Planning and Implementing ICD-10 Using a Team Approach

Gloryanne H. Bryant, BS, RHIT, CCS

Introduction

It's one thing to update the current coding system each year, but it's another to completely redesign it. This is what we have with ICD-10 , both the clinical modification for diagnosis coding and the PCS for the procedural coding. Like Y2K in 1999-2000, and recently with HIPAA, the healthcare industry has been implementing major initiatives that require significant planning for implementation. Time, effort, and dollars have gone into these two significant "projects," and the change to ICD-10 clinical coding system will take the same from us all. The HIM role for this major healthcare initiative should be one of leadership with a demonstrated skill set for project management. For a hospital or hospital system, we will need to coordinate, communicate, and collaborate with all aspects of planning and implementing this initiative.

Background and History

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the secretary of the Department of Health and Human Services to establish standard code sets for use by healthcare providers, plans and clearinghouses. In the August 17, 2000, final transaction standards regulation, the secretary mandated the use of certain medical code sets that, by and large, are the same code sets that hospitals and physicians already use in their day-to-day coding activities.

Our current coding system, International Classification of Diseases, 9 th edition, clinical modification (ICD-9-CM), was developed and implemented in the 1970s. Originally, ICD was planned to be updated with a new edition every 10 years. Shortcomings were visible with ICD-9-CM, and from a global perspective, the World Health Organization (WHO) wanted to address necessary changes. Prior to 2000, a move to revise and create ICD-10-CM was undertaken at a global level. In July 2000, ICD-10 was revised and available in 37 languages in 30 countries. Additional countries made the transition during 2001 and 2002. The countries of Australia and Canada have well documented implementation efforts and learning experiences that have been shared.

For the US, it was going to take bringing the issue of ICD-10-CM and PCS to the political front. However, it was agreed that the mortality reporting using ICD-10-CM would be used in the US, which began in January 1999.

Key limitations of ICD-9-CM include:

• Outdated and obsolete codes for many diseases
• Unable to address the increasing pressure for more specific codes
• A lack of codes that can keep up with new technology and advances in medical knowledge
• The healthcare industry has seen a shift in the delivery of care from hospital inpatient acute care to outpatient, home care, long-term care, and other delivery systems requiring great enhancements to ICD-9-CM
• ICD-9-CM codes are in many instances insufficient to provide detail for nonacute conditions
• Many of the code categories have become full, making it difficult to create new codes
• When a category is full, several types of similar procedures or diagnoses are combined under one code, or a place is found in another section of the classification for a new code
• Differences in resources are not easily identified because distinct codes are not available
• Coders find it difficult and confusing to squeeze current medical information into existing unspecified, or vague, ambiguous codes

Significant benefits and enhancements with ICD-10-CM and PCS have driven the movement for the HIM profession to welcome this change. HIM professionals could see that we would obtain more clinical information within one given code, which would reduce the need to look for several codes to capture important data. With ICD-10-CM and PCS in place , it will be easier for data retrieval and analysis. It will also contribute improved clinical data and healthcare as a whole.

ICD-10-CM would offer significant changes, including:

• Alphanumeric codes
• Restructuring chapters/categories
• Addition of sixth character
• Addition of laterality
• New features
• Expansion of detail codes (for example, injury, diabetes)
• Expansion of code extension for injuries and external causes of injuries

Restructuring for Injuries would appear as follows:

For the Injury and External Cause chapter, a "code extension" would be used to relate to the encounter and include the following: "a" = initial encounter, "d" = subsequent encounter, and "q" = sequelae.

Procedure Coding

The adoption of ICD-10-CM/PCS for the US has been tied to a process within the Administrative Simplification provisions of HIPAA. This includes holding public hearings, NPRM (National Proposed Rule Making-Federal Register publication), comment periods, and then final rule announcement with date for implementation. As of May 2004, we are still waiting for the proposed rule to be published and be open to comment.

