Role-based Model for ICD-10 Implementation: Long Term Care

Long Term Care

While there may be some similarities and overlap between settings this model will focus on roles in the LTC community and focus on steps to take to prepare. In order to prepare for implementation identifying who will need education, and knowledge level is a key step in successful implementation. There are many LTC roles impacted by the transition.

Below is a list of various roles that will require ICD-10-CM education before implementation:

  • HIM personnel
  • Independent HIM Consultants
  • Nurse Managers
  • Health Information Trainers
  • MDS Nurses
  • Nursing unit staff/clerks
  • Case managers
  • Corporate Office personnel
  • Compliance Office personnel working with ICD coding
  • Corporate administrative departments
  • Administration
  • Therapist (PT, OT, ST)
  • Billing/Admitting personnel
  • Medical Directors/Providers

One method in evaluating educational needs is to separate the roles into two groups: a group that primarily assigns codes and one that primarily does NOT assign codes. Each group requires different levels of ICD-10-CM knowledge. The different knowledge levels are typically defined as:

  • Awareness which could be considered a general knowledge of the code system and important differences between ICD-9-CM and ICD-10-CM
  • Use/professional knowledge level which would be for an individual who uses coded data but is typically not assigning codes daily
  • Application of the code set would be for those individuals who are routinely applying codes

Roles that DO NOT assign codes are impacted by ICD coded data but are not responsible for the selection of the initial code. These roles still require education as the classification system is part of their current role. Roles that ASSIGN codes are grouped into the following broad categories:

  • Current credentialed HIM person who knows ICD-9-CM
  • Employees with experience in coding who were trained on the job (not professionally)
  • Coding individuals or staff members who are new to coding who have education in anatomy/physiology, medical terminology, and pathophysiology

Code assignment is performed by various roles in LTC, but typically the health information management (HIM) roles assign the ICD codes. However the backgrounds of these individuals range from no formal education regarding ICD coding to possessing a HIM credential.

A coding professional’s educational time is estimated at 10 hours to learn ICD-10-CM by the Federal Register final rule for implementing ICD-10-CM. The education time should be considered cumulative and not continuous. Experienced HIM professionals currently trained in ICD-10-CM estimate educational time will be greater than estimated times published in the Federal Register. Sixteen hours for the credentialed HIM professional, eighteen hours for an employee experienced in coding, and thirty six hours for a brand new individual without formal education is being suggested. An exact total time of education varies based upon the needs of each individual’s skill level. Individuals currently coding need to obtain education on ICD-9-CM system regarding structure, organization and official coding guidelines to insure correct understanding of current coding practices and to allow for a smooth transition to ICD-10-CM.

It is recommended that intense coding education not be initiated until six to nine months before implementation  however there are steps to take now to be prepared for the transition.

Below are a few general suggested topics. This is not an all inclusive list. Organizational and individual assessments need to be included in topic determinations.

  • Structure of ICD-10-CM as it provides greater specificity of conditions and diagnoses.
  • Format, conventions and guidelines of ICD-10-CM
  • Injury coding, such as fractures, dislocations, sprains and use of extensions in ICD-10-CM

Educational Tasks Phase 1:

  1. Review the HIPAA Administrative Simplification: Modifications to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS final rule
  2. Read AHIMA’s analysis of the rule
  3. Follow Center for Medicare and Medicaid Services (CMS) website, publications, and outreach calls for detailed process changes related to ICD-10-CM.
  4. Learn about the structure, organization, and unique features of ICD-10-CM.
  5. Create an educational plan for all roles which require education at various levels
  6. Network with peers, access resources, and read literature to identify transition issues and best practices
  7. Provide opportunity for coders to review code structure and coding conventions for ICD-10-CM
  8. Take advantage of component HIM state association (CSA) education opportunities as well as educational opportunities offered by state hospital associations and state medical societies.
  9. For AHIMA credentialed individuals review the continuing education hours required to maintain the credential: http://ahima.org/certification/recertification.aspx

General Implementation Tasks Phase 1:

  1. Review ICD-10-CM/PCS Transition: Planning and Preparation Checklist
  2. Develop an implementation plan if not previously completed. Potential items to include are:
  3. Develop a budget based upon impact assessment.
  4. Identify current systems that input, store and utilize ICD data as these systems will need to be considered in the implementation.
  5. Identify who is currently performing the coding function in the facility is a key step; in addition to knowing what other role(s) or individuals who are cross-trained to do the code assignment
  6. Identify a role or individual to be educated to perform the coding function if the primary person is unavailable.
  7. Conduct detailed assessment of staff educational needs. 
    • Inform staff who will be responsible for education costs
  8. Assess knowledge of ICD-9-CM of current staff responsible for coding so that basic education can be obtained prior to ICD-10-CM implementation
  9. Assess areas of strength/weakness of coding staff in the biomedical sciences (e.g. anatomy and pathophysiology)
    • Develop and implement biomedical science refresher education based upon assessment results.
  10. Evaluate barriers or potential barriers (internal within facility and external outside facility) to preparing coding staff for ICD-10-CM, such as budget issues 
  11. Communicate throughout the organization the ICD-10-CM preparation activities
  12. Review current workflow to identify the areas of impact and analyze opportunities for improvements.  This should include any processes and procedures where an ICD-9-CM diagnosis code is present.  Information or data related to diagnoses, included but not limited to data located in MDS 3.0, health record, and claim form. Common workflow examples are diagnostic tests such as laboratory, radiology; therapy diagnoses and billing.
  13. Documentation Improvement Processes:
    • Analyze current documentation practices, physician, nursing and therapy to identify areas in need of improvement 
    • Identify current processes that may lead to poor data quality due to inadequate or outdated documentation practices
    • Conduct detailed assessment of staff educational needs related to documentation current documentation practices (clinicians, nurses, therapists, etc)
    • Review current workflow to identify the areas of impact and analyze opportunities for improvement

