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I’m lucky to have the opportunity to work closely with CFOs at a number of the nation’s leading hospital and health systems, and I give them a great deal of credit for tackling the challenges in front of them – from securing meaningful use funds to implementing pay-for-performance models to improving billing processes. But during recent conversations I’ve been shocked to hear that ICD-10 is not on every CFO’s short list of issues to address – and in some cases, it’s not even on their radar.

To many CFOs, the introduction of up to 155,000 new ICD-10 reimbursement codes by 2013 is strictly a coding issue that will fall under the domain of IT or information management departments. The deadline of October 2013 also is causing a sense of procrastination, as many CFOs say they’ll wait until January of that year to start exploring solutions. These reactions have led me to believe that most CFOs don’t understand the enormity, complexity and time-sensitivity of the issue, or the financial incentives to get started now. As a result, hospitals and health systems are at great risk of losing significant revenue if CFOs don’t start focusing on ICD-10 today.

Without preparing for ICD-10, hospitals face lost productivity and denied claims, which, coupled with undercoding, could deliver a financial hit of as much as $850,000 for an average 250-bed hospital. This threat comes at a time when operating margins are tight, the complexity of revenue cycle management continues to increase exponentially and self-pay receivables are 30 percent of total hospital receivables.

ICD-10 is a revenue/reimbursement issue, not just an education or coding issue. The CFOs who understand the impact and potential associated revenue loss of ICD-10 recognize that, in order to survive this transition, providers need computer-assisted coding (CAC) technology to increase coder productivity, improve coding accuracy and ensure compliance — and they need to start their CAC evaluation process now. They see that they can’t wait until 2013 to start preparing, because along with coding technology, ICD-10 readiness requires a complete overhaul of reimbursement business processes as well as the technology to crosswalk between ICD-9 and ICD-10 codes using pre- and post-2013 dates as claims flow through the system. They understand that building new workflows, adjusting staffing levels and implementing new documentation procedures will be critical to evaluating how many patients can flow through the system and how to allocate resources to secure a margin from an operational perspective (and absorb an inevitable cost increase 12 to 15 months out).

Unfortunately, fewer than 100 institutions have implemented the CAC solutions and process improvements needed in both inpatient and outpatient environments to ensure that clinicians can capture each episode of care and properly prepare for the dramatic shift in documentation that ICD-10 will bring. Industry analysts project that 2,000 additional facilities will implement CAC during the next three years, but the time to act is now. CFOs should evaluate carefully the looming loss of resources and revenue that ICD-10 will bring and start preparing for it today.

About the Author

Ron Jones, senior vice president of Hospital Solutions, OptumInsight, is a proven executive in healthcare IT who has provided leadership for the company’s hospital solutions group since April 2009. Jones provides leadership in driving growth, generating new revenue streams and overseeing business operations for a comprehensive portfolio of hospital revenue cycle, coding and consulting solutions.

I had to chuckle. At an introductory ICD-10 seminar for physicians, one of the attendees – an emergency department physician – just had asked a rather obvious question.  We were reviewing the new “language” of the codes for diabetes, in particular the ICD-9-CM verbiage as compared to the draft ICD-10-CM verbiage for type II diabetes mellitus (DM-II). As seen in ICD-9-CM’s code classification 250, the adjectives “controlled” and “uncontrolled” (or “not stated as uncontrolled”) no longer will be employed; instead, “with hyperglycemia” will be used in ICD-10-CM under code classification E11, i.e. E11.65 Type-2 diabetes mellitus with hyperglycemia (or, as appropriate, “with hypoglycemia” among other such descriptors such as “with/without coma,” etc.).

“But why do I need to select a code for diabetes with hyperglycemia when that already describes the condition, which is an aberrant state of glucose circulating in the blood due to various etiologies? Is there any common sense to the new system’s language at all?” the frustrated ED physician asked. As a physician assistant, I completely identified with the line of questioning and thoroughly empathized with his clinical perspective. Wasn’t this particular ICD-10-CM concept a tad redundant? Well, yes and no.

Specificity of ICD-10

In context with ICD-9-CM, select codes devised to communicate DM-II in ICD-10-CM will convey “with hyperglycemia” as the descriptor for a diabetic state not squarely under control. An option for “with hypoglycemia” likewise is provided. As we well know, the DM-II state may be transient or circumstantial, or it might have more malevolent long-term implications. Overall, diabetes mellitus can be primary, secondary and/or induced, or gestational. The ICD-10-CM codes for DM-II indicate the diabetes type, body systems affected and any complications or manifestations affecting those body systems.  As many codes as can be found within a particular category, such as E11, can be used to capture all the complications of the diabetic state, per the provider’s diagnostic statements.

