Entering the First Drop in Coder Productivity on the ICD-10 Roller Coaster

We are well on our way to moving through the second quarter of 2013.  This is the time many identified they would begin dual coding for ICD-10.  Let the drop in coder productivity commence!

As we look forward to the next few years making it through the big ICD-10 transition and getting past major implementations like Computer Assisted Coding (CAC), there are other twists, turns and major drops on this roller coaster.

After the dip from dual coding, many are looking to address their Clinical Documentation Improvement initiatives in preparation for physician education in the area of ICD-10.  When the query process picks up, productivity may experience another dip.  We will all catch our breath from those back-to-back drops only to have a massive hit again on October 1, 2014.  If Canada’s experience with the transition is a realistic expectation, this will be the “major thrill” of the ICD-10 productivity roller coaster.  We could see an immediate dip of 53%.

However, don’t worry.  The roller coaster will likely end with a leveling out at an overall 19% productivity hit (again, if Canada’s experience plays out here in the United States).  The last bastion of hope to off-set that 19% dip in productivity rests with Computer Assisted Coding.   CAC could come in and make up the difference for the productivity dip, and it’s expected to deliver on that hope.

Any way you slice it, productivity of an already overburdened coding staff is just now entering the thrill portion of the ICD-10 ride.  Hold on tight!

Build Versus Buy for ICD-10 Staffing? Do Both.

The need to augment staff before, during, and after the transition to ICD-10
should be a top revenue cycle issue and HIM priority (if it isn’t already for your organization). To effectively transition to ICD-10, staffing augmentation plans must be developed now, particularly in clinical documentation improvement, clinical coding and revenue cycle integrity.

Two strategies for staffing augmentation are to build and to buy: grow your own staff and outsource for back-up support.

Build a Team—and Grow

The “grow-your-own” strategy requires providers to identify internal ICD-10 experts now and ensure they receive in-depth training. Once trained, these experts serve as the organization’s ICD-10 specialists to lead ongoing staff development efforts. You can use a variety of instructional materials and learning approaches, including:

• onsite classes
• web-based materials
• partnerships with local community colleges

Costs for a “grow-your-own” program vary based on the existing knowledge base in biomedical sciences (anatomy and physiology, pathophysiology, advanced medical terminology, and pharmacology) and the training methodology used.

The best candidates for internal education are:

• coders who currently work in outpatient coding areas and who are familiar with CPT coding
• nurses and other ancillary professionals
• medical transcriptionists

Buy a Team—Secure Outsourcing Partners

Coding, billing, and CDI outsourcing companies are all recruiting from the same labor pool. So contracting for the best and brightest professionals now, rather than waiting until 2014, is critical. Below is a checklist of sample questions and talking points to ensure you’re covering all bases when searching for qualified outsourcing partners:

• Productivity, Quality, Turnaround Time
• Technical Support: Provider and Vendor
• Sufficient Ramp-Up Time: Average on-boarding time for an outsourced coding vendor is 40 to 60 days.
• References
• Credentials
• Processes
• ICD-10 Competency

Many healthcare provider organizations are financially unable to take advantage of both internal and external options. If your internal resources do not allow the “build” approach, arm yourself with enough “buy” research to fit an outsourcing partner to your specific needs.

Stay tuned for next month’s blog on my recommendations for a multi-partner approach.

CAC – A Palliative Measure for ICD-10

Just as analgesics relieve pain and help the body return to a state of normalcy, Computer Aided Coding (CAC) may have the same effect on coder productivity in a post ICD-10 world. CAC applications may be able to mitigate much of the productivity loss expected from coders at ICD-10 go-live.  If done properly, industry experts predict that CAC systems will provide a 10-20 percent productivity gain for clinical coders. However, “done properly” is the operative phrase.

Effective implementation of a CAC solution requires the same thoughtful approach utilized in any other successful technology deployment.  There are no “plug and play” solutions in healthcare anymore.  Organizations must develop realistic timelines and expectations for CAC deployments and be willing to do end-to-end testing to ascertain the realistic impact and benefits of its use.  Potential impact and actual impact are miles apart.  We must learn from our past naiveté and enter into this next generation of HIM technology with our eyes wide open.

NOT a Magic Elixir

What CAC will NOT do is replace your coders.  It is not a magic elixir.

CAC systems perform well only when complete, accurate, and terminology rich documentation is fed into them.  CAC can only code what is provided to them in electronic format.  These systems only recognize and read digitized data. Scanned or handwritten text simply will not suffice.

Even analyzing the digitized data is a skill set that is best accomplished by well trained coders. Hidden details and nuances are the realm of human coders.

It is estimated that in the months following ICD-10 adoption coder productivity will decrease significantly, most reports forecast an initial drop of as much as 50 percent and sustained losses of 20%, optimistically. CAC may be able to make up most of that downside – but only if you get it up, running, tuned, and integrated into your workflow soon.  This is a process best perfected before the ICD-10 storm hits.  Plus, if you are going to dual code in order to test – you will want to integrate your CAC into that testing.

For more information about the relationship between CAC and ICD-10, read our earlier blog on the 5 Steps to Continue for ICD-10.

