the switch for another six months. Only 6 percent said they were almost finished with implementation, while 10 percent said they were half done.
Before facilities can make the conversion to ICD-10, they must first transition from HIPAA 4010/4010A1 to X12 Version 5010 of the HIPAA transaction standards no later than Jan. 1, 2012. This will allow their systems to accept various differences between the new and old codes including the alphanumeric, seven-character system in ICD-10 vs. the five-numeric character ICD-9 standard.
Based on the AHIMA survey, 77 percent of facilities have either not started or just begun to determine what needs to be done for the 5010 conversion—despite the fact that AHIMA had recommended implementation planning teams be in place by September 2009.
Already behind?
| An ICD-10 Checklist for Hospitals |
With 2013 approaching faster than many healthcare organizations would like, now is the time to begin preparing for the ICD-10 transition. Semonia Diane McEntire, a senior healthcare consultant for professional services firm Culbert Healthcare Solutions, of Woburn, Mass., offers these five strategies to ease the ICD-10 transition for clinical staff:
|
"ICD-10 is the biggest thing to hit healthcare in a very long time and everyone needs to start preparing now to ensure a smooth transition as the compliance deadline rapidly approaches," says Kim Charland, vice president of consulting at MedLearn, a medical coding, compliance and reimbursement education firm and consultancy in St. Paul, Minn.
Providers need to focus on processes because most facilities don't know what they don't know. However, they also can't implement ICD-10 in a vacuum—organizations that take a holistic approach and work with vendors and payors on medical documentation, coding and disease management are most likely to succeed, according to the Ernst and Young webinar.
An important first step in ICD-10 implementation is building a team of physicians, representatives of coding, billing and finance, IT staff, business associates, and vendors—and performing a practice impact analysis. "You will first need to identify all the places in the practice that ICD-10 conversion will impact," says Charland.
Getting physicians, coders on the same page
Processes are at the heart of Tampa General Hospital's preparations for the transition to ICD-10, according to CMIO Richard Paula, MD, of Tampa General, a 1,004-bed private, not-for-profit hospital in Tampa, Fla., serving 12 West Central Florida counties."We started talking about [ICD-10 conversion] two years ago," says Paula. "People in the documentation department get the credit because they hired a documentation specialist who was working in Europe and was familiar with ICD-10. She had been working with ICD-10 for a couple of years, she knew the system and had used it before."
ICD-10 transition was already on Tampa General's radar screen at the time the organization was looking into implementing a systemwide EHR to replace approximately 35 disparate information systems, none of which were actual EHRs, says Paula. When Tampa was in the process of choosing its EHR system (Epic), "we asked what their preparations were for ICD-10," says Paula, who notes this should be a question that every healthcare facility asks its EHR, hospital information system, office practice management or other vendors—and early in the process.
"First, ask about meaningful use, then 'what are your preparations for ICD-10?' Especially if you're making purchasing decisions," he says. Encouraging a relationship of coders and physicians is equally important.
Tampa General has worked with Epic using a vendor-guided effort to drive the process, according to Paula. The facility is now creating templates for physician documentation. "I wanted to improve the relationship that coders have with physicians. Part of the [ICD-10 transition] team is the coding team: Developing that relationship with the coders allows them to participate in creation of templates. The docs know if they want the hospital to get paid for the care provided, this is the best way to go about it."
The goal is to make the process as transparent as possible to physicians, so that when go-live occurs, their workflows are not disrupted. However, physicians need to know that "some of these key phrases and the way templates are structured will have a dramatic effect on our organization," he says.
When it comes to those key phrases, Tampa General also is interested in the work being done by Nuance on computer-assisted physician documentation that has clinical language understanding, says Paula. The documentation uses algorithms to search for keywords used to explain a condition, then can "take those words out, and map them in whatever fashion is necessary" for proper coding of diagnosis. Looking at text itself in context has great potential to streamline processes, he says.
"In transcription and dictation, really looking at the text itself, you're going to see more and more the ability for computers to extract out of physician documentation the key phrases that are necessary and then have physicians sign off, with spot editing to make sure they're mapped out properly," he says.
In addition to enabling proper coding for ICD-10 at the point of care—thus increasing the likelihood of prompt claim payment—computer-assisted documentation may get organizations closer to automated clinical decision support, he adds.
For nursing documentation, Tampa General is working with Epic and is contracting with Clinical Practice Model Resource Center (Elsevier). While not involved in the move to ICD-10, they will similarly increase the details of nursing documentation. Hopefully, linking to standard codes including SNOMED-CT inside EPIC will be completed by 2013, Paula says.
He sees the use of augmented reality as a potential streamlining technology during the transition: "If you could somehow superimpose an algorithm on top of what you're viewing, you can apply the same thing to ICD-10. If you can have a clinical documentation that somehow operates in the background that can extract what is valuable and necessary, I think that is what is going to start to happen."
Tampa plans to complete its transition to ICD-10 during the summer of 2013, with time to test and refine systems before the Oct. 1, 2013, deadline, Paula says.
Training for all
Training for ICD-10 will be crucial, and IT leaders will need to work with their coding departments to ensure adequate training time. CMS recommends that training take place six to nine months prior to the compliance date. However, there will still be a long on-the-job learning curve for coders once the ICD-10 codes go live. Estimates range between three to six months, but some say those are conservative. In any event, the transition, if not properly handled, could result in a significant loss of productivity. The flip side of that is the greater detail that the new codes will allow, which will create less opportunity for claims to be rejected by payors, leading to more captured revenue.The benefits of staying ahead of the ICD-10 and HIPAA 5010 transitions clearly outweigh any headaches along the way, particularly because there is no getting around their implementation. At the very least, according to AHIMA, facilities should establish steering committees to oversee implementation, hold regular meetings to educate key stakeholders, begin an impact assessment for all systems applications and databases using ICD-9-CM codes and identify all systems changes that will need to be made.
The consequences of not doing so will result in unpredictable timelines and ever-ballooning budgets as facilities will inevitably wind up scrambling to make the transition in a haphazard manner. In other words, do your homework now or pay later.
It appears that more providers are starting to do that. The Ernst and Young webinar drew an audience of 1,700, and ICD-10 was a major topic of discussion at February's HIMSS 2011 conference. Panelists in one HIMSS educational session were asked what their Davies Award-winning health organization was doing to prepare for ICD-10. "I have a simple plan for ICD-10: I'll be retiring," quipped one panelist. Although it was a joke, his comment reflects some of the trepidation that's out there as facilities look toward Oct. 1, 2013.