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CAC (even concurrent models), however, has certain recognized limitations. Coding, computer-assisted or otherwise, is obviously dependent on complete, precise and accurate clinical documentation. Those in charge of clinical documentation improvement (CDI) programs long have appreciated this and have served as important promoters of HIM coding integrity. CDI initiatives progressively have moved toward concurrent and comprehensive processes as the need for presence on admission and continuous confirmation requirements have been mandated by payer review entities.
With the implications of ICD-10, CACs and the recovery audit contractors (RAC) in mind, this convergence of forces now has made the consideration of computer-assisted CDI a pressing reality. While the projected impact of ICD-10 on coding performance is undisputed, a corresponding burden to meet the enhanced requirements for specificity unquestionably will face CDI specialists as well. But CDI needs not only are shared with those of coders; they extend to significant clinical prerequisites that mandate credible supporting documentation, beyond that which defines an ICD-10 code itself. Thus the contribution that CAC provides is only one final benefit in the coding process. CDI additionally requires a pre-CAC, computer-assisted analytic system to identify clinically implied but omitted documentation.
CAC systems all are based on various implementations of natural language programming (NLP). This technology has a long history in the healthcare industry. It has been employed most commonly in the automated coding of clinical records, and it is virtually synonymous with CAC. But it has much broader utility than simply identifying terminology that can be coded in the clinical record. NLP can form the basis of a CDI expert system.
Expert systems typically are constructed on rules-based protocols that attempt to replicate human thought processes in arriving at appropriate diagnostic deductions and therapeutic interventions. In the case of clinical documentation improvement, a CDI expert system also can generate appropriate clinician-to-clinician clarifications with a high level of clinical confidence.
But the expectations of such advanced NLP-driven systems only can be met by integrating existing terminology with existing clinical data elements. Such integration should produce the same logical inferences of clinically plausible diagnoses and procedures that a CDI specialist would generate. The salient advantages of making such a process data-driven and automated are speed and consistency.
In the inpatient setting, CAC can be a helpful tool within the context of a larger coding and documentation process and workflow, but only when CAC isn’t your first course of action.
While CAC historically has been viewed as a coder productivity enhancement tool, the benefits of CAC can go well beyond this narrow focus, helping improve data integrity, consistency and payment accuracy – but only when CAC is implemented in tandem with a health organization’s clinical documentation improvement program.
In the inpatient setting, CAC alone won’t make your source data any better, and productivity gains from CAC are not as impressive as seen in the outpatient arena.
No matter how sophisticated the CAC tool, the unavoidable, fundamental fact is that a CAC program only assigns codes based on documentation in the record. Clinical documentation needs to be accurate in order to get the most out of CAC tools.
The role of the documentation specialist in the setting of concurrent CAC still requires validation and investigation of CAC-suggested diagnoses. The CDS still needs to determine if the diagnosis is clinically supported, consistent and determined in the absence of conflicting documentation. The CDS must determine if the documentation will hold up under repayment scrutiny, demands from the audit contracting industry and compliance requirements.
Computer-assisted coding can provide an important support tool for all clinical documentation improvement (CDI) programs. The prerequisites for success include creating an established, successful CDI program and defining the collaborative, tandem workflow processes involving CAC, concurrent documentation review and final coding.
About the Author
Melinda Tully MSN, CCDS, CDIP is the senior vice president at J. A. Thomas and Associates. Mel has extensive experience as a provider in multiple healthcare arenas, a clinical manager in a large academic facility, and as an expert in clinical documentation improvement (CDI). She has played an important role in the development and expansion of advanced CDI for the past 13 years. She is recognized for her expertise, vision, and promotion of CDI. Mel is a recognized national speaker for compliance, clinical documentation, and the Hospital Quality Initiative.
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WHO Official Calls Delay of ICD-10 Implementation “Fascinating and Inexplicable”
By Janis OppeltAt the rate the federal government is moving, “2013 is an optimistic expectation” for the implementation of ICD-10, Dr. T.B. Üstün, team coordinator of classification, terminologies, and standards of the Department of Health Statistics and Informatics for the World Health Organization (WHO) in Geneva, Switzerland. He finds our country’s continued delay “fascinating and inexplicable” not to mention “quite perplexing”—sentiments shared by the majority (62 percent) of listeners who responded to ICD-10 Monitor’s poll question during the August 14 Talk Ten Tuesday show: What’s your opinion on our continued delay and inability to implement ICD-10?