Calling All Coders! Broaden Your Focus

ICD-9 coders are adept professionals. They extract information from clinical documentation and assign a code – often from memory.  ICD-10 changes all this. It wipes out coders’ memories and requires a complete re-tooling of their skills. The sheer volume of codes requires much more analysis and research by these life-long, career professionals. Coders’ focus will change. Their skill sets will transition.

• New Skills
• Expanded Knowledge
• Better Opportunities

With ICD-10, coders must fully understand the ramifications of revenue cycle, audit, and clinical documentation.  This larger view forces coders to step outside the world of HIM and build new skills in communication, tact, and cross department relationship building.

On the flip side, ICD-10 drives new benefits for clinical coders. Doors will open in the areas of new opportunities, expanded professionalism and more career options. To seize these opportunities, coders must insist on expanded education and training from their employers. They must become more clinically adept while also increasing their knowledge of charge masters, revenue codes, modifiers, and UBs.

Get Ready to Shine!

To excel in this new active world, it behooves coders to become much more active in the transition to ICD-10.  You can help drive the process by getting the skills you need now versus waiting until 2014. TrustHCS recently conducted an ICD-10 readiness survey. Nearly 100 percent of respondents stated that coders would (or are) undergoing additional training.

Make sure your training is broad and wide. Understand the impact of ICD-10 across all departments. Think horizontal workflow with ICD-10. And abandon the vertical silos of ICD-9.

For more tips on how coders can prepare for ICD-10 and HIM Directors can prepare, read my September blog here.

Planning for the Drop. What’s Your Strategy?

HIM professionals should begin now to plan for the drop in coder productivity predicted for ICD-10; and then define a strategy to mitigate it. Strategies can range from backfill outsourcing to complete outsourcing and computer-assisted-coding (CAC).

The important point is to develop your strategy now and secure executive support as mentioned in a recent blog, “Three Points for Your CEO”. From a financial perspective, your CFO should understand the anticipated drop in coder productivity and plan for the possibility of delayed revenue and stymied cash flow.

One piece of the puzzle, CAC, will require particular focus and attention as costs are high and implementation timelines are long. If CAC is part of your strategy, now is the time to get started.

And while CAC systems will be an effective tool for ICD-10, they are not a panacea to cure all ills.  They are only as good as the underlying NLP engine and system interfaces (including EHR interface).   Careful evaluation, implementation, training and rollout are essential.

Post implementation of a CAC, coders will become auditors of the system. They must be able to quickly identify errors that will then spur further education and system development.

Finally, your coder auditing program post ICD-10 should be discussed and a plan created. We recommend you treat ICD-10 the same as all new coders and audit very frequently until there is a high level of confidence in the new coding system.  Then we suggest moving to a quarterly auditing program to ensure quality. Check out our “7 Tips for Highly Effective Audits”.

Don’t let a drop in coder productivity inhibit your ability to get bills out the door in 2014. Decide now what strategies you will employ to account for the drop and get them implemented. There will be plenty of other roadblocks; your coders don’t have to be one of them!

Ready. Set. Go. Repeat. Three Things HIM Should Do Now.

The certainty of uncertainty is finally over. With the new ICD-10 go live date firmly in place, healthcare providers can get back to work on ICD-10 preparation, education and implementation.

Bring out those plans and re-convene the team. It is time to get back to work for ICD-10! Here are the top three things to get done in 2012.

• Fine-Tune Educational Plan

Now is the time to lay out a detailed educational plan for coders and clinical documentation improvement (CDI) teams. ICD-10 education requires a great deal of time, effort and money, especially for coders and CDI. Be sure to include all associated costs and obtain executive approval.

Over the past six months, TrustHCS has been conducting joint training workshops for coders and CDI one MDC at a time.  The results are impressive and feedback has been very positive and supportive of this educational approach  We highly suggest training these two groups side-by-side.

• Assess Clinical Documentation

Industry experts suggest that 73% of existing clinical documentation won’t pass muster for ICD-10.  If this is truly the case, there is a lot of work to do in this area.

Another important task to begin now is assessing the adequacy of your Clinical Documentation Integrity program.  Are your physicians responding to 100% of their queries?  Do you feel you are missing opportunities to code CC’s and MCCs? Do your coders and CDI Specialists meet routinely with their leadership to compare data and plan operational improvements?

Robust CDI programs reflect quality in care that is publically reported, impact length of stay, support medical necessity, and maximize revenue to name just a few.  Focusing on specific diagnosis and procedures that carry new or more-specific documentation requirements in ICD-10 is critically important. It is also important that you align all documentation stakeholders toward the goal of having outstanding clinical documentation that reflects the highest quality of care.

Check out our other blog posts on this critical topic!

• Update Executive Team

If your organization placed ICD-10 on the back burner these past six months, now is also the time to re-ignite senior executives. Leadership needs to lead and support the areas that will be operationalized for ICD-10.