Educational Resources Phase 1:

General Implementation Resources Phase 1:

Educational Tasks Phase 2:

  1. Create an educational plan for roles who assign codes
  2. Provide education on the fundamentals of the ICD-10-CM  systems
  3. Take advantage of component state association (CSA) educational opportunities as well as educational opportunities offered by state hospital associations and state medical societies.
  4. Provide opportunity for coders to analyze and practice applying the ICD-10-CM Coding Guidelines. Intensive education will be initiated 6-9 months prior to implementation.
  5. Provide opportunity for coders to continue to review and refresh knowledge of anatomy and physiology concepts
  6. Continue to have educational sessions with clinical staff in the facility to help coders learn more about disease processes for commonly reported conditions and diagnoses related to long term care facilities.
  7. Take advantage of component HIM state association (CSA) educational opportunities as well as educational opportunities offered by state hospital associations and state medical societies.
  8. Determine if AHIMA component state associations, state hospital associations, and/or state medical societies plan to offer ICD-10-CM/PCS coding practice sessions.
  9. Network with peers, access resources, and read literature to seek answers to cases and confirm application of ICD-10-CM codes.
  10. Determine if AHIMA component state associations, state hospital associations, and/or state medical societies plan to offer anatomy and physiology sessions tailored to ICD-10-CM. 

General Implementation Tasks Phase 2:

  1. Communicate with others throughout the facility regarding ICD-10-CM preparation activities. 
  2. Talk with vendors and other business associates regarding their ICD-10-CM ability to be prepared to accept/transmit ICD-10-CM codes (readiness).  Determine date of installation of organization’s ICD-10-CM database (code library) software that must be utilized in a parallel manner with current ICD-9-CM code library.  (Do not uninstall legacy ICD-9-CM database.)
  3. Address timeline to begin coding current residents’ diagnoses in the implementation year.  Assess impact of reduced code assignment productivity
  4. Evaluate the potential for decreased coding accuracy
  5. Continue to address impact of code change such as required system changes and report modifications
  6. Address legacy data issues in regards to how ICD-9-CM coded data is currently used.  Determine all departments that utilize ICD-9-CM data.  
  7. Evaluate barriers or potential barriers (internal within facility and external outside facility) to preparing your coding staff for ICD-10-CM, such as issues related to budget

Educational Resources Phase 2:

General Implementation Resources Phase 2:

Educational Tasks Phase 3:

  1. Continue to network with peers, access resources, and read literature, to seek answers to cases and confirm application of ICD-10-CM codes.
  2. Continue educational plan, which should include intensive education for roles who primarily assign codes.
  3. Determine if AHIMA component state associations, state hospital associations, and/or state medical societies plan to offer anatomy and physiology sessions tailored to ICD-10-CM. 
  4. Determine if AHIMA component state associations, state hospital associations, and/or state medical societies plan to offer ICD-10-CM/PCS coding practice sessions. 
  5. Practice ICD-10-CM coding of current records for education. Implement process for parallel coding of current residents with ICD-10-CM to facilitate future data entry. (Example:  Code a designated percentage of current records on a regular basis within the three or four months prior to theimplementation date, perhaps with schedule of MDS assessments.  Enter codes into ICD-10-CM database when system upgrade is tested and according to facility implementation plan.
  6. Take advantage of component HIM state association (CSA) educational opportunities as well as educational opportunities offered by state hospital associations and state medical societies.
  7. Develop a process to provide more intensive educational and consultative support to ICD-10-CM coders and to users of coded data for a period of time following implementation.
  8. Continue to evaluate barriers or potential barriers (internal within facility and external outside facility) to preparing coding staff for ICD-10-CM
  9. Determine areas where additional education is needed for coders, CDI, and care providers in regards to coding and documentation now that ICD-10-CM has been implemented.
  10. Network with peers to evaluate issues that have been identified elsewhere both locally and nationally

General Implementation Tasks Phase 3:

  1. Communicate with others throughout the facility regarding ICD-10-CM preparation activities. 
  2. Continue documentation improvements in areas identified for opportunity to improve
  3. Install ICD-10-CM vendor software (code library) into the system to prepare for transition and to allow coding of a sampling of current records.  Perform software system testing to ensure ICD-10-CM compliance. ICD-9-CM legacy data must be maintained and available with ICD-10-CM data for period of time as determined by industry and facility plan.
  4. Prepare plan of action to keep productivity at an acceptable level during time of implementation
  5. Communicate with companies supplying contracted coding staff to ensure they have received the necessary education and ask for documentation to confirm that education has occurred and has been provided by a qualified source (e.g., AHIMA ICD-10-CM approved trainer). 
  6. Evaluate status of all implementation-related tasks.
  7. Closely monitor productivity and quality measures for issues that might be related to the implementation of the new code sets.
  8. Evaluate additional resources or support, if any, that external sources and vendors will provide during the adjustment period following ICD-10-CM implementation.

Educational Resources Phase 3:

  • Have the coding staff complete exercises in the CodeWrite free e-newsletter from AHIMA

General Implementation Resources Phase 3:

Resources Post Implementation:

  • Network with peers in the ICD-10 Implementation CoP  and other AHIMA Communities of Practice(available only to AHIMA members)