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Four industry experts share their thoughts about the upsides and downsides of ICD-10.
On the pro side of the value equation, the transition to ICD-10 will bolster performance improvement efforts, say industry experts. The increased specificity and thoroughness of ICD-10 coding will deepen the understanding of diseases and help to identify the most effective approaches to treatment and disease management. Providers and payers also expect to see a reduction in the volume of rejected and fraudulent claims and an increase in the accuracy of payments for new procedures. But this transition is a costly one—both in terms of dollars and staff time.
How will the shift to ICD-10 coding improve quality improvement efforts?
Strumwasser: Because ICD-9 coding was less specific, our quality improvement projects at Swedish Medical Center were laborious. Because the diagnostic codes were relatively non-specific, it was difficult to accurately compare the care of patients who had similar disease processes. With ICD-10, comparisons will be more specific, and quality improvement initiatives will be more fruitful.
ICD-10 should make quality improvement efforts easier because we will be gathering more accurate and more actionable data. When we have greater specificity of coding, it will allow us to capture more data so we can make sure we are comparing apples to apples. For example, the new coding system expands clinical classifications so coders can distinguish between persistent or intermittent forms of disease instead of placing all patients in the same disease category. Our quality improvement team can then begin to assess the effects of disease management and patient noncompliance on outcomes.
Bowman: With the ICD-9 codes, providers could only identify patients in rather large buckets because that was the level of specificity they had. For example, records of patients who had a mishap in a hospital or who had certain types of surgeries received the same code regardless of the circumstances surrounding the adverse event or the degree of difficulty of the surgical procedure.
With ICD-10 codes, providers get far more refined information so they can do more detailed levels of analysis. The ICD-10 coding system allows providers to learn whether a patient fell in the bathroom or in the corridor or in the hospital cafeteria. The expanded number of codes for surgical approaches and anatomical locations allows providers to link patient outcomes with the way a surgical procedure was performed.
What major steps have been taken so far to gear up for ICD-10?
Strumwasser: We have had a clinical documentation integrity program for three or four years. Even before we started on ICD-10 work, our clinical documentation specialists worked closely with physicians to make sure we captured all the comorbidities and acuity we needed to. We have people in the organization who are now training coders in ICD-10, and we are allocating FTEs to educate the physicians’ offices on the ICD-10 coding requirements. We’ve met with groups of our affiliated physicians to teach them what ICD-10 will mean for their specialties. In orthopedics, for instance, we are focusing on the nuances, such as the cause of a condition, the type of encounter with the patient, and the place where an injury occurred, that now need to be incorporated in the patient narrative. We also are incorporating automated “smart tools,” such as templates and handheld applications, to make documentation easier for our physicians.
Mihalik: I don’t know that everyone has recognized the breadth and scope of this change and its downstream effects. At Cleveland Clinic, many of our clinical specialties have their own unique outcome and quality measures in quality registries. We have had to make sure we are prepared to report to those quality registries after ICD-10 implementation by providing the appropriate mapping that will accurately reflect the specificity of care provided, leveraged by the additional opportunities that ICD-10 provides.
Watson: Aetna has been on the journey toward ICD-10 since the end of 2009 so most of our remediation work has been completed, and much of what we have currently underway relates to testing. We are working and testing with a targeted group of providers that share vested interests with Aetna because of their contracting methodology and because of their high level of interest in how the ICD transformation proceeds. We are impressed with our partners; they are right on track.
For the testing that has been planned for 2014, we have an agreement with all of our partners that there will be no change; we will proceed to the end of that plan. Our goal is to take the output of that effort and share our results in general terms as broadly as we can with providers at industry conferences.
Bowman: The provider organizations have been reviewing samples of their records to see if clinical documentation supports the specificity in ICD-10 codes. If it doesn’t, they have begun educating doctors about the clinical documentation that is needed to support the more detailed ICD-10 codes.
Providers have also been doing impact assessments to examine every policy and system touched by ICD-10 codes, including utilization management and patient scheduling/registration, which use codes to identify medical necessity criteria. Providers have been converting systems, and training coders and other staff.
How have plans changed since the announcement of the delay in ICD-10 implementation?
Strumwasser: We are trying to operationalize as much as we can in advance of the ICD-10 rollout to make the organization ready. So we are ignoring the delay and proceeding with the same timeline as before. Swedish is now part of the Providence Health System. As a member of that 34-hospital system, we are beginning the process of incorporating ICD-10 in our coding as a sort of beta case in order to be fully prepared once we are asked to do ICD-10 coding routinely. The Providence health system is planning to be ready for end-to-end testing of 837 claims and 835 remittances with its clearinghouse trading partner in the next few months.
