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!

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.