Chicago Bulls win the NBA Championship and ICD-10 has been postponed! Just kidding. However, as much as I am hoping for the former, I am sure many healthcare organizations are hoping for the latter. Unfortunately the chances of that happening are as slim as me becoming a Miami Heat fan! One thing is certain, when ICD-10 kicks in on October 1, 2014, productivity will take a hit. If you want to come out winning (least impact), you better come prepared with your offensive game.
Areas of Impact
Clinical Documentation – With the increase in granularity of the ICD-10 codes, there will be an increase in the amount of information that a provider must include in the patient record. This will directly impact the time spent on each patient encounter. Things that a provider may not have needed to capture with ICD-9 are now being required with ICD-10. For example, things such as1:
- Type of encounter (initial or subsequent)
- Applied specificity (did the patient lose consciousness?)
- Acute versus chronic
- Relief or non-relief (intractable versus non-intractable)
- External cause (what caused the accident?)
- Activity (what was the patient doing when she was injured?)
- Location (where was the patient when she was injured?)
According to a study conducted by Nachimson Advisors, LLC, the move from ICD-9 to the ICD-10 will increase documentation activities about 15 percent to 20 percent2. This is not just an implementation or learning curve increase. This translates into a permanent increase of 3 percent to 4 percent of physician time spent on documentation for ICD-102. Those providers thinking that their electronic health record (EHR) will eliminate extra documentation time are sadly mistaken. Many templates within in the system itself will need to be changed to accommodate the new codes sets resulting in additional work.
Coding – There is no doubt, given the sheer increase in the number of the codes from ICD-9 to ICD-10, there will be an impact on coder productivity, but as Angela Carmichael points out, the important question we should be asking ourselves is “how much” of an impact. She highlights some of the main reasons for the direct impact to coder productivity3:
- An increase in the volume of codes available for assignment
- An increase in the number of characters comprising a valid code
- An increase in the specificity of approximately 20 percent of diagnosis codes and 99 percent of procedure codes
- An increase in the number of physician queries
- An addition of alphabetical characters to what was once only a system of numerical codes;
- A complete overhaul of the procedure reporting system
- Changes to coding guidelines
In her article, ICD-10 and its Impact on Coder Productivity, Ms. Carmichael explains 3, “The increase in the volume of codes available for assignment coupled with the enhanced clinical nature and specificity of these codes will require a more intense review of documentation, leading to more dialogue between coders and providers. As a result, it could take twice as long to code and finalize billing of an inpatient record using ICD-10-CM/PCS as compared to ICD-9-CM. But as with all new things, there will be a learning curve with ICD-10, and this one is predicted to last approximately six months (this is based on Canada’s and Australia’s experiences in transitioning to ICD-10). This is not to say that on April 1, 2014 our productivity losses attributed to ICD-10 magically will be reversed, as many expect a long-term loss of inpatient coding productivity ranging anywhere from of 10 to 30 percent.”
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The American Academy of Professional Coders, (AAPC) points out that “today the diagnosis codes are mostly numeric (with the exception of V and E codes), but with ICD-10 the codes are alphanumeric. The process of entering the new codes alone will slow productivity because we will no longer be able to rely solely on a number keypad to enter all the codes. Also, it will be very important to distinguish between letters and numbers when a diagnosis code is written as opposed to a narrative description. For instance, depending on penmanship, it may be easy to mistake a number two for the letter Z or the number zero for the letter O.” 4
Payment – Coder productivity will not be the only impact on cash flow resulting from ICD-10. Payers are expected to take longer to pay claims, and the payment error rate is expected to rise to as high as 10 percent as a result of an increase in coding, billing and payment errors3. Again, the importance of documentation cannot be overstated as this directly impacts coding and billing. “About half of all allegations of inaccurate billing arise from insufficient documentation in the medical record, resulting in denials based upon lack of medical necessity or due to alleged upcoding. Two particular problems frequently cited include the review of patients’ medical and personal histories, and failures to provide adequate supporting documentation for diagnoses and procedures.”5 Organizations will also be tasked with determining how payers interpret the new coding system, and employees will have to analyze payer responses to claims over the first few months to identify deficiencies6. It is very likely that payers will end up denying more claims due to improper coding. Many payers are expecting providers to continue to code the “unspecified” option of a diagnosis. However, this will result in a payer either (1) rejecting the claim outright or (2) pending the claim and asking for more information5. Both of these outcomes result in extra work and decreased efficiencies for both the payer and the provider5.
Approach: Offense vs. Defense
We have all heard the old adage, “the best defense if a good offense”. This same phrase that applies to sports and war, applies to ICD-10. An offensive (proactive) approach vs. a defensive (reactive) approach will prove to help alleviate some loss in productivity. What better offense, then proper preparation and planning. AHIMA provides the following to assist providers and coders with their offense8:
- Conduct gap analysis of coding staff knowledge and skills for ICD-10 environment.
- Assess coding staff knowledge in biomedical sciences (anatomy and physiology, pathophysiology), medical terminology, and pharmacology.
- Refresh coding staff knowledge as needed based on the assessment results.
- Communicate with contract coding services to ensure their coding staff is being prepared similarly to meet the demands of ICD-10 coding and to determine their strategy and timeline for ensuring their coding staff achieve professional ICD-10 competence.
- Assess quality of medical record documentation
- Implement documentation improvement strategies to address areas where documentation is found to be lacking.
- Evaluate samples of various types of medical records to determine whether documentation supports the level of detail found in ICD-10.
- Sampling techniques could include random samples, most frequent diagnoses or procedures; diagnostic or procedural categories known to represent documentation problems with ICD-9-CM.
- Consider changes in documentation capture processes (such as prompts in electronic health record systems) to facilitate improvements in documentation practices.
- Educate medical staff on findings from documentation review and the documentation elements needed to support ICD-10 codes, through the use of specific examples, and emphasize the value of more concise 15:21 10/2/2012 data capture for high-quality data.
- Designate a physician champion to assist in medical staff education and promote the positive aspects of the ICD-10 transition.
Assess training needs
- Keep in mind that multiple categories of users of coded data require varying types and levels of ICD-10 education and it will be needed at different times.
- Determine who needs education, what type and level of education they need, and when they need education.
- Determine the most appropriate and cost-effective method of providing ICD-10 education to the different categories of individuals (e.g., traditional face-to-face classroom teaching, audio conferences, self-directed learning programs, web-based instruction (self-directed or instructor-led).
- Determine whether education will be provided through internal or external mechanisms, or a combination of both.
“Preparing coders, physicians, and other staff for the ICD-10 transition may seem like a daunting task, but early, comprehensive education will be the key to a successful October 1. A thorough organizational assessment will help prepare every necessary department to receive the proper instruction, and investing in education will prevent a lapse in productivity once ICD-10 finally arrives” states Jennifer Bresnick of EHR Intelligence7.
The ball’s in your court. Get your game faces on and prepare for victory!!!
Join us tomorrow for the webinar, “ICD-10: Short-Term Challenges and Long-Term Gains.”
Resources cited in this blog: