So Many Squirrels: Which One to Chase?

Squirrels and dogs. This morning my hound chased yet another squirrel, crossing her invisible fence along the way. Just as my pup gets totally frustrated with chasing squirrels and never catching one, healthcare providers are continually faced with new regulatory requirements and deadlines. Costly, elusive and resource-draining, three of these deadlines are converging upon providers in 2014. So which one should you chase?

According to Nelly Leon-Chison, RHIA, director of coding and classification for the American Hospital Association, there are multiple initiatives that all require your attention. You need to chase all of them and three are interrelated:

• ICD-10
• Meaningful Use of EHRs, Stage Two
• Healthcare Reform

At AHIMA’s recent ICD-10 Summit, Leon-Chison suggested providers create interrelated steering committees for these three initiatives, since the technology and resources to support them are interconnected. ICD-10 will be the enabler for these and many other requirements going forward.

Organizations that ignore ICD-10 preparations do so at the risk of getting repeatedly “shocked” by the invisible fence. There will be qualified personnel shortages in four key categories: clinical coders, clinical documentation experts, physicians and billers. When my dog crosses the barrier, her collar shocks her and constantly reminds her of her infraction.  Capital and human resources may be the “pain” your organization will suffer around ICD-10 when you’re out of people or money.

Further complicating the 2014 chase, HHS has also proposed a rule that would adopt a standard for three new identifiers.  These include:

• A unique health plan identifier (HPID)
• An “other entity” identifier (OEID)
• A National Provider Identifier (NPI)

These new identifiers were announced as part of the ICD-10 compliance date announcement, so they are part of a larger initiative. And anytime the word “standard” is used by the federal government, things tend to get a little unpredictable. Just like those squirrels and the dogs that chase them.

TrustHCS wishes you the best of luck in your pursuit. We are here and ready to assist with know-how, technology partners, and educational resources. Now, I need to go find that dog!

Planting a Great Tree—Grandpa’s Advice

My grandfather always told me that to grow a great tree; you need a great hole…and some good dirt. In many ways the move to ICD-10 is similar.  Great clinical documentation is the hole. And strong clinical coding is the dirt. Together they make a great tree.

Clinical documentation improvement (CDI) professionals bring it all together and make sure the great tree not only grows, but thrives. The bring continuous fertilization of current knowledge related to requirements, guidelines, queries and more to the entire documentation, coding and billing process.

So to use Grandpa’s advice, healthcare providers should ensure strong clinical documentation first and foremost as they proceed towards successful conversion to ICD-10.  Physicians, coders and CDI professionals…they all go hand-in-hand together and feed off of each other to make each complete.

According to recent studies, only 37 percent of physician documentation in existence would meet standards set by ICD-10.  Most organizations, in other words, will find that the documentation they have on hand is nowhere near as specific as it should be to support ICD-10 coding. The most important element of ICD-10 preparation process is clinical documentation assessment and improvement.

If your organization has not yet established a CDI program, there’s no time to wait. Beyond ICD-10, the benefits of improved clinical documentation include:

-          Improved patient safety and quality care

-          More accurate public reporting

-          Reduced denials and audits

-          Fewer physician queries and coding delays

-          Improved case mix index

The professional team of CDI experts at TrustHCS has shared a few important points about clinical documentation below. Use these to justify your program with executives or increase funding for your current efforts.

• There is a direct link between improved documentation and higher reported quality findings.
• As documentation improves, so does the overall picture of quality care.
• Understand your patient population and what DRG changes you’ll see in ICD-10: then drill down into documentation with assessments, education, training, and testing.
• Begin documentation quality reviews now and move them forward; into real time physician queries as they are creating reports within the EHR or via transcription.
• You can invest in computer-assisted-coding, but if your documentation isn’t there, CAC won’t help at all.
• Bring all diagnosis capture methodologies together to make it easier for physicians: paper, transcription, speech, EHR templates.
• Categorize your physician problem list into acute, chronic but stable and cured.
• Make sure your EHR documentation templates are ready for ICD-10; they need to be much more specific.
• Increased specification of location is significant in ICD-10; teach physicians to be very specific about physical location and make sure coders know their anatomy and physiology!