Controlling Ambiguity

In ICD-9-CM, “controlled” (i.e., not stated as uncontrolled) and “uncontrolled” was the language of the day; in ICD-10-CM, specific reference to hyperglycemia will denote a correlated diabetic state and whether the descriptors “controlled,” “uncontrolled,” “out of control” or “poorly controlled” apply. This relieves much of the ambiguity of some of these clinical scenarios and could eliminate the need to pin down the provider for specific documentation via a query (though some scenarios still will require this), and furthermore, it specifies a certain DM-II status at a certain point in time.

The selection of an ICD-10-CM code based on the provider’s documentation represents the patient’s status as of a particular date of service, essentially creating a “snapshot in time” of the patient’s episode of care for the DM-II. Note that, similar to ICD-9-CM guidelines, the ICD-10-CM guidelines likewise affirm that if the type of DM is not referenced in the provider’s documentation, the default will be E11 DM-II.

Medical Record Language

That brings up one of the implicit messages of ICD-10-CM/PCS and its attendant documentation requirements: ICD-10 can enrich diagnostic and procedural information while enhancing the overall communication capabilities of medical record data. Much of the former ambiguity inherent in ICD-9-CM will fall to the wayside with the implementation of the new coding system. But in no way by using ICD-10-CM/PCS is the healthcare industry stating that physicians must change their medical record “language” or learn an entirely new way of documenting patient care.  And that, after those initial chuckles, was the first part of my response to the questioning physician.

Clinical Documentation Improvement

If by chance there already is a need for clinical documentation improvement (CDI) by providers requiring remedial training or retraining, whether under ICD-9-CM or ICD-10-CM, then the bounce from one system to the other perhaps will be a bit bumpy. Engaging in CDI exercises in these cases will cause providers to lose nothing but will help them gain infinite advantages by applying specific CDI standards and techniques juxtaposed to ICD-10-CM/PCS.



Lessons Learned

The subsequent and more emphatic portion of my message to the frustrated physician was accompanied by a coding exercise. That’s correct: the physicians in this particular seminar were led through a coding exercise to experience firsthand the challenges faced by their own coding staffs. And the benefits of this exercise as well as the potential pitfalls in ICD-10-CM were immediately apparent. If or when a specific provider’s documentation is not as detailed as it should be, and particularly when the documentation is vague or even ambiguous, the coding of a patient encounter may present a problem. This often is found in cases pertaining to DM-II and its clinical state of “controlled” or “uncontrolled” during the patient’s episode of care. The lesson: knowing the documentation requirements under ICD-10-CM facilitates improved provider documentation up front and promotes more efficient physician back-office processes (namely coding, billing, reimbursement, appeals, etc.).

Ambiguous medical record documentation always will require clarification. The opportunities presented in the application of ICD-10-CM/PCS, a data-rich and highly conversant coding system, can lessen the need for such clarification without necessarily changing a provider’s approach to documenting patient care. Knowing the “language” of ICD-10-CM/PCS and what it means, bringing medical record documentation up to standards, being aware of the challenges coders face, and striking a balance between all of these aspects is a central theme in the transition from ICD-9 to ICD-10.

About the Author

Michael G. Calahan, PA, MBA, is the director of physician services at KForce Healthcare, Inc. Michael has more than 25 years of experience in health care, beginning as a physician assistant with the USN. He has served as an administrator for several physician practices and has enjoyed a varied career in healthcare consulting, being affiliated with Ingenix, CGI, Navigant, PWC and Parente-Randolph. He has authored numerous industry publications and articles in physician, IP/OP/ASC, DMEPOS, ESRD, HHA, ambulance, HIPAA and in Medicare Parts C & D for Medicare Advantage.

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At any time of year, giving thanks is an appropriate sentiment. During the holiday season it is especially fulfilling to recognize the people and companies that have supported you of late, particularly during this time of transition as healthcare organizations manage multiple reform initiatives, including migrating to 5010 and adopting ICD-10.

Successfully achieving ICD-10 implementation requires skill, knowledge and input from many different specialists and disciplines. Combined with 5010, it will bring monumental change affecting people, processes and technology.

