ICD-10: The Final Push

It’s been a long journey from ICD-9 to ICD-10, but the deadline is at last in range—barring any more last-minute changes.

As organizations approach the final stretch, they have upped their game. They are investing their resources in physician training and robust clinical documentation improvement programs, dual coding and reimbursement analysis.

Gap Analysis

ICD-10 diagnosis codes are more complex and detailed than ICD-9, so where to start? Before anything, a gap analysis or review of medical records is required to determine whether documentation supports the level of detail found in ICD-10.

Techniques of an analysis include random sampling, sampling by clinical specialty, reviewing the top 10-20 diagnoses or procedures for each service line, as well as high-volume and high-cost diagnoses and procedures, according to Melanie Endicott, MBA, senior director of HIM practice excellence for the American Health Information Management Association who spoke during a Centers for Medicare & Medicaid Services and AHIMA webinar on making the transition.

Also, leaders should look at diagnostic and procedural categories already creating problems in ICD-9, she says.

Philadelphia-based Thomas Jefferson University Hospitals, which encompasses three hospitals, conducted an initial impact assessment in December 2011, according to Shiny George, senior director of HIM. This entailed a review of systems, people and processes—including both electronic and paper systems that utilize ICD-9. “Entire forms had to be changed.”

This process is managed by a governance committee, including 80 people in different capacities, which reports to executives. Thomas Jefferson also partnered with an external vendor that reviewed a set number of records on a quarterly basis. They analyzed top DRGs, and top services rendered by each service line.

“We used the 80/20 rule,” George says, meaning staff reviewed 80 percent of data from a revenue perspective as well as documentation, including primary and secondary diagnoses and their level of specificity. “If we don’t know our current situation, it’ll be hard on physicians. We want to make sure we understand issues now.”

Leaders at Boston Medical Center (BMC) conducted an assessment in the summer of 2012, and opened a program management office, which began remediating gaps one year later. The center took part in a paper analysis impact as well, according to Cindy Charyulu, vice president of revenue cycle.

The one-year delay required the center to ramp down on a number of resources already lined up in preparation of the compliance date. Still, BMC is deep into its preparations, which revolves around IT systems and documentation and change management. Also, “we’re just starting our reimbursement analysis and putting rigor around that.”

‘Data-driven education’

“High-quality documentation provides a more accurate clinical picture of the quality of care being provided. Better clinical documentation promotes better patient care and more accurate capture of acuity, severity and risk of mortality,” says Angie Comfort, senior director of HIM practice excellence at AHIMA.

As such, physician training is critical from the onset. It’s important to educate staff on findings from documentation reviews and to use very specific examples. “They want to see how documentation impacts coding. It’s important to emphasize the value of higher quality data,” says Endicott.

Thomas Jefferson uses an ICD-10 analytical tool system, which can process three years of data and report risk areas, including financial ones (i.e., what top service lines have potential risks from documentation impacts on revenue). “You can use charts, medical records and billing data and see what the data are telling us,” George says.

Thomas Jefferson’s clinical documentation team takes these findings to the front line, where they become integral to educating physicians on clinical documentation improvement. “We wanted data-driven education.”

Showing physicians their data engages and excites them. “Physicians are excited, they are getting it now. This is not about data but your publicly reported reputation.”

BMC has implemented three-tiered enterprise training. To get up to speed, physicians and coders participate both in e-learning and in-person sessions by their practice and specialty, according to Charyulu.

“One of the benefits of having a clinical documentation improvement program is it facilitates a collaborative approach between your coders, your medical staff, nursing staff—to get them on the same page,” says Endicott. Also, such a program reduces coding errors as well as physician queries. Moreover, it leads to fewer claims denials, because the full documentation is available.

Dual Coding

Thomas Jefferson began dual coding in April 2013. “That has been a true eye-opener,” says George. Each week, coders meet to discuss specific cases and identify opportunities to improve documentation such as through adding more specificity on forms.

At BMC, they began dual coding across departments last November. Each coder is required to dual code a subset of their overall work. This exercise has provided input into the reimbursement analysis by understanding the productivity of the coder.

“We had anticipated a 30 percent decrease in productivity, but it was actually higher than that,” says Charyulu. “We’re hoping that as they practice and get more proficient, they will be more productive.”

She notes that the U.S. is seeing more coders retire as ICD-10 approaches. “There is a shortage of coders, which is driving the gap.”

Also, while it’s still too early to tell, Erika Gaudreau, BMC’s senior director of patient access, says the dual coding analysis, which was done by specialty and ICD-10-impacting department, has revealed some procedures and supporting diagnoses that were inadequately documented.

Working Smarter, Not Harder

ICD-10 planning works best when organizations identify how better coding and documentation can impact various initiatives like Meaningful Use, value-based purchasing and reporting, says Endicott.

Each provider should look to develop forms and templates, education, system prompts and other operational changes to facilitate ICD-10. “Think about your low-hanging fruit and prioritize those,” Endicott says.

Some options to work smarter include using automation to facilitate coding and documentation such as EHR, templates and computer-assisted coding as opposed to hiring more coders. Proper documentation can be facilitated through use of EHR templates and prompts, and such data can be repurposed for multiple initiatives.

EHR documentation templates are helpful, but she advises only using them when documentation is not optimal. You don’t want templates for everything, she says. “Avoid using templates too broadly. Use default values with extreme caution to avoid inaccurate information. Do not include coding nomenclature in a template.”

She suggests the following details to add to EHR templates: laterality, devices, encounter type, anatomic details, severity and disease relationships. Otherwise, she cautioned, “non-specific documentation results in non-specific code assignments.”

Learning Isn’t Over

As providers ramp up their preparations, everyone agrees that the learning is not over once Oct. 1 finally arrives.

“I’m sure we’re going to learn. We’re going to have a lot of work to do post-implementation. No one has done ICD-10, so you can’t call colleagues for help,” George says. The best thing to do is get people ready so “coders and clinicians are ready to jump in.”