Strong clinical documentation is the first step in better coding, reimbursement and ICD-10 success. Just like Grandpa said, you need a great hole. Get digging!

AMA Pushes Back Again…The Real Issue

The American Medical Association, not satisfied with HHS’s push-back of the ICD-10 deadline to October 1, 2014, has protested again. Perhaps one of the reasons for their continued dissent is lack of guidance and support.

While much has been published about the implementation of ICD-10 for hospitals, the body of knowledge for physician practices and medical groups is sorely lacking. Vendor upon vendor is assisting hospitals, but who is helping the docs?

I readily admit the move from ICD-9 to ICD-10 is a huge undertaking. However, only diagnosis codes change for practices and groups, not procedure codes. And while physician payment is not driven by diagnoses codes, they are still required to show medical necessity. This is where practices must be thoroughly prepared to make the leap.

Specialty Matters

Family practice, hospitalists and internal medicine groups may have a more difficult time converting from ICD-9 to ICD-10. Specialists will find the transition much easier. Why?

Generalists see a large variety of patient conditions. So their documentation and support staff must be educated in all anatomy, physiology and disease processes—while specialists treat a limited sub-set of the patient population. Therefore their documentation needs to be refined in only a few key areas. And staff only needs to focus on one or two body systems.

To get started, CMS has prepared ICD-10CM information on their website. Now is a good time for practices to test the water with what to expect; and begin developing a training plan, even for single practitioner practices

Tips from TrustHCS

Our experts have also provided some tips for practices and groups to ease the transition to ICD-10. We’re always available to help and support your efforts. We’ll make the move to ICD-10 easier…really!

• Practices owned, managed or affiliated with a hospital should reach out for guidance and resources.
• A targeted, specific training approach is the most cost effective and practical strategy for specialty practices.
• Train in small increments and preferably have another physician involved for peer-to-peer support.
• Deepen your staffs’ biomedical knowledge, particularly in the body systems that you treat.
• Take a tailored step-by-step approach and do a thorough ICD-10 assessment and planning early.
• A period of parallel testing with both I-10 and I-9 codes is recommended if at all possible.
• Work with like practices, payers and hospitals as a regional consortium on the I-10 issues facing you all.

Start Your Engines…Again

May is an important month for starts. The greatest two minutes in sports starts in May. The fastest two hours of racing starts in May. And perhaps the green flag on ICD-10 will drop in May.

In my March 7, 2012, blog post, “What to do Regardless. 5 ICD-10 Steps to Continue.”, I suggested a one-year delay for ICD-10 would give providers the right amount of time to prepare, train and test.  Perhaps Secretary Sebelius read my blog. Or perhaps not. Either way, a one year delay is the best solution for our entire industry; and TrustHCS strongly supports this recommendation.

So as you sit through a 30-day rain delay (comment period), go ahead and re-adjust your ICD-10 schedule and race-day strategy, with a 2014 checkered flag in mind. Here are some suggestions.

Procrastinators

If your organization hasn’t started the race towards ICD-10, the one-year delay is an answer to prayer.  The additional 12 months gives you time to catch up and get your engines started.  If your organization is still a rookie, here are three critical steps to take right now.

• Establish a multi-disciplinary committee.
• Create an organization-wide inventory of all software applications that house an ICD-9 code. Ask if systems will be ready for ICD-10 and when.
• Conduct an overall ICD-10 readiness assessment of your entire organization.

Back of the Pack

Perhaps you started the race but find yourself back in the pack. The additional year provides you with much-needed breathing room and reduces your stress in 2012. Use the extra time to:

• Fine-tune your ICD-10 plan and budget.
• Begin a CDI program if you don’t already have one; or integrate the one you have into your ICD-10 team.
• Meet with your payers and vendors to discuss dates for system readiness and testing.
• Plan and budget for a period of parallel coding in ICD-9 and ICD-10 to assess documentation or coding deficiencies and how they will impact your cash flow.

