By Mary Butler
Anyone who has bought a home has inevitably heard at some point along the way that “real estate is always a gamble.” That’s cold comfort for anyone who’s plunked down earnest money on a fixer upper. But smart buyers know that if they’ve done their research and invested in the right places, their dream home is well within reach if they can just look past the spackle smears, dried wallpaper paste, and leaky pipes.
The transition from renting to owning is enough to send anyone into a panic, but putting the process off comes with risks as well. What happens when your family suddenly gets bigger and you’re stuck with a leased home where nobody fits? Tempers flare and pretty soon paying those inspection and lawyer fees starts to feel like a bargain in exchange for your sanity.
The transition from ICD-9-CM to ICD-10-CM/PCS has been fraught with similar frustrations. Medical researchers, coders, billers, and payers have been struggling to make do with an outmoded classification system for decades, and at a great cost to the healthcare system. They’ve been sidelined by politics, bureaucracy, and providers intimidated by the costs and investments required to make the transition.
On October 1, 2015 it should quickly become clear to coders and health information management (HIM) departments whether or not their investments paid off. Like the new homeowners about to take a sledge hammer to drywall for the first time, things might get messy at first, but there’s no turning back in pursuit of a better way.
To make the switch to ICD-10 successful, the healthcare industry will be looking to HIM leaders to help them look through the implementation dust and debris of change and outward into the near future—when the healthcare industry will finally be living the benefits of ICD-10. It’s up to HIM leaders to let their facilities know what to expect when the coding switches flip on October 1, six months after that, a year after that, and beyond. Like real estate agents selling buyers on their dreams, HIM has to be able to communicate the reality of the ICD-10 world.
ICD-10’s Long, Dramatic Timeline
ICD-9-CM is implemented in the United States.
The National Committee on Vital and Health Statistics (NCVHS) sends the Secretary of the US Department of Health and Human Services (HHS) a letter saying ICD-9-CM could stress the quality of the healthcare system to the point where quality care could become compromised.
ICD-10 is released by the World Health Organization.
The Healthcare Financing Administration contracts with 3M to develop the procedure classification system to replace Volume 3 of ICD-9-CM (hospital inpatient procedures), known as ICD-10-PCS. The new procedure classification adheres to the criteria established by NCVHS for a procedure classification system in 1993.
The Centers for Medicare and Medicaid Services (CMS) posts the ICD-10-PCS coding system, training material, and crosswalk to ICD-9-CM procedure codes on its website.
ICD-10 is implemented in the US for mortality reporting.
Subcommittee on Health of House Ways and Means Committee holds hearing on the adoption of ICD-10-CM and ICD-10-PCS.
HHS publishes a notice of proposed rulemaking for the replacement of ICD-9-CM by ICD-10-CM and ICD-10-PCS on October 1, 2011.
HHS publishes a final rule for adoption of ICD-10-CM/PCS, pushing the implementation deadline to October 1, 2013.
CMS institutes a code freeze in preparation for ICD-10.
Facing backlash from physicians’ groups, HHS publishes a final rule that delays the compliance date for ICD-10-CM/PCS from October 1, 2013 to October 1, 2014.
The Protecting Access to Medicare Act of 2014 is enacted,
which contains a provision prohibiting the HHS Secretary from adopting the
ICD-10 code prior to October 1, 2015.
CMS begins end to end testing of ICD-10.
October 1, 2015
ICD-10-CM/PCS implementation deadline.
Life After ICD-10: Implementation Date to Six Months
With ink on the contract and house keys in hand, new homeowners can finally see what they’re dealing with. Once they start putting primer and color on the walls, it’s much easier to imagine what life will look like in the coming months.
Similarly, speculating about what life might be like for coders, physicians, and hospitals immediately after the ICD-10 go-live date is as hypothetical now as it will be in October—and one’s viewpoint is likely to have a lot to do with their level of preparedness. Facilities that have practiced dual coding or engaged in end-to-end testing with their payers and with the Centers for Medicare and Medicaid Services (CMS) will be much better off than providers who have not, though a drop in coder productivity is expected across the board.
Pat Maccariella-Hafey, RHIA, CCS, CCS-P, CIRCC, director of education at Health Information Associates, says the biggest slowdowns in productivity are likely to be a result of the complexity of procedure codes.