While resistance to change is a normal response, it sometimes can prevent us from being thankful for the benefits that change will bring. Yes, ICD-10 has had some opposition – the AMA recently announced its plans to “work vigorously to stop ICD-10,” and while their position is understandable, the intent of healthcare reform is to improve care dramatically. Realizing that goal will require continued support, commitment and focus from the entire professional community.

Thanks to Many

As healthcare organizations continue to move forward with the new coding system, we want to recognize the many organizations, groups and social media websites that have supported the ICD-10 transition. We appreciate their contributions to support change and minimize risk as providers migrate toward the new system. It is the combined efforts of these groups that move us all toward better internal processes that improve the quality of care.

The U.S. Department of Health and Human Services (HHS) mandated the change to 5010 by Jan. 1, 2012 and to ICD-10 by Oct. 1, 2013. We are thankful for their role in supporting a more secure environment for electronic transactions and advancing a system that accommodates new procedures and diagnoses with the promise of benefits to follow.

The Centers for Medicare & Medicaid Services (CMS) has developed dedicated resources to support a smooth transition. From guiding the overall policy and regulatory changes – including the hosting of conference calls and producing materials and training to help providers, payers and vendors understand the changes – they have been instrumental in helping everyone navigate government healthcare reform initiatives.

The American Health Information Management Association (AHIMA) made the connection between preparedness and success and has been in lockstep with inpatient and outpatient health information management professionals, including coders, during the transition. The level of training and resources offered to their user groups speaks to the magnitude of change coming due to ICD-10 and demonstrates their commitment to quality education and leadership.

The Health Information and Management Systems Society (HIMMS) recognizes the need for members of the general healthcare community to have tools to assist them in preparing for the transition and has promoted the sharing of many success stories. Through modeling and other decision support systems, organizations can identify, evaluate and select technology to meet organizational objectives.

The Workgroup for Electronic Data Interchange (WEDI) is improving healthcare by keeping members “in the know” through industry changes and the challenges they face. As organizations increase their use of electronic transactions, WEDI is a real asset to healthcare stakeholders in an evolving health information technology environment.

The American Medical Association (AMA) recently said it’s going to fight implementation of the new code sets. The professionals who know the most about the human body today can have unprecedented access to information and deliver on the intent of healthcare reform by using data to provide better care. We understand their position and appreciate the pushback, because it keeps everyone thinking about better ways to deliver care and how to stay focused on the best process improvements and ensure that appropriate education is delivered.



Other Support Recognized

There are many other entities – including those supporting insurance agencies and revenue cycle, social media sites, data aggregators and industry websites promoting unique content (such as ICD10monitor) – that have provided support during this time of transition, not to mention all the vendors who support end users and the industry as a whole. We are thankful to them for keeping the conversation going and ensuring that issues and opportunities remain at the forefront for healthcare professionals.

Different objectives and focus certainly will change the list of organizations, websites, publications and agencies to whom thanks should be given. The important thing is not to judge the list, but rather to share our thoughts and talk about our efforts during this holiday season.

It Takes a Community

Successful ICD-10 adoption requires full community support. With all the work that already has been done, moving toward compliance must result in positive outcomes for individuals and institutions. Healthcare reform initiatives collectively can provide benefit only by ensuring that those within the industry are working together and proactively using data to improve quality in the healthcare delivery system.

Collectively, we already have done tremendous work. However, there is a great deal left to be done. With 5010 almost behind us, let’s give thanks for what we have accomplished and what we will accomplish in the future as we continue to migrate and adopt the ICD-10 code sets.

About the Author

Veronica Hoy, MBA, is vice president of SOURCECORP HealthSERVE Consulting, Inc. Veronica has been an operating executive for 10 years, focusing on providing strategic leadership and direction to healthcare professionals and organizations. She has more than 20 years of healthcare experience in business process outsourcing, accounts receivable management, coding, billing, release of information, consulting and systems implementation.

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Two years from now, ICD-10-CM/PCS will be implemented in the United States. As we get closer to the Oct. 1, 2013 implementation date, more and more valuable resources are being posted online. Many of these resources are available for free, and with all of the expenses that ICD-10 implementation will bring, providers would be wise to make use of any and all ICD-10 resources readily available to the general public. Examples of two such resources are detailed below.

Hospital providers may now view and download the fiscal year 2012 changes to the ICD-10-PCS codes at the website of the Centers for Medicare & Medicaid Services. A review of these changes shows that the number of codes for has decreased by 163—from 72,081 procedure codes in FY2011 to 71,918 for FY2012. Here’s the breakdown by type of change:

Do you remember the Warner Bros. cartoon “A Sheep in the Deep” with the sheepdog and the wolf (Sam and Ralph, respectively) who both punch a time clock and begin to wreak havoc upon each other until a whistle blows and they break for a leisurely, collegial lunch?