ICD-10 is a C-suite and Board of Directors responsibility first and foremost. Delegation of ICD-10 readiness cannot be laid at the feet of HIM.  Additionally, revenue cycle needs to be actively engaged as does the IT department and many clinicians, over and above physicians.  Executive presentations should address these three areas:

• Financial Risk
• Reputational Harm
• Staffing Impact

Learn  more by reading Torrey’s blog on this topic: “Three Points for Your CEO”.

ICD-10: Three Points for Your CEO

As a rule, healthcare CEOs rarely get involved with health information management (HIM) concerns. Until now. The move to ICD-10 is the exception to the rule. Chief executive officers at healthcare provider organizations (hospitals or large physician groups) should be educated, informed and wary of ICD-10 for three strategic reasons.

Financial Risk

Reimbursement will change under ICD-10. Additional costs will be incurred. The bottom line –financial health is at risk.

Inform your CEO of ICD-10 costs including the groundswell of technology expenses, operational outlays and consultant fees. All of these expenses will be incurred under their watch and reported to the hospital board.  Secondly, conduct as many revenue analyses as possible to predict service-line winners and losers under ICD-10. Share this information openly with your CEO.

Reputational Harm

CEOs must ensure their organization is the first choice for quality healthcare services within the communities they serve.  Quality reporting and consumer access to quality scorecards has become an important step in achieving this goal.  However, most CEOs do not understand how faulty coding leads to incorrect quality reporting, and paints a negative picture of care delivery.

Educate your CEO of the cause-and-effect relationship between coding and public scorecards. And beyond coding, the underlying impact that clinical documentation has on quality reporting. Clinical documentation, coding and quality; they are all tightly intertwined in ICD-10. This is a fact all executives must understand!

Staffing Surge

There will be an increase in the amount of human resources needed to get cases coded and billed. Organizations will be forced to hire more staff and increase their use of outsourced services. While both these facts are well-understood by HIM, CEOs may not understand.

Don’t let your CEO be caught off-guard when human resource and outsourcing costs explode. Cost-justify these expenditures now and sharpen your predictions for additional staff. An informed CEO is HIM’s greatest ally.

ICD-10: It Takes a Village

Great efforts require strong collaboration.  No significant change has ever been accomplished alone. From starting a small business to developing a nationwide information infrastructure, partnerships are stepping stones to success.   And the implementation of ICD-10 is no exception.

As providers await news of the final conversion deadline, many are already underway with their ICD-10 preparations. Selecting key partners for the transition has become best practice and part of nearly everyone’s plan. But what types of partners are necessary? And where can they be found?

In our experience, there are five types of partners you will need for the transition to ICD-10. These include:

• Project Management
• Technology
• Training / Education
• Staff Augmentation
• Revenue / Reimbursement Analytics

Most providers have already identified a project management partner. This partner will help assess your current readiness, conduct a gap analysis, create timelines and budgets, etc. While many organizations have selected a “big six” firm to manage their ICD-10 project, smaller companies are also ready and willing to help. Asking regional peers for their recommendations is a good place to start.

Technology partners will work with your existing IT leadership and software vendors to identify all systems impacted by ICD-10, create a vendor spreadsheet or database, and ensure all technology is ready for ICD-10. Include in your spreadsheet: vendor and product name, primary area of usage, impacted system interfaces, internal business owner, primary technical lead and all contacts.

Beyond the basics, ask your vendors about their readiness and keep track of their replies. Some questions to ask include:

• Where are they and what code level will be required?
• How has the delay affected their strategy?
• What collateral/support/tools are or will be available?
• Will the application be updated….or sunset?
• Can we see a demo?
• What is the timeline for development, testing and go-live?
• Can they provide a complete checklist / milestone survey?

Securing a training and education partner should be your next task. There are many options available designed to suit every budget and learning style. AHIMA provides much practical guidance on what types of training will be needed and when.  Different users throughout the health system will require varying depth of ICD-10 knowledge. Training and education should be planned with each user’s needs in mind—no more, no less. And based on the Canadian experience, coder and physician training in particular will be an ongoing concern.

Experience tells us that productivity drops significantly with ICD-10 and may never return to ICD-9 levels. This is true for coders as well as clinical documentation improvement and billing professionals. Assuming a productivity drop during the training period and an ongoing deficit, staff augmentation is essential.

Keep in mind that all staffing and outsourcing agencies will be recruiting from the same pool of credentialed coders, so be sure to contract with a reputable, high-quality firm early. For one of our clients, Northern Arizona Healthcare (NAH), a not-for-profit healthcare system serving Northern and Central Arizona, the partnership for both education and staffing was approached holistically across the organization, versus exclusively from a coder or health information management (HIM) perspective.

Finally, intense revenue/reimbursement analytics should be performed for two reasons. First, providers should understand which DRGs will be revenue winners and losers under ICD-10 based on current clinical documentation. With this knowledge, specific documentation weaknesses can be addressed. Second, reimbursement must be monitored and managed post-conversion to continually identify areas for improvement and make strategic, service-line decisions.

We’ve had nearly three decades of experience with ICD-9, tracking the revenue impact and educating our staffs. None of our progress has been made alone. We’ve used technology, auditors, consultants and staff. ICD-10 is much the same. Partnerships and collaboration are more important than ever…and should be top of mind for us all.

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!

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.