But seriously, as the London games continue to unfold I have been thinking about our healthcare practices and hospitals – and I wondered, what kind of ICD-10 athletes would these Olympic athletes make during the next two years?
Take Michael Phelps, for example. Certainly one of the most decorated Olympians of modern times, now actually THE most decorated athlete of the Summer Olympic Games. What kind of ICD-10 athlete would he be? Maybe he’s one of those early implementers who flew through the first stages of preparation, but then, because of the government’s interference and too much other stuff on his plate, lost focus and commitment. When the final push came, was he unable to achieve all that he certainly could have, because his final preparation was too little and too late to count?
Or how about the U.S. women’s cycling team during the 140-kilometer road race? In the final few kilometers of that three-and-a-half hour endurance contest, world-class sprinter and almost certain medalist Shelley Olds blew a tire and teammate Kristin Armstrong took a nasty spill on a rain-slicked road. But the American women rallied and pushed each other for our best finish since Barcelona in 1992. The ICD-10 analogy is this: the healthcare practice or hospital that chugs along, steadily adhering to its plan and preparation, can pick itself up, blooded but unbowed, and still drive toward the finish line when unforeseen disaster strikes toward the end of the transition period.
Then there’s Columbian soccer player Lady Andrade. Ooh, you don’t want to be her. Frustrated by the stellar play of the American captain, she sucker-punched Abby Wambach, giving her a black eye and earning herself a two-match suspension. How did Abby respond? Soon after getting knocked to the turf, she put the ball in the back of the net. Which one of those women do you want to be? The one who’s exasperated and in denial, who lashes out at the inevitable ICD-10 implementation because of a lack of understanding, preparation, and yes, discipline? Or the one who picks herself up despite the black eye and prevails when ICD-10 adversity is literally punching her in the face?
When it comes to ICD-10, here’s the Olympic athlete you want to be: the U.S.’s Kim Rhode. In skeet she shot an amazing 99 out of 100 targets, breaking the Olympic record to bring home the gold. For ICD-10, that would be picture-perfect preparation over the long haul of the ICD-10 transition. It would be concentration and focus on whatever ICD-10 objective is at hand at any given moment in time. And then, in step-by-step fashion, or clay pigeon by clay pigeon, it would be knocking all of those objectives out in order to achieve.
What do all successful athletes have in common? Long-term preparation. Teamwork. Commitment. To win gold medals in swimming, do you think Missy Franklin or Ryan Lochte woke up three months ago and said to themselves, “Hey! I better start training for London”? You know they achieved greatness because they started preparing years ago – they had a plan for success and stuck to it.
Implementing ICD-10 is like preparing for the 400-meter individual medley in swimming. There are four different tasks: butterfly, breaststroke, backstroke and freestyle, each with its own unique preparation. Success comes when you can put all four disciplines together in one race. For ICD-10, our four disciplines are planning, people, technology and processes. Just as in the 400-meter IM, each takes its own preparation and commitment, all occurring at the same time. For ICD-10, while you perform your impact assessments and plan, you have to train your people, upgrade your technology and adapt your day-to-day work processes – all during an extended period of time.
For ICD-10, when the starting gun goes off on what we think will be Oct. 1, 2014, it all has to come together to achieve success. Don’t get caught unprepared when the time comes. ICD-10 is not a sprint, it’s a marathon, and it takes longer than a few months to prepare. So start now, pull your own dream team together, and don’t give up when you get punched in the face or take a nasty spill. Your team is counting on you.
Of everyone I’ve seen perform at the Olympics so far, who would I want to be? It’s either James Bond (Daniel Craig) skydiving with the Queen or David Beckham driving that fast boat with the hot chick holding the Olympic flame. Hmm.
That’s a toss-up.
About the Author
Denny is the president of Complete Practice Resources, a healthcare education, consulting, and software company headquartered in Slidell, Louisiana. He formerly served as the CEO of a large, multi-specialty physician group, full service MSO. Denny has authored or co-authored numerous “common sense” practice management books and implementation manuals. He is an award winning, nationally known consultant, speaker, and educator bringing his expertise to making the complex “simple.” He currently serves on the editorial board of ICD10 Monitor. Educated at the United States Air Force Academy, Denny had a distinguished career as an Air Force pilot and has a long history of commitment to excellence and dedication to his clients’ success.