Discussion

Efforts to address the planning and implementation of ICD-10-CM/PCS will need to include communication and significant collaboration outside of HIM with key stakeholders in information technology and systems, finance, clinical areas, payers, and outcomes and research. The initial stages of planning for this project will begin with the identification of key leaders in several healthcare disciplines and the establishment of an e-mail distribution list. For IT/IS , anticipated changes will involve multi-platforms; any support system that has ICD-9-CM will need to be identified and then expanded. Key areas of focus will be the DRG and grouper software, billing systems (payers and providers), abstracting systems, clinical data reporting, test ordering systems, medical necessity/ABN software, and utilization management.

In addition, IT/IS will be impacted in several major system areas, including:

• Payer-process claims
• Decision support
• Managed care (HEDIS) reporting
• Clinical departments (lab, EKG, radiology, etc.)
• Pharmacy
• Joint Commission on Accreditation of Healthcare Organizations and Oryx
• CCI editing

With respect to HIM--in particular, coding and clinical data management-- planning and implementation efforts will need to include the following:

• Healthcare policy and the design of reimbursement systems
• Resource utilization
• Research and clinical trials
• Healthcare quality measurement
• Safety and efficacy
• Public health and risk tracking
• Clinical performance improvement
• Financial performance improvement
• Healthcare claims processing and reimbursement

Healthcare coding settings that will be impacted by the change to ICD-10-CM/PCS include, but are not limited to the following:

• Inpatient (IPPS) and nonIPPS
• Outpatient (OPPS) and nonOPPS
• Outpatient surgery
• Emergency room encounters
• Ancillary encounters
• Observation
• SNF PPS and nonSNF PPS
• Acute inpatient rehab PPS and nonAIR PPS
• Physician setting (professional fee)
• Psychiatric facility PPS
• Home health PPS and nonhome health PPS
• Drug and alcohol facilities and services

Implementation of ICD-10-CM/PCS might include an "ICD-10-CM/PCS Q/A" communication site within the facility, company, or vendor organization via e-mail or a section of a Web site. Keeping the organization informed of the steps taken and the implementation milestones achieved will be critical.

Strategies

Project management skills and tools will play a significant role with the ICD-10-CM/PCS planning and implementation process for each facility or institution.

The key stakeholders can be divided into groups and include risk areas for the disciplines, for example, HIM/coding, IT/IS, business office/PFS (patient financial services), and care management/UR. Stakeholders will need to work together and in subgroups.

Implementation is still a couple of years away (once the final rule is published, we should be allowed two years to the go-live date), but starting early can be advantageous. HIM professionals should consider the transition and impact from ICD-9-CM to ICD-10-CM for diagnosis coding and ICD-9-CM to ICD-10-PCS for procedure coding for all providers and payers, as this will be significant. HIM professionals should look closely at how the codes = data and dollars, in other words, how changes to any existing coding system can pose threats to revenue and compliance. The new coding system will pose many operational challenges across many hospital departments, including HIM, education and training, IS/decision support, finance and patient financial services (PFS), physicians and medical staff, and other clinical staff departments.

Since the impact of ICD-10-CM/PCS on systems and computer technology is broad, your IT/IS department will need to take the lead in identifying systems that will be impacted by ICD-10-CM/PCS implementation. A spreadsheet should be developed listing each department impacted and then listing the area or function within the department currently using ICD-9-CM.

Identifying target and risk areas will promote discussion across disciplines and lead to solutions and an action plan.  

HIM departments will need to develop their own project management, which may include these areas:

• Skills and knowledge assessment outside and inside of the HIM department
• Training and education for both HIM professionals and those outside of the department
• Process for coding records
• Data collection processes
• Results and survey tools
• Coding validation
• Retraining and education
• Testing, corrections, and improvements

Initial planning steps will include conducting ICD-9-CM user surveys to determine the disciplines that are potentially impacted by the change. Each impacted department or area should establish goals, objectives, and needs. There should be processes for establishing the budget and/or cost estimates by specific departmental areas.