“A big area that will be challenging for coders is understanding the procedures that the physicians are actually doing—understanding what the physician’s objectives are in order for them to appropriately assign root operations and other characters of the PCS code,” Maccariella-Hafey says. “That seems to be where most coders struggle [and] will be an issue after implementation. That in turn will likely impact more than productivity.”
She says there’s a big difference between learning a coding or classification system and being able to understand clinical factors of a diagnosis. This is especially true in coding surgical procedures. Making sure coders have a strong understanding of the guidelines of ICD root operations should be a focus in preparation. This will be less of a problem for hospitals that have invested in dual coding and payer testing, but Maccariella-Hafey says there are still hospitals out there that believe another delay is in the offing and have put off this type of practice.
Hospitals and physician practices need to continue ICD-10 training for coding staff well after October 1, says Maggie Foley, PhD, RHIA, CCS, associate professor in the HIM department at Temple University.
“We provide lengthy clarifications in [in-house] coding clinics, and that information will need to be discussed with coding staff. [We will also need to] address issues identified in audits when training the coders,” Foley says. “I think the clinical documentation improvement (CDI) efforts will continue to focus more on procedural information than diagnostic information compared to ICD-9 because of the greater specificity in codes.”
Providers need to remain mindful that ICD-10 is also being used to drive quality initiatives, and continue training efforts as such. “CMS and other insurers are moving towards reimbursement systems with greater emphasis on quality of care and outcome measures. ICD-10’s greater detail related to these topics will enhance the use of codes for assessing quality and reporting outcomes,” Foley says. “An example of this is the greater detail in complication coding in ICD-10-CM. When coding a procedural complication, such as a hemorrhage or stroke, ICD-10-CM requires further specificity to indicate whether the event occurred intraoperatively or postoperatively,” Foley says.
Some HIM professionals anticipate that a degree of chaos will ensue after the go-live date, and many have found in audits that their current ICD-9 coding is far from perfect—which complicates matters. This was evident with the recent success of Recovery Audit Contractors (RAC), who found plenty of issues to scrutinize in ICD-9.
Wendy Coplan-Gould, RHIA, president of HRS, says she is concerned that competing health IT initiatives, in combination with the ICD-10 transition, could force some hospitals to close in the long-term, particularly those hospitals that didn’t get a line of credit in advance of claim denials or hospitals that didn’t put extra cash in the payroll coffers. She fears that the loss of coder productivity could hurt providers’ bottom line. But she emphasizes that practice makes perfect.
“I think that anybody and everybody should be chomping at the bit to do end-to-end testing. The end-to-end testing can bring up many more problems than just coding problems. It can help identify IT questions and demographics and claim edits. The more you practice, the better off you are when you go-live,” Coplan-Gould says.
Come October 1, coders and HIM departments will need to be prepared to defend their code assignments for accurate and timely reimbursement. Danielle Reno, MHA, CHC, CCS, CCS-P, ICD-10 director at Sutter Health, says the business validation of report remediation is absolutely critical to ensure providers have a seamless transition after ICD-10 go-live.
At Sutter, Reno says her team has taken reports to quality review specialists, nurses, and HIM departments for review and asked, “Are these reports what you think you need to see in an ICD-10 world?” and “Can you help us understand if these are correct?”
“If you don’t get that business validation, the meaning behind the initial reporting might be changed,” Reno says. “There are so many new codes in ICD-10 that when you map the ICD-9 codes to the ICD-10 codes, it could be a one-too-many situation where you have to have someone that really knows the code set or an HIM resource that can validate a code set to be included in that new reporting.”
Even among facilities that have been diligent in their preparations for ICD-10, close auditing of ICD-9 coding has revealed weaknesses that could show up in ICD-10 coding as well. Unless these weaknesses are addressed in training, they could persist and cause problems after the transition. Foley says that conditions such as sepsis and procedures like spinal fusions are commonly coded improperly. “Those topics are difficult in ICD-9, they continue to be difficult in ICD-10. But you start to recognize some of the weaknesses in the coding staff regardless of the coding system,” Foley explains. “Whether it’s understanding the clinical process of sepsis, or whether it’s understanding what’s actually done during a fusion procedure and all the different ways they can be done, you need an understanding.”