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Workers in the healthcare industries of other countries have lived through the implementation of an ICD-10 system and so can we. That’s the gist of the advice from three professionals—one from England, one from Australia, and one from the United States who worked in Palestine—who helped to implement the new system in those countries. The three were panelists on Talk-Ten-Tuesday, the live, 30-minute Internet radio broadcast heard on July 31, 2012.
The reason for ICD-10 is more than those frequently stated: “Older data structure” or “We’re running out of space for new codes,” and let’s not forget that ICD-9 hasn’t kept pace with current medical practice. All of these reasons are very true and important, but let’s not overlook reasons like disease management programs, quality outcomes, and device recalls.
To better understand where I am going with this, just ask any primary care physician (PCP) how many asthma patients they have in their practice. They could easily answer that question by searching their ICD-9-CM code files. But then ask, “How many of those have persistent asthma that is moderate or severe?” PCPs have no way to answer that question without doing a retrospective record review or prospectively asking every asthma patient clinically oriented questions.
If the ICD-10-CM system were already in use in this country, a simple computer search for subcategories J45.4- and J45.5- would provide a quick answer. Unfortunately, to date, there is no cure for the disease of asthma, but with ICD-10, asthma patients would benefit from and probably welcome better managing a disease that limits their physical activity. Other chronic diseases could benefit from the same intervention if it were easier to identify the severity of the at-risk patients in the organization, practice, or hospital population.
What about ICD-10-PCS? One of the biggest benefits of the ICD-10-PCS system is the specificity and number of different concepts captured within a single seven-character code. It captures the detailed body part, including left or right, as well as other features of the surgery, such as the approach, the device that remains in place after the procedure, and other unique details, in the qualifier value.
Medical Device Recalls
Let’s look at the case of the multiple device recalls in the last few years that involve all-metal hip prostheses. Two major manufacturers, DePuy and Zimmer, have both had recalls on all-metal devices. In the ICD-9 procedure system, we can track that the patient has had a hip replacement and even the type of bearing surface used in the replacement. Today, your data search would include a two-code combination to explain the procedure. If subsequent revision were performed, the information regarding “all-metal portion” may be misleading. Unfortunately, ICD-9 codes do not detail original placement versus revision, and when they are considered together, data analysis can become rather difficult.
Let’s partner this up with another little-known fact. Kevin J. Bozic, MD, an orthopedic surgeon and vice chairman of orthopedics at the University of California San Francisco Medical Center, was quoted in the August 26, 2010, issue of Arthritis Today as saying, “We happen to be one of the only developed countries in the world that doesn’t track joint replacements through a patient registry.”
It might make you wonder how officials figured out the all-metal hip prostheses were a problem. Sadly, we had to be told by the British! Arthritis Today reports that the British Joint Registry showed that about one in eight, or 12 percent, of those who received these implants needed corrective procedures within five years. Other sources report that a typical joint prosthesis can last between ten and 15 years, depending on the patient’s activity level.
In current practice, tracking of joint prosthesis placement is hit or miss. Some facilities track it through an operating room registry, others through the central supply department, and others only through identification of the prosthesis in the paper or electronic medical record.
It’s hard to believe that we are the only developed country that has not implemented a system directly tied to data management, patient safety, and high quality outcomes. I’m not talking about joint registry, but rather ICD-10. If both ICD-10-CM and ICD-10-PCS were in place, the diagnosis codes for the complications related to prostheses would reveal the exact hip, as well as the specific complication. The procedure codes would tell us the exact hip, as well as the material used on the bearing surface of the prosthesis, and whether it was cemented in place or un-cemented. The simplicity of having one diagnosis code associated with one procedure code is ripe for data mining techniques that can detect issues far easier, and result in better outcomes.
Hopefully this article gives you better insight as to why ICD-10 is so important for us to adopt. In light of the case examples above, your outlook on ICD-10 should be promising, calm your heartburn, and give you hope for a better tomorrow, knowing that data, patient safety, and high quality outcomes are all tied together.
The old adage “You can’t monitor what you can’t measure” has never been truer.
About the Author
Maria T. Bounos, RN, MPM, CPC-H, is the Business Development Manager for Regulatory and Reimbursement software solutions for Wolters Kluwer. Maria began her career at Wolters Kluwer as a product manager, responsible for product development, maintenance, enhancements and business development and now solely focuses on business development. She has more than twenty years of experience in healthcare including nursing, coding, healthcare consulting, and software solutions.