On the Lead Lap

Congratulations. You’ve made significant strides toward ICD-10 and are well-positioned to take the lead. Here are a few ways to guarantee a smooth transition.

• Continue to test systems and payor transactions.
• Extend your CDI and training efforts; particularly with physicians.
• Implement new technologies like computer-assisted-coding (CAC) to offset expected drops in coder productivity.
• Review and update all your documentation forms and templates; especially those within your EHR to ensure your clinicians capture the specificity needed for ICD-10.

All great race teams experience delays. Rain, crashes and time-outs are common. So do what the best racers do; keep your engine warm, put on fresh tires, take on more fuel, and be ready when the green flag drops.

Be sure to introduce yourself to us at next week’s AHIMA ICD-10 Summit. We are an official sponsor and will be moderating a general session on Monday, “Three Paths to Preparedness: Providers, Payers and Vendors Speak Out on ICD-10”.

Improving the Improvement Program

Many providers have CDI programs. The belief is that more accurate, detailed clinical documentation is better for the patient, the institution, the government, researchers, and all aspects of quality of care. So why not have an improvement program for the improvement program?

Too many CDI programs focus on the short-term goals of reduced denials and fewer queries only for those DRGs and types of cases payers are reviewing today. But a truly visionary CDI program takes a much longer-term view of both the areas for documentation improvement and the ability  for programs to achieve a return on investment.

Certainly, CDI programs should focus on current areas of weakness that are impacting cash flow, but with a focus on the longer-term goals; like successfully implementing ICD-10 and building the framework for strong documentation practices that will support future  upgrades to coding systems.Quality initiatives and pay for performance seem to be gaining traction as healthcare initiatives, which would also benefit from better, more accurate documentation. Looking forward to incorporate these programs into today’s CDI initiatives gives providers time for a methodical, transition to any new reimbursement model – not to mention solid quality data and business intelligence to make better, long-term decisions.

Trying to jam change into the last minute is a formula for mediocrity. You get done the absolute minimum needed to meet a program’s needs but you never reap the upside benefits that these programs present.

Your CDI initiative is a living process that should be proactive to future needs, not reactive. Preventative medicine is always preferred to illness intervention. Make sure your CDI program has an oversight group charged with improving the improvement program. While ICD-10 and the many other initiatives in healthcare seem to be overwhelming, a successful CDI program can greatly smooth the road to change.

Do The Work Anyway

In the ICD-10 transition there is only one question that is relevant. Will it happen or not? If you think not, then you need read no further. Of course, you would be in the minority. Practically everyone in the healthcare industry believes the transition to ICD-10 is going to happen, the only real question is “when”.

With Y2K we actually had an advantage – the date could not change. With ICD-10 the date can…and has, again!

The AMA in its infinite wisdom flexed its muscle and pressured the government to call a time out in the process. The government, a paragon of productivity, has decided to do something. What, we do not know. When, we do not know.

To take a project of this size, which has been in the works for years, and put it on hold does a major disservice to those who are doing the work to make the transition. And unfortunately rewards those who chose to ignore it. It seems like a sorry state of affairs.

The ICD-10 deadline is not a surprise to anybody. The rest of the civilized world has been using the code set for years. The Oct. 1, 2013 deadline has been in place for years. The healthcare industry has been talking about it for years. Perhaps that is the problem.

In the healthcare industry we talk and talk and talk; and then scramble to do the work. Like students who procrastinate until the due date looms we wait until the last minute and then complain about the amount of work that needs to be done. Of course, to add credence to our arguments we state there is too much other activity going on; we couldn’t possibly fit it all in.

My observation is that healthcare has been in this state for at least 30 years and there does not seem to be any end in sight. Waiting for a respite in workload is really an argument to not do the transition, since there will not be a respite-ever.

This all being said, it is obvious to me, and many others in the industry, that there is only one logical course of action. Just Do It!

If you do the work to transition to ICD-10 and the date does not change, then you are in good shape and early. If you do the work and the date moves further out, you are blessed with more testing time, more time to insure vendors and payers are up to speed, more time to hone coder skills and minimize productivity loss, and more time to get it right.

