By Kathleen B. Vega

Two years ago, Catholic Health East (CHE)—a faith-based health system with multiple institutions located throughout 11 eastern states—embarked on a journey toward ICD-10 implementation.


“We knew this effort would be complex and time-consuming, and we decided to start early so we could effectively prepare for the ICD-10 transition,” says Cynthia D. Fry, PhD, vice president revenue for CHE. “We also wanted to leverage our system’s size and identify any ‘one and done’ components that we could implement systemwide to gain efficiencies and streamline work. Not everything can be done at the system level, but items such as a project plan, financial impact analysis, assessing payer readiness and software vendor preparation do lend themselves to a global approach.”

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Taking the First Steps

To begin, CHE developed a business plan. “We started information gathering early on—reading about ICD-10, attending webinars, and talking with colleagues in other organizations,” says Howard Walker, ICD-10 program manager for CHE. “All the research was used to form an initial business plan, which included a concise description of the core changes that would result from the new coding system.”

Once the plan was created, Fry and Walker met with senior leadership to educate them on the plan and garner support.

“We brought in an outside speaker who was a former senior leader in a multihospital system and an acknowledged expert in ICD-10,” says Fry. “She talked about the potential impacts of the new coding system and spelled out the risks to our organization if we did not have a well-defined, comprehensive approach to implementation.”

After the speaker laid the groundwork, Fry and Walker presented the initial business plan and obtained leadership support as well as a budget for the work. "I believe this approach of having a peer introduce the topic of ICD-10 was beneficial, because she was able to effectively pave the way for our presentation," comments Fry.

In conjunction with developing the business plan and meeting with senior leadership, CHE also created a core team at the system level to guide the ICD-10 work. Made up of representatives from the revenue cycle, IT, health information management, and nursing, this team meets bi-weekly to talk about ICD-10 implementation and other related topics.

“We have found there is always something to discuss,” says Fry. “Our various hospitals also have ICD-10 teams, but the system-level team covers many of the issues that will impact the entire organization. For example, we searched and selected an ICD-10 Web-based training tool designed to accommodate the various stakeholders from coders to physicians. As a system, we leveraged our size to get preferred pricing and purchased unlimited licenses. Every stakeholder group at all our hospitals is now assured to receive the same training, and we can track who is attending and who is not.”

Creating Five Goals for Implementation

As CHE was laying the groundwork for implementation, the following five goals for the work emerged as part of the business plan:

  • Eliminating erosions in coder productivity
  • Avoiding any unfavorable financial impacts through the analysis of current coding and documentation patterns
  • Minimizing disruptions in patient throughput in the outpatient setting
  • Ensuring that physician documentation is ICD-10 compliant
  • Implementing information systems to support the work

“We basically segmented the implementation process into five distinct buckets,” comments Walker. “These efforts not only drive the ICD-10 work, but are also significant initiatives on their own with dedicated committees, budgets, project plans, and processes. At the system level, we are planning for and working toward all of these goals to ensure an effective ICD-10 transition.”

Goal 1: Eliminating erosions in coderproductivity. CHE is turning to technology to help address this goal. “We are implementing a computer-assisted coding tool across the system,” says Walker. “We want to get this tool in place well before the switch to ICD-10 so we can get past the learning curve before the code sets change.”

To further enhance productivity, CHE also partnered with a local community college to provide online training to coders systemwide in anatomy and physiology. “Because the level of detail is much greater in ICD-10, we wanted to supplement coder knowledge and be sure all received the same level of training,” comments Fry. CHE is also evaluating its coder backfill strategy and coder retention plan.

Goal 2: Avoiding any unfavorable financial impacts through the analysis of current coding and documentation patterns. “We found a tool to help us expedite data analysis at an ICD-10 conference,” says Fry. “An accounting firm developed a software tool that analyzes the impact of ICD-10 based on current claims data. This tool answers the question, ‘What would the financial impact be at the DRG level if we flipped a switch to ICD-10 today?’ We have completed a first pass on the data for all our hospitals and are now drilling down to the specific issues identified at each hospital.”

CHE is also assessing payer readiness and whether the payers will be processing claims in ICD-10 or mapping back to ICD-9. Expecting an increase in claim denials and payment variances, CHE is developing a resource plan to support central billing offices (CBOs).

Goal 3: Minimizing disruptions in patient throughput in the outpatient setting. The switch to ICD-10 will not affect every department in an organization in the same way. For example, what happens if an inordinate amount of patients present themselves on Oct. 1, 2014, with an order for a test that does not have an ICD-10 code or the written diagnosis is not specific enough? How will medical necessity be checked? Outpatient areas that currently use ICD-9 codes will need specific attention in updating their processes for ICD-10. To identify departments that need attention, CHE created a 31-question online survey to assess department needs.