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- I’m cynical
- I’m anti-CMS
- I’m anti-ICD-10
- I don’t know jack
- All of the above, and more.
If you came to any of those conclusions, I would confess you are partially right, while declaring you largely wrong.
- I’m cynical only in matters of politics and certain individuals I’ve known whom I shall not name. (“If you cannot say something nice about someone, say nothing.” – my mother)
- I’m a person who holds the staff of CMS in high regard, because a) they always are helpful when I ask and b) they do some genuinely brilliant work. (Really READ the IPPS/LTCH Final Rule this year if you doubt me.)
- I’m certain the selling of ICD-10 to us all includes some of the elements of a well-played confidence game… and it IS an election year.
- The only things about which I write are things I know OR things on which I have an opinion… in other words, I write about exactly the same things everyone else does.
At this point, you’re probably thinking: “Why doesn’t he just get on with it and makes his point for this month?!” Here it is:
It is irrelevant whether anyone likes ICD-10. It’s the law.
It may be delayed, surely, but it’s still the law. After all, some parts of the PPACA are not in effect, but it’s still the law. You are not obligated to pay property tax until early next year, but it’s still the law. Frankly, there are LOTS of laws that don’t impress me much, but I still follow them, and I know you do, as well. (If you do not, we probably should put a sign on your back that says: “Misdemeanor Walking.”)
So, to manage the ICD-10 conversion process—whether it is fully implemented in 2013, 2014, or beyond—there is one overriding action we each must take:
We must accept the reality and do the work.
If you (or your supervisor or employer) resist ICD-10, all you’re doing is setting yourself up for failure. Consider this little fable:
- You work for Alpha Medical Center (AMC).
- Beta Community Hospital (BCH) across town shares your Medical Staff.
- Both hospitals are buying ICD-10 “encoder software” when the deadline draws near.
- Both hospitals are training their coders to do both ICD-9 and ICD-10 coding, because you can’t assume ICD-9 is EVER going away.
- But… BCH and all its employees are embracing ICD-10 as if it were the Holy Grail of Healthcare, while you at AMC are not. You’re doing the minimum necessary to keep filing claims after ICD-10 is law, and that’s the extent of it.
Well, guess what: That shared Medical Staff is picking up two very different moods at your two hospitals.
- At BCH, they enjoy lots of support as they prepare their own ICD-10 conversions.
- At your hospital, AMC, they don’t.
- At BCH, everyone from Access to Nursing to the Clinical Ancillaries to the Support functions (like Dietary and Environmental Services) can “Walk the Walk and Talk the Talk,” at least to the extent it impacts their jobs.
- At AMC, you can’t.
- At BCH, they setup an EMR that’s integrated with HIM supporting both ICD-9 and ICD-10, and also can support the billing and record keeping in each physician’s office.
- At AMC, you haven’t and you can’t.
- At BCH, clean claims are going to go to payers as long as the hospital is open for business, and they’ll be paid in the timely manner to which they’ve become accustomed.
- At your AMC, “denial” is destined to become the most common word in the PFS Manager’s vocabulary.
Any time there is a monumental change in any system, the inputs and outputs to the system must be realigned if the system is to continue functioning. That is, it must adjust to the environment. If you don’t embrace ICD-10—not tolerate it, but really EMBRACE it—then you are setting yourself and your organization up for failure. And that is unconscionable.
It’s very simple, really:
ICD-10 is law—or soon will be law—and with every breath you take you should be endorsing it, supporting it, proselytizing for it. You should be a vocal leader in its adoption; a mentor to those in your organization who still don’t “get it;” and a hero to your employer, your community, and your patients, all of whom are DEPENDING on you to do it right the first time. Anything less is failure.
Make a choice. Join the movement, or get out of the road.
About the Author
Billy K. Richburg, M.S., FHFMA is HFMA-Certified in Accounting and Finance, Patient Accounting and Managed Care. Bill graduated from the U. of Alaska, Anchorage and earned his M.S. in Health Care Administration from Trinity University, San Antonio, TX. Over a career spanning more than 40 years, Bill has held positions including CEO, COO, CFO, and CIO in hospitals ranging from 75 beds to over 300 beds, and in home health agencies, DME stores, and a home infusion company. Bill is a Board Member of the Lone Star Chapter, HFMA, and is Director of Government Programs for the Revenue Cycle Technologies business segment of MedAssets, Inc. His office is in Plano, Texas.