Lastly, if you haven’t started and now are waiting for a new date, then shame on you.

What Do You Do Regardless? Five ICD-10 Steps to Continue.

The AMA lobby is strong. And U. S. government program delays are common. The two came together on February 16, 2012 when Health and Human Services Secretary, Kathleen Sebelius, announced a potential delay in the October 1, 2013 deadline for ICD-10 implementation.

The announcement, made just before the start of the HIMSS12 Annual Conference, left a lot of attendees scratching their heads and asking themselves, “now what”? Most agreed a delay of one year or less gives everyone more time to prepare, train and test. However, a delay of greater than one year spells chaos for healthcare providers and payers.

While at HIMSS, TrustHCS had the honor of sponsoring an executive roundtable on ICD-10.  During the roundtable, speakers discussed five ICD-10 projects that should be continued, full steam ahead, despite the delay. It’s a good list and worth sharing.

In general, the panel’s advice was to identify ICD-10 tasks that have collateral benefit for ICD-9 coding. These are the tasks that should be continued until such time as HHS makes another announcement regarding their plans, intentions and deadlines.

Vendor and Payer Assessments

Continue checking-in with vendors and payers to see when systems will be ready for testing. Know what the ICD-10 upgrade will cost your organization, if anything. And if your vendor simply can’t accommodate, start evaluating new systems to replace them.  Conduct ICD-10 testing with your payers whenever and wherever possible to help reduce backlogs and denials upon go live.

Clinical Documentation Improvement

Any improvement in clinical documentation specificity and granularity will help support better, higher quality coding.  And reduce time wasted querying physicians. Coders can only code what is documented. This same core principle applies in ICD-10. CDI programs must be continued regardless of a delay.

Coder BioMedical Training

While educating coders in the finer nuances of ICD-10 coding can be postponed, strengthening their knowledge of the basics can’t.  Many coders graduated from programs ten, fifteen, even twenty years ago. Medical science and our knowledge of anatomy, physiology and disease processes has grown exponentially. Now’s the time to make sure your coders are brilliant at the basics. Anatomy and physiology training should continue to be conducted: online, through a service provider or at a local community college.

Computer Assisted Coding (CAC) Technology

Coder productivity is predicted to drop by 50% during the implementation of ICD-10. And perhaps remain 10-20% below normal output for ICD-9 coding. CAC systems help offset this productivity loss by electronically “reading” the record and suggesting codes to the human coder. While CAC systems don’t replace coders, they do make them more productive and efficient.  The delay provides more time for organizations to evaluate and implement this technology.

Assess and Refine Your Work Plan

Conduct a methodical step-by-step review of your initial plan. This process will identify which tasks can be pushed out and which cannot. The review will also uncover other tasks that have “collateral benefit” for ICD-9. For each task in your work plan, ask yourself, “does the delay impact this task” or “does the delay not impact this task”.

Industry experts are already predicting the cost of an ICD-10 delay. Other experts are predicting law suits by providers to help recoup monies already spent. This expert simply suggests that you stay the course and keep working toward ICD-10 preparedness. We will all have to get there eventually. Better to be early than late on this one!

CDI: Easier Said than Done

In January, For The Record published an article on the difficulties and benefits of implementing a clinical documentation improvement (CDI) program. As well as input from me, it includes valuable insights from Drs. William Walker and Jerri Williamson. Including physician input to the article underscores one of the main success factors of any CDI program. That is, the need for physician involvement.

When we say physician involvement we really mean involvement! Peer to peer communication is widely viewed as the best practice in any physician interaction.

Physician champions are essential for training and explaining. They are needed to not just explain the “what” of CDI but also the “why”. Giving good reasons to alter documentation behavior, backed by actual case examples and financial impacts, greatly increases your medical staff’s motivation to change.

Another key point mentioned in the article is healthcare’s natural tendency to link CDI with coding and reimbursement. Instead, I propose that HIM professionals and physician advisors are better served to focus on quality data, accuracy of severity and acuity.