With leadership from AHIMA on ICD-10-CM/PCS implementation, each state will have coding leaders identified to help with statewide educational efforts through the Component State Associations (CSAs). Individual facility and institutional education efforts will need to be designed and provided.

Conclusion

Change remains the fear factor for coders and other HIM professionals. Awareness and introduction to ICD-10-CM/PCS is to key to defusing anxiety. Within CHW (Catholic Healthcare West), we have provided two separate two-hour in-services in 2004, one for ICD-10-CM (diagnosis) and one for ICD-10-PCS (procedure coding system.) This introduction has already produced positive comments and increased interest in learning more about this new coding system. Outlining a project in steps and stages, while maintaining goals, objectives, and timelines, should result in successful implementation.

We have recently seen suggestions regarding the implementation of ICD-10-CM/PCS through the President's Information Technology Advisory Commission (PITAC). As stated in the May 2004 issue of the Advance for Health Information Professionals:

A draft recommendation from PITAC (President's Information Technology Advisory Commission) suggests that a study be undertaken to assess SNOMED as an alternative to ICD-10 with the rationale being that this might incentivize the healthcare industry to adopt an EHR.¹

The prospect of not implementing ICD-10-CM/PCS, but instead favoring SNOMED, has brought critical responses from HIM professionals. Sue Prophet-Bowman, AHIMA director of coding and compliance, stated:

AHIMA is working on a response to this recommendation, with our position being that both SNOMED and ICD-10-CM/PCS are necessary, as they have very different roles and purposes. SNOMED is a controlled medical vocabulary for use in an EHR and ICD-10-CM/PCS are designed for administrative purposes, as they group clinical concepts into more manageable categories for use in administrative functions. Also, SNOMED can only be used in an EHR--it cannot be used in a paper-based system. So, even if it were feasible to use SNOMED for administrative purposes (such as reimbursement), 100% of all providers and payers would have to have a fully implemented EHR in order to use SNOMED! Clearly, it is going to be some time before that happens.²

Other national HIM leaders like Donna Pickett, MPH, RHIA, of the National Center for Health Statistics have played a key role in enhancing awareness for the need of ICD-10-CM.

Remembering the reasons for this important change in healthcare will provide the incentives for success:

• The World Health Organization (WHO) requires the use of ICD-10-CM for mortality reporting
• The ICD-9-CM diagnosis coding system has run out of numbers
• The current codes under ICD-9-CM are not specific or sufficient enough for today's healthcare complexities
• Clinical data exchange across the globe
• Many other countries around the world have already migrated to ICD-10-CM, but the US is preparing a Clinical Modification
• The need to monitor the effectiveness of healthcare services and resources has increased over time
• The need for complete descriptions and specificity

Endnotes

1. "AHIMA Urges PITAC to Reconsider ICD-10, SNOMED-CT Recommendation." Advance for Health Information Professionals, (May 2004).
2. Sue Prophet-Bowman, AHIMA, 2004

References

ICD-10-CM-Field Testing Project. Report on Findings: Perceptions, Ideas and Recommendations from Coding Professionals across the Nation, AHIMA, HIM Body of Knowledge, September 23, 2003.

"ICD-10-CM Review." Anita C. Hazelwood, MLS, RHIA, FAJIMA, and Carol A. Venable, MPH, RHIA, AHIMA 2003.

"Development of the ICD-10 Procedure Coding System (ICD-10-PCS)." Richard F. Averill, MS, Robert L. Mullin, MD. Barbara A. Steinbeck, RHIT, Norbert I. Goldfield, MD, and Thelma Grant, RHIA. 3M HIS Working Paper 5/98.

"Understanding the New ICD-10-CM Diagnosis Coding and ICD-10-PCS Procedure Coding Systems and Preparing for Implementation." Jugna Shah and Gloryanne Bryant, HcPro Audio Seminar, January 2004.