Life After ICD-10: One to Five Years
One year after closing, our plucky homeowners barely recognize the home they had when they first got the keys. Hammers have been put away, sconces have been hung, and their furniture is finally starting to look like it belongs there, though long-term projects remain. At least nobody is arguing about sharing the bathroom. A year after October 1, 2015, coders will still likely face some uncertainty, but real change should be apparent.
Sandra Kersten, MPH, RHIA, a senior consultant for eCatalyst Healthcare Solutions currently assigned as an ICD-10 project manager at a Chicago-area hospital, says that based on the results of dual coding efforts she’s seen, there’s reason to believe there will be a permanent reduction in coder productivity. This means that investing in extra coders before and after the transition is a smart move for facilities that can afford it. Clearly, this is an opportunity for student coders.
“I think another piece in the short term [is] that it might actually level the playing field for newer coders because you just think about it,” Kersten says. “If no one has much experience on ICD-10 coding then maybe, if we need new coders, hospitals will be a little more open to hiring coders with less experience.”
Results of preliminary provider end-to-end testing with the Centers for Medicare and Medicaid Services (CMS) is one encouraging spot for those concerned about denial rates. According to the results from one week of testing with CMS that ran January 26, 2015 to February 3, 2015, 81 percent of test claims submitted by providers were accepted. What’s more, the leading reason for rejected claims was non-ICD-10-related errors, such as use of an incorrect National Provider Identifier, an incorrect health insurance claim number, or dates of service outside the range valid for testing. Nearly 660 providers participated, submitting about 15,000 test claims.
By its very nature, coding in ICD-10 requires an elevated clinical understanding of disease processes, the clinical factors behind a diagnosis, and an ability to read and understand lab values and diagnostic reports. Maccariella-Hafey says the benefits of a more sophisticated coding workforce will be evident well before the five years post-implementation mark.
“I can see that coders will be even more educated in the clinical aspects of medicine and surgery. So coders are going to become more knowledgeable and the coding will be more accurate because there won’t be problem areas that need to be addressed through Coding Clinics,” she says.
Sutter Health’s Reno strongly believes that the availability of more precise, accurate data from ICD-10 will benefit the healthcare system within the first five years after implementation.
“I absolutely believe we’re going to have better patient care. I also believe that our payment and reimbursement systems are going to change. The data that government and commercial payers have right now doesn’t really indicate how good or bad patients are at taking care of themselves—or the quality of care they’re receiving from practitioners,” Reno says. “I believe that in five years from now—and I think it’s going to be even faster than that—we’re probably going to be able to monitor patients’ investments in their own health and monitor the quality of care from individuals to providers.”
Rhonda Butler, CCS, CCS-P, senior clinical research analyst at 3M Health Information Systems, has an optimistic short-term outlook with regard to ICD-10 implementation. Many have speculated that some hospitals won’t make the transition at all, and it is true that some hospitals and physician offices have put off ICD-10 training and other transition planning until the last minute. But that doesn’t mean October 1 is going to spell disaster, Butler says.
“I don’t subscribe to the gloom and doom predictions of dire impact on small hospitals, at least as far as coding goes,” she says. “By definition, small hospitals have less complex cases to code, and their coding tends to be the common scenarios for which there is plenty of accessible coding advice and resources. I believe that coders everywhere are rising to the challenge.”
HIM departments need to be proactive in making sure their vendors are ready before the transition, but tweaking will continue after implementation, too, particularly with electronic health record (EHR) systems. Reno says she is working with her vendor to make sure the EHR is able to capture the documentation specificity necessary to code charts in ICD-10. However, some other providers are taking a wait-and-see approach.
“We’ve had to work with them [the EHR vendor] pretty tightly on what we call ‘smart tools’ where the physicians can actually select within the ‘smart text’ the specificity they want,” Reno says. “[For example,] if they type ‘congestive heart failure’ they can select whether it’s acute or chronic right in the smart text too.”
Life After ICD-10: Five to 10 Years
Post-Implementation (and Beyond)
Within five or 10 years of purchasing a home, lucky homeowners have a hard time remembering the angst of the early days. A garden is blooming out back, granite counter tops look like they’ve been there forever, and entertaining in the space is a breeze. A mortgage still looms, but paying it is routine.