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In the midst of running through our seminar content about creating project charters and communication processes, assessing current readiness, conducting impact and gap analysis, and developing an implementation plan, we realized that the doctors, though politely listening, were completely … not engaged. Our seminar leaders compared notes, and that’s when we had our epiphany. We realized it wasn’t pushback against ICD-10 that was causing this lack of connection; it was that most physicians don’t know the first thing about ICD-10. How can we talk to them about impact analyses, implementation planning and budgeting for staff training when they don’t know what ICD-10 really is?
As a result, we completely changed our physician education strategy and initial focus. What is immediately necessary is a sane, measured approach that first and foremost engages and motivates physicians through a discussion about ICD-10 in terms of the basic realities of what it is and what it means for them. Both the pros and the cons must be explained. The main concept they must understand and be prepared to embrace is that the new documentation requirements necessary to achieve sufficient code specificity is their primary responsibility and the key to ICD-10 success – and that, simply put, it is not that big of a deal.
We let them know gently that, despite the negative messages being spread by many, ICD-10 is not all bad and there exist real long-term benefits associated with it: fewer medical necessity denials, less wasted time and resources on requests for additional information, and the ability to create accurate, acuity-level databases with which the need for better reimbursement can be demonstrated.
When physicians understand what is really important to know, right now – their role as the cornerstone of ICD-10 transition success, in terms of providing adequate documentation for coding purposes – the obstacles to implementation can be cleared.
Moreover, for all specialties the new documentation elements that must be learned number in the dozens, and this should be a main focus instead of the increase to “ALMOST 70,000 ICD-10 CODES!” (as peer leadership loves to trumpet in their rush to scare doctors about ICD-10).
After conducting more than 50 ICD-10 readiness and impact assessments, we have come to realize that nobody really knows how ICD-10 is going to pan out. What we do know is that it doesn’t seem to be as daunting a challenge for physicians as most (ourselves included) seem to be making it out to be when the correct processes are followed and ample time is given.
Thanks to the delay, we now have that time. Teaching physicians about the specificity of the new code set and requisite documentation applicable to their specific practice is what is important right now. Technology available today, combined with the specificity of ICD-10, make accurate code selection based on complete documentation even easier than with ICD-9 and its 14,000 codes.
ICD-10 implementation needs to occur under a phased approach, with one phase serving as the prerequisite for the next. The good news about the delay is that we have time to roll out these phases to physician practices in a cost-effective and reasonable way, which can dramatically reduce the short-term negative impacts of making the switch to ICD-10.
The longer a practice waits, the less time it will have to make changes and the more expensive the transition will be in terms of productivity losses. This is due to a rushed pace that upends your ability to conduct day-to-day business (good luck finding the time or outside resources to help at the last minute). Two-plus years, however, allows for a deliberate and phased approach if you start right now. Here are the phases:
1. Engaging and educating physicians and staff
2. Assessing current readiness and impact
3. Creating your timeline and transition plan
4. Implementing your transition plan
5. Post-transition analysis and reporting
You can’t skip ahead to phases 2-4 without first getting physicians and staff on board. in other words, you can’t implement without first learning. You also can’t expect physicians to embrace gap analyses, training budgets and implementation planning when they really don’t have an accurate picture of what ICD-10 is all about.
I am reminded of one of my father’s favorite sayings: you can’t teach a pig to sing. It’s a waste of time and you just end up annoying the pig. Please don’t misunderstand; I am in no way comparing physicians to pigs.
My point is that you can’t teach physicians and staff about the complexities of ICD-10 implementation when they don’t have a clear sense of what ICD-10 really means to their practices.
About the Author
Denny is the president of Complete Practice Resources, a health care education, consulting, and software company headquartered in Slidell, Louisiana. He formerly served as the CEO of a large, multi-specialty physician group, full service MSO and was certified as a CPC through AAPC. He has authored or co-authored numerous “common sense” practice management books and implementation manuals. He is an award-winning, nationally known consultant, speaker, and educator bringing his expertise to making the complex “simple.”
Educated at the United States Air Force Academy, Denny had a distinguished career as an Air Force pilot and has a long history of commitment to excellence and dedication to his clients’ success.