Eventually the whistle blows again and they proceed to throttle each other some more; the halcyon lunch break was nice, but it was gone shortly thereafter and replaced with a harsher reality.

We think ICD-10 revenue neutrality will follow the same path. At present our payer and provider clients are all on the revenue neutrality bandwagon. Neither side wants the transition to ICD-10 to have a negative material impact on cash flow. Therefore, neither side is driving toward maximizing financial benefit from the mandated transition. As in the cartoon, a (metaphoric) whistle blew and a new dynamic exists.

This mutually beneficial philosophy is likely to last through the ICD-10 “go live” date of Oct. 1, 2013. But we don’t see it surviving for more than six to nine months after.

Rather, come the first or second quarter of the 2014 calendar year, we expect that payers or providers in a dominant market-share position in any given geographic area or market segment will begin to impose their will, to borrow a phrase common to mixed martial arts.

Payers that have the lion’s share of the members for a given provider will try to leverage the increased specificity and power of ICD-10 to reimburse less.

Providers that have a particularly strong negotiating posture in a market will try to leverage the change to be reimbursed more. Revenue neutrality will become a defunct notion, yielding to Darwinistic survival-of-the-fittest and capitalistic market forces.

We can’t foresee any outcome other than the eventual demise of revenue neutrality. The changes (reductions) in Medicaid and Medicare reimbursement and other market forces are going to suck money out of the system and we anticipate fairly mercenary behavior among trading partners seeking to recoup some of their losses.

So while you participate and cooperate with your trading partners now to achieve revenue neutrality, you should consider how to prepare for the post-implementation period of revenue bias. We think you would do well to be prepared with both offensive and defensive strategies and tactics.

Whether you’re in an offensive or a defensive position, key infrastructural elements will be your ability to model and contract efficiently.

Improved modeling processes and tools will be required to define various financial outcomes based on changes to your or your trading partners’ pricing and contracting strategies (though this is especially true if you find yourself in a defensive posture). Improved contracting processes will be required to capture the new terms and conditions and codify them within your production systems.

Whether you view your organization as the sheepdog or the wolf, we recommend that you evaluate your ability to model (which likely will require the ability to cross-correlate ICD-9 and ICD-10 data) and your ability to price and contract. The lunch-ending second whistle blow is inevitable.

About the Author

John Wollman is the Executive Vice President of Healthcare for HighPoint Solutions, a Management and Information Technology consulting firm focused on Healthcare and Life Sciences.  John is responsible for HighPoint’s Healthcare industry group, catering to Payers and Providers.  John is a recognized expert in several healthcare business domains (Reform, HIPAA 5010, ICD-10, Platform Strategy) and technical domains (Master Data Management, Analytics).  Since graduating from Duke University, John has held executive level positions at consulting and technology companies over his 25 years in business.

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It is pretty safe to say that by this point, most organizations understand that the magnitude of the change to ICD-10 is huge and the impact on an organization is enterprise-wide.

This conversion impacts a broad spectrum of processes, from patient scheduling through claims processing to payment and beyond. The scope of the change requires a well-constructed ICD-10 conversion project plan. Furthermore, this challenge is not the only one being faced by organizations.

Meaningful use, 5010 and EHR implementations represent an extra layer of complexity and risk. The healthcare industry is overwhelmed by multiple initiatives, and focusing on ICD-10 initiatives has strained resources both in terms of manpower and subject matter expertise. However, with every challenge presents opportunity.

Organizations can leverage this opportunity into a strategic advantage that will result in a positive impact on key areas of patient care, revenue cycle and compliance.

Complementary or Conflicting Initiatives?

Meaningful use and ICD-10: are they complementary or conflicting initiatives? I think it depends on how you are asking the question. If you are managing these initiatives separately from a tactical perspective, they are conflicting being as they are separate initiatives managed in a parallel fashion by different work teams. If you are managing these initiatives strategically as one, meaningful use and ICD-10 are complementary initiatives. Synergies will be gained by the evaluation and implementation of these changes. Meaningful use measures have CMS-defined coding requirements that will be impacted by ICD-10 changes, particularly related to measurement reporting during the transition from ICD-9 to ICD-10.