Mihalik: We were on a path toward suc--cess and felt that we were well prepared to manage the change to ICD-10 this year. The challenge with the new compliance date is to balance ICD-10 work with other technology initiatives. We wanted to complete the transition to ICD-10 so we could focus on other projects; now we need to shift all our priorities.
The process we are going through right now is to resize our ICD-10 efforts and time them appropriately so we will be well prepared when the new compliance date arrives. We are making sure all our work streams are active until we get an organizational perspective on where we are, what we need to finish, and what we can put away and bring out another day. We need to take time to figure out the cost/benefit relationship for all our health information management initiatives to make sure we continue to leverage the skill sets we have built already and use them in the most efficient way.
Watson: We are doing what many entities have been doing. We are taking stock of our program, looking at how business is being affected by the change. We’re looking at what makes sense to continue doing and what may need to ramp down and ramp back up when we get to this time next year. We don’t have crystal clarity on how the delay is impacting our program, but we are going through the exercise of looking across all activities and reforecasting a plan now that we know we will have a new implementation date.
What specific concerns are arising because of the delay in implementation?
Bowman: Many providers have started dual coding so they could compare their case mix and service lines and see how reimbursement would change with ICD-10. But that is expensive, and providers don’t know if they can keep that up for 1 ½ years due to the cost.
There is also the whole issue of retraining. A large number of providers have done most or all of their training. An issue related to the move to a 2015 ICD-10 compliance date is how to ensure that coders maintain coding skills. If coders are not using ICD-10 data, they will not be able to keep their skills up to date and they will have to be retrained or sent back for refresher courses. An unfortunate ramification of a delay this close to the go-live date is the effect on graduating HIM students who have learned only ICD-10 and whose employment prospects are thus jeopardized by the delay.
Mihalik: Cleveland Clinic has a detailed education plan that focused on our most significant needs from the ICD-10 perspective, and we were ready to roll out that education plan for our physicians this spring. But it just doesn’t make good sense to invest our clinicians’ time in learning about ICD-10 language when they won’t use it for a year. So we will wait and do that specific work later in the ICD-10 planning process.
Watson: Aetna has many surveys and questionnaires submitted to us from providers, and we have seen an uptick recently in the number of questions about our own readiness. We want to reassure providers that we have performed significant testing internally and externally and addressed any issues that were identified. We hope that providers stay the course so they will be ready for the 2015 compliance date. We worry that won’t happen and that providers will not use this time wisely to work with vendors on their software needs, make sure their connections with clearinghouses work, analyze the effect of ICD-10, and streamline systems to remove the impediments that interfere with their own readiness for ICD-10.
What are some strategies for keeping costs down?
Bowman: Thorough planning and preparation are key. Don’t let the delay impact your momentum. It’s important to “stay the course” in order to avoid having to scramble to get ready for the compliance date. Focusing on clinical documentation excellence helps to reduce costs down the road by leading to improved coding accuracy and productivity, reduced physician queries, and reduced claims denials. Use of computer-assisted coding technology can also decrease costs down the road by improving coding productivity.
Mihalik: All the different aspects of preparing for ICD-10 are important and they all depend on one another. The physician education, coding, IT readiness—they all fit together, and the work stream for ICD-10 affects the other work the organization has underway. We have to look work stream by work stream to find the right cost/benefit balance for each area.
Bowman: Providers have not reduced expenses in one area, and that is coder training. Providers have given coders the full amount of training, because they realize careful coding will affect costs down the road. But one approach to help decrease initial training costs is to have one coder become an ICD-10 trainer for the rest of the coding staff. This avoids incurring the cost of travel for sending all the coders out for training.
Mihalik: Coding is an area in which we have already made significant investment. Nearly all our coders and clinical documentation staff are trained on ICD-10. That’s not an investment we will walk away from and pick up later. But we need to be creative in how we maintain the coding skill set while ICD-10 is not in compliance mode. Our plan is to do some focused dual coding skill labs and workshops to keep folks fresh with their ICD-10 skills. The coders who have been trained only in ICD-10 need to get trained in ICD-9 for the short-term and then be ready to go on ICD-10 when the compliance date arrives.
We believe cost savings will come from our focus on clinical documentation, which will ultimately reduce denials and any rework questions that may come up. Our focus on training and education will minimize the negative impact on productivity in the initial stages of ICD-10 compliance. By building our own internal staffing expertise on coding and clinical documentation, we will be able to reduce our reliance on external vendors, and that also will be a saving for us.
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Large Health System Drives 10% UP (Patient Payments) and 10% DOWN (Billing-related Costs)
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ICD-10: Managing Performance
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Yuma Regional Medical Center case study
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