Updated on: November 28, 2016

Auld Lang Syne to ICD-9: Ten Weeks of ICD-10

Original story posted on: December 7, 2015

On Oct. 1, 2015, health systems across the country bid farewell to ICD-9 as they transitioned to the International Classification of Diseases’ 10th Revision – ICD-10.


While many healthcare providers thought that the majority of the heavy lifting and financial resources was spent on pre-ICD-10 operations, many now are quickly realizing that the need for precision in course correction delivery is a current best practice. It is widely anticipated that the implementation of ICD-10 will continue to present financial challenges to healthcare providers far into the future.

Effectively managing the entire revenue cycle in a time of uncertainty is going to be key to your success and financial well-being.

  • Coding now is being managed without national benchmarks for coding productivity and accuracy/compliance expectations. As a result, providers must create their own metrics for managing the coding workflow, which is a complex ordeal when the entire “pipeline” was not thoroughly addressed during planning for ICD-10.

    • Productivity: Following the implementation of ICD-10, coders now have to deal with more than five times as many codes as they did with ICD-9. This has impacted productivity to a great extent. In order to deal with diminishing productivity and ensure timely payments, providers will have the options of hiring new coders trained in ICD-10, outsourcing coding to a third party, or hiring coders on contract (which will increase expenses).
    • Compliance with coding guidelines: It is critical to monitor compliance as it pertains to documentation available at the time of coding, and to determine accuracy rates for every clinical specialty and every coder. Do not assume that the trainer(s) you performed pre-implementation work with will provide you with the assurance plan that you need. If your technology partners have not provided you with a solution for routine monitoring, ask yourself how this will be done, as spot-checking with manual audits are definitely not enough for ICD-10 in 2016.
    • ICD10 audit plan: Have you created an ICD-10 audit plan for evaluating accuracy of ICD-10 coding? Is it updated daily for every coder? What are your metrics for monitoring, and do you know how they are calculated? Is it manual or electronic? Do you have staff to conduct internal audits, or are you outsourcing this function? Do you have technology-enabled compliance monitoring integrated into your encoder or computer-assisted coding solutions? You have 30 days to be sure that you have the budget to cover a coding audit project plan with dedicated resources, time frames, reporting tools, and deliverables.
    • Staffing: Do your staffing levels meet your current needs, and are they the same or similar to what you predicted for the early months of ICD-10? If you did not create a coder retention program with incentives to stay with your organization, be on the lookout, as you want to retain your high performers. If productivity and accuracy is not what you expected, do you have contingency plans with qualified strategic sourcing partners to outsource some of the work? 
  • Clinical documentation integrity (CDI): Continue to assess the focus, priorities and staffing levels in your CDI program. Re-assess ICD-10 knowledge of front-end revenue cycle staff to prevent errors from cycling through to the back end.
    • Define new roles and responsibilities for health information management (HIM) and CDI staff as they relate to revenue cycle activities. Have staff responsible for payer contract maintenance and staying up to date with payer rules regarding pre-certification, authorization, and new processes.
    • Renew focus on denial management processes by creating a spirit of continuous quality improvement. Be sure that denial outcomes are shared with all appropriate internal stakeholders and you close any “misses” that result from lack of ICD-10 knowledge management.
  • Refine your CDI program to meet the changing needs of healthcare reform and ICD-10 with technology enablement, expanding scope of CDI efforts, and retraining on ICD-10 lessons learned.
  • Revenue cycle management: The Healthcare Financial Management Association (HFMA) has metrics for revenue cycle management called map keys. In a statement from HFMA President and CEO Joseph J. Fifer,  he noted that “successful ICD-10 implementation begins with thorough preparation, but it doesn’t end there.”

“Over the coming months, providers should monitor revenue cycle performance closely through metrics such as HFMA's MAP keys and take steps to stabilize cash flow and other financial results, as needed,” Fifer added. “Also, payers and providers alike should assess the impact of ICD-10 on payment levels and make appropriate changes in contractual provisions.”

The HFMA map keys are industry standard metrics used to track organizations’ revenue cycle performance using objective, consistent calculations for both healthcare providers as well as physician practice management. The map keys can be found online at http://www.hfma.org/map/mapkeys/.

  • DNFB (discharged not final billed): It is a must to have dedicated staff monitoring DNFB on a daily basis. If this metric increases, make sure to take a closer look and evaluate the reasons causing the delay and holding up individual cases. For example, with the increased amounts of codes, specificity could be the culprit. Are too many cases still waiting on specificity? For how many days? If you are using contracted staff (both clinical documentation specialists and coders), make sure to monitor their quality and accuracy as well as productivity – especially early in the process – and look to make the adjustments required to make the DNFB metric fall back into reasonable thresholds.
  • Days in AR, denials of claims, resubmission of claims, and financial impact of denials all require process redesign changes, training, and monitoring by your teams. Check out the HFMA key maps for guidelines to implement best practices in your organization.

Earlier this year, Joshua Berman, the ICD-10 director for RelayHealth Financial, posted a blog on ICD-10 Watch with the following recommendations on areas to focus on:

  • Denial rates. It’s reasonable to expect that denial rates will go up due to coding errors with ICD-10. Hospitals should note which claim categories have the highest volume and value, and investigate the cause of the denials.
  • Rejection rates. Focus on improving clinical documentation and coding to find any errors that need addressing and avoid rejection of claims.
  • Payment speed. We will likely see payors taking longer to pay claims because they’ll spend more time considering why a claim should be reimbursed. That means it may be beneficial to create a revenue cushion so other aspects of your operations aren’t affected by any reimbursement delays.
  • Billing efficiency. From the time a patient is discharged to the time the invoice goes out, a lot happens, and it all takes time. Hospitals need to continue to look to refine their billing efficiency, since ICD-10 is going to slow things down.

As we are about to close the book on 2015, let us remember that the healthcare industry has spent many years investing in people, processes, and technology necessary for a successful transition to ICD-10. Be sure to take the time to celebrate your well-deserved accomplishments associated with ICD-10 implementation.


Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS

Bonnie Cassidy is a leading HIM executive advisor, focusing her efforts on advancing clinical documentation integrity, risk-adjusted reimbursement, and health information governance. Cassidy was the 2015 chair of the Board of Directors for The Commission on Accreditation for Health Informatics and Information Management (CAHIIM) and the 2011 President /Chair of AHIMA. She is also a fellow of AHIMA, an AHIMA Academy ICD-10-CM/PCS certificate holder, and an ICD-10 ambassador, as well as a fellow of HIMSS and an advanced member of HFMA. Cassidy was honored to be the recipient of the 2014 Distinguished Member Triumph Award from AHIMA and the 2015 Distinguished Member Award from the Georgia Health Information Management Association. She is also a recipient of the Distinguished Member Award from the Ohio Health Information Management Association.

 Bonnie Cassidy has served as an executive with nThrive, Nuance, QuadraMed, the Certification Commission for Healthcare Information Technology (CCHIT), Price Waterhouse, and Ernst & Young, and was a HIM administrator at two major teaching hospitals, including the Cleveland Clinic Foundation. She is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.

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