Making ICD-10 a strategic advantage by gaining synergies with meaningful use and ICD-10 documentation requirements requires multi-disciplinary expertise to integrate the two. Integration of these documentation requirements into the EHR to optimize the return on technology investments is the key to turning these initiatives from a matter of merely “complying” into a strategic advantage.

As with any physician documentation initiative, physicians will need education and guidance, plus assistance navigating the myriad documentation requirements for both meaningful use and ICD-10.

Integrating these requirements into the EHR to facilitate the capture of documentation at the point of entry by the physician will be required to manage future data-capture requirements effectively. It is this integrated focus that will provide organizations with the optimal efficiencies, representing a cost-effective solution for achieving compliance and value from investment in the EHR.

Strategic Alignment of Requirements

Start by performing an impact assessment to establish the current meaningful use and ICD-10 requirements, including the following steps:

  • Assess clinical documentation data capture of all data elements required for meaningful use, core, menu, clinical quality measures and ICD-10;
  • Assess any documentation gaps in data required for outcome severity adjustment;
  • Determine comprehensiveness of capture of structured, unique data requirement; and
  • Discover any “hidden” data required.

Once these requirements are identified, align them with the clinical documentation focus areas of your organization. Keeping in mind the clinical documentation management program structure of your organization, align the focus areas for ICD-9 documentation improvement outcomes with ICD-10 documentation requirements.

Strategic decisions will need to be made for the EHR documentation optimization design to achieve desired outcomes. At the conclusion of this evaluation, the EHR documentation template design will require IT resources that can translate data requirements into EHR templates. A key success factor will be gaining physician input as it pertains to the design of the EHR templates. These templates, if designed for optimal effectiveness, will complement your organization’s clinical documentation improvement program, enhancing your meaningful use and medical necessity documentation requirements.

Using the EHR to optimize the capture of clinical documentation will facilitate the capture of documentation requirements for both meaningful use and ICD-10, creating a strategic advantage for your organization.

About the Author

John Pitsikoulis, RHIA, is a Strategic Advisory Services Client Executive and ICD-10 Practice leader at CTG Health Solutions (CTGHS). John is responsible for the strategic advisory services such as ICD-10, EMR clinical documentation integration program, and Computer Assisted Documentation Services. John has over 25 years of Health Information Management (HIM), coding, and compliance consulting experience working with clients on ICD-10 services, RAC, coding, and clinical documentation improvement engagements.

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The best-prepared healthcare organizations are those that actively are assessing and interacting with their affiliates to ensure readiness for the upcoming ICD-10 transition.

For payers this means all affiliates, not just those that submit directly. For providers this means your internal departments, staff and all of those affiliated with your institution. The reason is simple: it is in no one’s best interests to see claims and billing process disrupted at the time of transition. Assessing readiness is the first step in that process, and it should extend to tracking progress and taking action when problem areas are identified. This is the only way any organization can ensure a successful transition that does not affect revenue adversely.

Testing is Critical

Most payers have affiliates that submit claims directly and others that submit through clearinghouses. Since testing will be critical to a successful transition to ICD-10, this rightfully is getting a great deal of attention. For 5010, testing can be limited to those that submit claims directly; however for ICD-10, it will be necessary to test with all affiliates, including those that submit through clearinghouses. One large payer told me that they have 10 times as many providers who submit though clearinghouses. It is this increase in the scope of this task that garners significant attention.

Affiliate Engagement

However, payers have more than just testing with which to deal. There are three major components to affiliate engagement:

  • Communication: Any complex process like the ICD-10 transition requires extensive communication. Recognize that you will need to make it easy for people to get information they need. Using a combination of e-mail and online resources will be essential to make sure that people are alerted to new information and have easily identifiable places to get any necessary policies, procedures, forms and the like.
  • Testing: Testing is the core of the transition process. Ensuring the accuracy of the content of electronic transactions is essential. That is why payers need to work with all of their providers, not just those that submit directly. Again, this will represent a much broader effort than the 5010 Level II compliance testing currently in progress. Several payers have told me they want to begin testing as soon as possible because they recognize that time will be needed to fix problems and retest. This will mean a great deal of interaction with providers to identify issues and track these tasks to completion.
  • Business Issues: Contracts will need to be updated to account for ICD-10. Payers will experience a substantial surge in terms of document flow with all of their affected providers. Setting up a system to track status will be essential.

