Train the coders: check. Update the software: check. Let the transition begin.
Oh, if it were only that simple.
As many practices move from planning for to actually implementing the new code set for the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), a few things are strikingly apparent. The transition from International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to ICD-10-CM is not about the coders, it is not about ensuring that your software vendor has loaded the new code set, and it is not solely about testing claim submission with your clearinghouse. ICD-10-CM will impact every aspect of the healthcare organization and will need to be given the same due diligence as that last
new piece of equipment you purchased or when the electronic medical record was brought on board.
This new code set will dramatically highlight the medical necessity or reason(s) behind the services that are performed. Many claims have been paid to date, honestly, because the payers have accepted the unspecified (xxx.x9) codes. It was cost-prohibitive for the payer to manually review each and every case against the medical record when, in many situations, the claim was appropriate. There wasn’t a better code to use. Now, with an exponentially expanded code set, believe me, there is a better code. Each organization should carefully evaluate the impact on their operational workflow, reimbursement systems, and provider documentation well in advance of the “go live” date of October 1, 2014.
Challenges and Implications Abound
Operationally, this new adventure impacts more than the software. The system updates may, in fact, be the simplest piece of the puzzle. The first challenge is to determine each and every pathway for diagnosis codes. Where do they come from, who enters them, into which system are they entered, and then what? How are the codes used within the organization beyond the insurance claim form? Think clinical trials. Think marketing or other nonclinical data-mining project(s). Think about the process for ordering imaging studies and laboratory work. Think about the conversion of data for patients whose care crosses the implementation date.
In late October you will need to include additional information on that follow-up office visit—past treatments, the specifics related to the location of the primary tumor that was treated 5 years ago, and even emergency department status. Will these data be available on that progress note? How far back into the medical record will you have to dig to find the data? What process is being used to convert old clinical data into the new code set (Hint: using general equivalence mappings is not the correct answer)?
And then there are more practical implications. Every diagnosis code requires keystrokes. Whether coding entails the “clicks” from a physician selecting codes from a drop-down box of favorites or a coder abstracting the new extended level of details, the process still requires time. The time to click/enter 5 digits—which may occasionally be an alphanumeric format—is completely different from 7 characters that will always be alphanumeric. The time to click/enter a primary and, occasionally, a secondary diagnosis code is completely different than reporting 3 to 6 or more diagnoses on each claim—even the office visits. That productivity loss is not about a learning curve; it is the “new normal” and every organization will need to brace for the impact. As you think through the impact on productivity, don’t forget about the humans in the system. Employees typically take vacation and benefit time in the fourth quarter. Many organizations have implemented a benefit policy of “use it or lose it.” It may be necessary to reevaluate that policy and establish a vacation schedule to limit the number of employees needing a significant number of days once the critical implementation stage of this new project is upon us.
It is anticipated that the payers will deny claims that have, as mentioned, previously been paid now that they can more specifically track the reason for the service(s). Most payers will have their local coverage determinations or other coverage guidelines posted with the new code set by the spring of 2014. It will be important to evaluate the websites and ensure that what you think was covered will be. If your organization has negotiated any carve-outs within your managed care contracts, now is the time to evaluate just how those sections will be “crossed” into the new system. Additionally, the reality is that this new process will increase the denials and delay claims processing for at least the first 6 months—if not longer. Reimbursement—or, more accurately, the entire charge-capture process will be impacted by the implementation of ICD-10-CM. If your organization had to manage an increase in denials that may reach 200%, or had to accept the days in accounts receivable stretching out another 40%, what would be the results? As this implementation is set for “go live” in the fourth quarter, has the organization thought through its plans for year-end bonus/compensations?
Finally, it is one thing to say that there is a clinical documentation improvement project within your organization and quite another to drill down and evaluate what really needs to “improve.” Unfortunately, up to 60% of our current reports are insufficient for ICD-10-CM guidelines, and probably a large percentage of those really are insufficient for ICD-9-CM guidelines. But global comments aren’t helpful when training “your” providers. There must be a strategic, prioritized approach to provider training. And don’t forget the clinical support staff members who are also responsible in many organizations for updating or at least “resolving” acute conditions/side effects that may occur during treatment. It is also critical to understand that you cannot expect “more specificity” if the system has limited options for free text. The providers may also push back when historical data are expected on every follow-up visit, but systematically pulling data forward is not the answer either. Do not expect appropriate results without appropriate training.
Conclusion
The implementation of ICD-10-CM is a multifaceted project that will have long-reaching implications to your organization, your staff, and, ultimately, your patients. Take each step in your plan cautiously and make sure you involve all of the appropriate stakeholders.
Over the next year, Oncology Practice Management will offer additional information at a more granular level to assist you with those various steps. Today, start with your organizational workflow. Be able to identify where diagnosis information comes from and how it is used within all areas of your organization. Perhaps start with scheduling, registration, preauthorization, and follow the codes from there. Once you have identified where the initial information comes from and worked to improve the data collection at those points, you will be ready to move on to the next phase in managing your ICD-10-CM transition. Stay tuned to upcoming issues to see where you can look next to be sure your organization is ready when ICD-10-CM “goes live.”
About the Author
Karna W. Morrow is a senior consultant at CSI Coding Strategies, Inc, in Powder Springs, Georgia, and an Editorial Advisory Board member of Oncology Practice Management.