A common refrain from the government and other industry advocates pushing for the transition to ICD-10 is that it’s time for the US to catch up with the rest of the world. And within 10 years of implementing ICD-10 those advocates should see that vision become a reality. A major expectation about ICD-10 is that it will help stimulate programs like patient-centered medical homes, value-based purchasing, and accountable care organizations by giving the government and care management organizations better data to work with. Everyone stands to benefit from improved data quality, says Maccariella-Hafey. “From a reimbursement standpoint, I could see—whether it’s CMS or insurance companies—making more specific coverage determinations based on more accurate and precise data,” she notes. “From a quality perspective a lot of entities will use this data. The more specific the data, the more accurate decisions can be made, and accurate assumptions based on that data. I know CMS uses it for a lot of different core measures.”
Researchers and public health monitoring organizations want to be able to compare data apples to apples for global disease monitoring. And the US government needs more accurate data to advance reimbursement reforms. Butler believes that when ICD-10 is in full swing—10 years from now and beyond—the US will be well on its way to achieving those goals.
“Both ICD-10-CM and ICD-10-PCS are database friendly, in the sense that the same level and type of detail is applied consistently across the code set. That means they are much easier to incorporate into smart and cool apps that take advantage of that consistency,” Butler says. “My hope is that for the long term we will be able to significantly enlarge the sweet spot where machines can efficiently and accurately take on as much of the coding burden that it can, and leave the fun stuff for the next generation of coders—a bunch of smart multi-taskers who are perfectly at home in the world of information delivered electronically.”
She is quick to note that more accurate data doesn’t “magically translate into increased healthcare quality and value.” It will take lots of good people working together, and using great tools, to realize the potential of ICD-10, she notes.
But that’s not to minimize the power of ICD-10 to help fix some of healthcare’s biggest challenges. John Hughes, MD, professor of medicine at Yale School of Medicine, has been using ICD-9 data for 15 years for his research. Dr. Hughes’ research focuses on patient classification systems with a specific interest in readmission complications and predicting resource use.
Dr. Hughes says he started to become frustrated with the lack of precision in ICD-9 about 10 years ago when he and his colleagues were investigating causes of hospital readmissions but had to create workarounds to identify various causes of complications.
“We had to come up with combinations of diagnosis codes, which might be vague, and then procedure codes to find what the complication was or the severity of the complication. Very often the procedure codes weren’t that precise either,” Dr. Hughes says. “So that was just the way of the world and we dealt with it. But, there was always that lack of precision.”
A common cause of hospital readmissions is post-surgical complications. But for researchers like Dr. Hughes, it’s difficult to find patterns in surgical complications when the codes aren’t specific enough to capture an error with a technique or instrument.
To demonstrate the inadequacy, Dr. Hughes uses the hypothetical scenario in which a patient sustains a puncture wound that severed the left femoral artery. The patient undergoes surgery where the damaged portion of the artery was replaced with a synthetic graft, which is coded in ICD-9 as “resection with replacement” without any mention of the type of replacement or which side of the body the procedure was done. This lack of detail is problematic when a complication such as bleeding at the graft site occurs, and the ensuing surgical fix is coded in ICD-9 as “mechanical complication of other vascular device or graft” with a procedure code of “revision of vascular procedure.”
When this event is coded in ICD-10 a researcher can learn that the complication was a hemorrhage, know exactly where it happened, and that the revision involved a procedure to re-suture the graft using an open approach.
“When we have new procedures, inevitably there are going to be complications. It’s very useful to be able to look to see what types of complications are happening in relation to procedures and to focus on possible problems with the procedures. A lot of that stuff you can’t do prospectively. It’s only after people have been performing the surgeries in the real world that you see these patterns emerge where there seems to be complications,” Dr. Hughes says. “If there’s patterns, you may be able to say ‘This is a problem with this particular technique or this particular procedure and we need to examine why that’s happening and try to fix it.’”
He notes that using ICD-10 for his and others’ research won’t start a revolution, “just a much more sensible and effective way to perform the task already being done.”
Like a homeowner, the repairs and renovations (updates and corrections) will never fully be done in ICD-10-CM/PCS. But with the bulk of the implementation heavy lifting done in the first couple years, healthcare professionals will be set up for years and years of use of a new code set that provides more specificity, accuracy, and data that leads to a better quality of life for patients.
Mary Butler (firstname.lastname@example.org) is associate editor at the Journal of AHIMA.
"Life After ICD-10: How the Healthcare World Will Change After ICD-10's Implementation"
Journal of AHIMA