People and Systems

The most significant source of complexity for providers is that ICD-10 affects people as well as systems.  Coders, physicians and other staff must be trained, and it is critical to monitor and track their progress, as revenue neutrality will depend on these people. Payers recognize that it is in their interests to ensure that their provider affiliates are ready, and institutions should treat their own affiliates the same way. If your physicians have severe problems at the transition, it will have an adverse effect on the hospital even if the physicians are not employees. Hospitals must be in a good position to assist when appropriate and maintain a vested interest in their affiliates’ success.

I have heard concerns about how Stark Law may affect this process. At a minimum, hospitals and other providers need to understand where their affiliates stand in terms of readiness. This will be essential for hospitals’ abilities to develop their own plans, including contingency plans.

Ultimately, testing will be critical to ensure a successful transition. As WEDI notes:

“External testing may involve coordinating with a large number of entities. Careful planning is needed to ensure that there will be adequate time for testing, remediation and re-testing with trading partners.”

You will need to exchange a great deal of information with your affiliates, ranging from test data to contracts to training status. Both payers and providers recognize that this has the potential to be one of the most labor-intensive processes connected to their respective ICD-10 programs.

About the Author

Hugh Kelly is the
 Vice President of Marketing and Sales for Avior Computing. 

Mr. Kelly has more than 20 years in the software and technology business at organizations ranging from start-ups to publicly traded companies. Mr. Kelly has been involved in all aspects of marketing and sales, with considerable focus on channel development.  During his executive tenure, his organizations have raised over $200M in external capital.  He is a venture partner at Ascent Ventures.

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Computerized provider order entry (CPOE) is one of the 15 core objectives required for Stage 1 of Meaningful Use under the federal Electronic Health Records (HER) Incentive Program. This objective requires the use of CPOE for medication orders entered directly by any licensed healthcare professional who can enter orders into the medical record in accordance with state, local and professional guidelines. According to CMS, CPOE entails the provider’s use of computer assistance to enter medication orders directly from a computer or mobile device. The orders also are documented or captured in a digital, structured and computable format for use in improving safety and organization.

The implementation of CPOE is expected to reduce medication errors, to limit adverse effects and to improve patient safety. However, many healthcare facilities and providers are struggling with this core objective due to a number of difficulties. While there have been many successful implementations, the objective is viewed by some as one of the major stumbling blocks in EHR adoption.

The core measure for CPOE implementation requires that more than 30 percent of all unique patients with at least one medication in their medication list who are seen by the eligible professional (EP) have at least one medication order entered using CPOE. The exception to this measure is any EP who writes fewer than 100 prescriptions during the EHR reporting period. In addition, the CPOE order must be entered by someone with the ability to exercise clinical judgment in case the entry generates any alerts about possible harmful interactions or requires other forms of clinical decisions.

Studies have indicated that in those hospitals that have implemented CPOE successfully, the ability to identify potentially harmful medication orders varies significantly. One of the key success factors in implementation of CPOE is whether clinical decision support systems (CDSS) are utilized. CDSS for CPOE assists providers by suggesting appropriate orders  (using, for example, disease-based drug protocols) or analyzing completed orders using alerts or messages (warning of, for example, drug interactions). While nearly all CPOE systems either include CDSS or have interface capability, there is a great deal of variability. This variability can pose problems for healthcare facilities and providers implementing EHR systems.

The development of standard order sets or templates is critical to the implementation of CPOE.  Standard order sets are important because they are an essential part of clinical protocols and algorithms used to aid clinical decision-making. It also is important to ensure that standard order sets are complete and reflect best practices. Healthcare facilities and providers that have not taken the necessary steps in this respect may encounter difficulties meeting this core objective. The Institute for Safe Medical Practices advocates the application of a multi-disciplinary approach in the development of standard order sets to avoid potential problems. Guidelines for the development of standard order sets can be found online at

About the Author

As Director of ICD-10 and Educational Services for Precyse, Anita Majerowicz, MS, RHIA, is the director of ICD-10 and educational services for Precyse. Anita manages Precyse’s ICD-10 education and implementation services working closely with Precyse University, the organization’s industry-leading education platform. She has more than 25 years experience in the HIM field. She most recently was Director of Clinical Coding and Reimbursement at AHIMA.

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Those who want a reference to all things ICD-10 should check out the CMS Medicare Severity (MS) Grouper with Medicare Code Editor (MCE) ICD-10 R1 Pilot Software (v28). Also available is the updated ICD-10 MS-DRG (v28) R1 Definitions Manual. The draft ICD-10 MS DRG 28.0 R1 definitions are displayed in “grouper logic order” and listed in the order in which the grouper recognizes them. This, in turn, enables users to see instances where grouper logic order differs from strict numerical order.