Much of a hospital’s coded information gets translated into publicly available physician ratings and rankings. And since physicians are extremely competitive, they will work hard to protect their image and make sure they are not an outlier of adverse outcomes. Accurate documentation portrays the correct severity of illness of a presenting patient and therefore communicates the correct outcome.

Finally, better documentation improves patient outcomes. All healthcare professionals who subsequently treat the patient see a complete picture of condition and treatment.

In summary, the goal for HIM and CDI professionals is to train and educate physicians about coding and reimbursement implications while also stressing the end product: improved patient care and better quality indicators. Your commitment to these goals, clearly communicated, results in stronger physician commitment and better clinical documentation.

Making Mistakes. Check Your ICD-10 Education Budget.

If you are going to make a mistake, make it in the direction of action. Clearly an adage the 2011 Congress never understood. From my experience, embracing action instead of perpetually chasing perfection makes more sense—and gets better results. Since no one in the U.S. has implemented ICD-10 coding, mistakes will happen and providers will be caught off-guard.

A recent AHIMA survey confirmed that most organizations are uncertain about ICD-10 education and training requirements. There still seems to be some confusion about how much to budget and when to start. When asked what they “expected to budget” 40 percent thought a low amount was adequate. However among those that have actually budgeted for ICD-Training, only 27 percent were low while 39 percent budgeted high amounts. It seems that those that have thought it through are finding there is more than meets the eye. The survey was done by AHIMA and is available here: HTTP://journal.ahima.org/2011/12/12/expecting-a-bargain-on-ICD-10-training/ . While they did not state the actual numbers of the high and low estimates, they did say that there was a $2000 difference per coder between high and low.

It is true that approximately 50 hours of training is required for learning the technical aspects of ICD-10. But there is a wealth of biomedical information required to understand the granularity of coding in I-10. If you are going to have a “miss”, it is likely that it will be in the area of bio-medical education, a mistake that will most certainly cost organization in both time and money..

All of the international experience with ICD-10 shows that countries wish they had started earlier and budgeted more. But those countries do not use I-10 for reimbursement. The U.S. revenue model is going to complicate implementation further. So on top of all else, your revenue stream is at risk.

Make the investment of time and money to educate and train-and make it now. In 2012, training should be condensed and budgets formulated for a shorter period. Assess the base knowledge levels of your coders now (AHIMA has the tools). Then spend 2012 laying the educational foundation for success. In 2013, conduct technical ICD-10 training.

It is always best practice to do something. Even, if it is a mistake-make it in the direction of action. I think you will find, in this case, that it is not a mistake!

What’s A MAtter with Them?

The AMA in their infinite wisdom voted in November of 2011 to “work vigorously to stop implementation of ICD-10.” They characterize the system as having no direct benefit to individual patient’s care and being a significant burden on the practice of medicine.

Well, they are half right; it will be a significant burden, one that has been coming for years. The announcement that it will go live on Oct. 1, 2013 has been in place for years, but the AMA has waited until now to say “we don’t want to!”

In a recent ICD10Watch.com poll, the majority of readers believe ICD-10 is written in stone and AMA’s efforts will not succeed. Only time will tell, but a quick tour of  ICD-10′s benefits is certainly in order.

Every civilized country in the world is on ICD-10 and has been for as much as 15 years. We are the lone laggards who still use the out dated, inadequate ICD-9 classification system. Oddly, the other countries seem to see a clinical benefit of having more accurate, granular information describing a patient’s health status.

Yes there is a lot going on in healthcare at this time, but I do not remember when there was a time without a lot going on. So, bite the bullet and do the work and the pain shall all pass.

HHS has helped the cause by delaying the meaningful use (MU) stage 2 deadline to 2014 for eligible professionals and hospitals. The announcement was made by Dept. of Health and Human Services Secretary Kathleen Sebelius. The announcement was cited as part of an initiative to speed the use of health IT in physician office and hospitals to improve healthcare and create jobs nationwide. Both goals are admirable.

Physicians should take advantage of this “breathing room” and implement ICD-10. It seems the large effort to try and stop ICD-10 could be better utilized to help implement ICD-10