“We piloted the survey with one facility to see if the questions were relevant and generated meaningful answers,” says Fry. “Once we determined we could glean the necessary information using the survey, we are starting to implement hospital by hospital. We identify high-risk outpatient departments and then go on site to conduct a review and develop recommendations.” (See the workflow analysis survey questions.)

Even without the survey, CHE knows that certain departments will need more attention than others. To understand the scope of ICD-10 impact in these areas, CHE is developing a picture of current state process flow that identifies the flow of paper, use of systems, and where current ICD-9 and future ICD-10 codes are and will be used. The organization is then performing a gap analysis, evaluating risk along the process flow to further pinpoint areas that will need focused attention. Two exhibits illustrate this effort for one of CHE's emergency departments. The Emergency Department Patient Flow diagram shows a current state process flow for the department at one hospital. 

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In addition an ED-specific ICD-10 Analysis shows how CHE assigns risk to the different components of the process flow.

Access related tool: ICD-Impact on ED Patient Flow 

Goal 4: Ensuring that physician documentation is ICD-10 compliant. “Prior to starting work on ICD-10, we did not have a systemwide clinical documentation program,” says Fry. “We developed a business plan, created a steering committee, and have implemented a clinical documentation program across the organization. The clinical documentation improvement (CDI) specialists are completing our ICD-10 Web-based training now and will start coaching physicians on some of the basics of ICD-10 documentation such as specificity, underlying cause, and documentation of associated relationships. Physicians will learn proper documentation without knowing it is ICD-10 documentation that they are learning.”

Goal 5: Implementing information systems to support the work. Progress toward meeting this goal can be seen in the work involved with all the other goals. Specifically, the implementation of a computer-assisted coding tool will help realize a smooth ICD-10 transition. CHE is also working to develop structured templates in the electronic health record that support the documentation requirements for ICD-10.

Looking Externally for Support

As CHE pursues its ICD-10 goals, it is also leveraging relationships with external partners. “We maintain strong relationships with all our vendor partners, and they have been very helpful as we work to get ready for implementation,” comments Walker. “They have provided resources, education, and creative thinking to help us identify solutions that address the unique needs and characteristics of our system.”

CHE is also sharing information with other hospitals and health systems. “Most of the time you don’t collaborate with your competitors, but ICD-10 is one thing we can work on together,” says Walker. “We have regular conference calls with several hospitals in our geographic area in which we discuss our work toward implementation, problems we are having, information we have learned, and so on. We talk about payer issues, vendor readiness, and training needs and resources. We have even brought in speakers to talk with the group on specific topics.”

The Effects of the Delay

CHE started focusing on ICD-10 early and experienced tremendous momentum toward implementation. The recently announced delay in the ICD-10 deadline to Oct. 1, 2014, has slowed organizationwide progress but not halted it.

“Although we were frustrated by the delay at first, because we were afraid the ICD-10 work would become a lesser organizationwide priority, we are now seeing a benefit to the delay,” says Walker. “Some of our technology that will support the transition, such as the computer-assisted coding tool, has taken longer to move forward than we originally anticipated, so it's nice to have the extra time. As it is now, we can continue to work toward achieving our implementation goals and make sure we are truly ready when the new deadline arrives.”

Kathleen B. Vega is a freelance healthcare writer and editor, La Grange, Ill. (

Interviewed for this article were Cynthia D. Fry, PhD, vice president revenue for Catholic Health East, Newtown Square, Pa., and a member of HFMA’s Metropolitan Philadelphia Chapter (; and Howard Walker, ICD-10 project manager for Catholic Health East, Newtown Square, Pa. (

About Catholic Health East

Catholic Health East is a not-for-profit health system headquartered in Newtown Square, Pa., with facilities in 11 eastern states. The health system comprises 35 acute care hospitals, four long-term acute care hospitals, 26 freestanding and hospital-based long-term care facilities, 12 assisted-living facilities, four continuing care retirement communities, eight behavioral health and rehabilitation facilities, 31 home health/hospice agencies, and numerous ambulatory and community-based health services. Catholic Health East facilities employ more than 60,000 FTEs.

The health system is the largest not-for-profit provider of home healthcare services—ranked by number of visits—in the nation, as well as the nation’s leading provider of Program of All Inclusive Care for the Elderly (PACE), based on the number of programs.

Publication Date: Monday, October 01, 2012