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ICD-10-CM: Money Pit or Money Maker? Major Chapters with Changes
By Maria Bounos, RN, MPH, CPC-H
While it is imperative that payers and vendors consider the entire ICD-10-CM code set, it is a reality that some providers will have to focus on only a small subset of the classification system. A big question for most is this: Who will be impacted the greatest, and will it be a money pit for you, or a money maker?
Let’s look at the sections of ICD-10-CM that have experienced significant changes, some of which may impact how you consider doing business in the future.
Obstetrics
Those providers that deliver babies will see a significant change in coding. Although the integrity of the classification system is intact under ICD-10, the axis that identifies the current episode of care (delivery, antepartum, etc.) has been eliminated. New to ICD-10-CM is the axis for capturing the trimester. The side-by-side illustration below (Table 1) focuses on the diagnosis of severe pre-eclampsia:
Table 1
ICD-9-CM | ICD-10-CM |
642.5- Severe pre-eclampsia
(The fourth digit identifies current episode of care, such as antepartum condition, delivery, etc.) | O14.1 Severe pre-eclampsia O14.10 Severe pre-eclampsia, unspecified trimester O14.12 Severe pre-eclampsia, second trimester O14.13 Severe pre-eclampsia, third trimester |
In 2012, new maternal codes were added to indicate weeks of gestation; codes from the Z3A category identify the specific week of gestation during the encounter. Table 2 below provides an illustration of the code range.
Table 2
Example:
Z3A.13 13 weeks of gestation of pregnancy
|
Fracture Treatment
Any providers that deliver care for treatment of fractures will be required to capture a greater level of detail with their diagnoses. In addition to laterality (left/right), coders will apply a seventh character that identifies encounter. For illustrative purposes, let’s consider a patient who is seen in the emergency department after falling. The ED physician makes the diagnosis of a closed, displaced fracture of the head of the right radius. See Table 3 below for a comparison.
Table 3
ICD-9-CM | ICD-10-CM |
813.05 Fracture head of radius (closed) | S52.12 Fracture of head of radius S52.121 Displaced fracture of head of right radius S52.122 Displaced fracture of head of left radius S52.123 Displaced fracture of head of unspecified radius S52.124 Nondisplaced fracture of head of right radius S52.125 Nondisplaced fracture of head of left radius S52.126 Nondisplaced fracture of head of unspecified radius |
The integrity of the classification system is maintained at the fifth character, with both systems classifying a closed fracture of the head of the radius. Further exploration of the code selection in ICD-10-CM reveals the ability to capture a displaced/undisplaced fracture and laterality (right/left). For this case study, the ICD-9-CM code would be 814.05; the tentative ICD-10-CM code would be S52.121.
It is important to note that the coding assignment is incomplete without the seventh character, which captures the encounter. See the following excerpt (Table 4) for seventh characters in ICD-10-CM:
Table 4
A Initial encounter for closed fracture D Subsequent encounter for fracture with routine healing S Sequela |
The correct coding assignment for this case would be S52.121A.
If the patient was referred to an orthopedic surgeon for surgical intervention, the code would still be S52.121A for an initial encounter.
If the patient was seen in the physical therapy department the following week for treatment, the correct coding assignment would be S52.121D.
There is a complete listing of all the seventh characters in the ICD-10-CM code set. The seventh characters allow for classification of open fractures, non-healing (malunion, nonunion) fractures and sequela as a result of a fracture.
These seventh characters also apply to diagnoses related to the injury and to the poisoning chapter in ICD-10-CM. In addition, seventh characters appear in the External Causes of Morbidity chapter.
External Causes
Traditionally, use of external cause (E codes) has been selective, based on reporting requirements and internal data needs. External cause codes provide another level of detail to the “patient’s story.” For example, in the coding illustration above, we would not know the rest of the story without use of E codes. The patient could have suffered the fracture due to an automobile accident, a football game or from falling down the stairs. If the patient suffered a fall from an escalator, Table 5 displays a side-by-side comparison of ICD-9-CM and ICD-10-CM application.
Table 5
ICD-9-CM | ICD-10-CM |
E880.0 Fall from escalator | W10.0xxA Fall from escalator (seventh character for initial encounter)
|
There is the ability to capture more detail via the place of occurrence, activity and external cause status. For illustrative purposes, let’s assume the documentation states that the patient fell on an escalator in an airport while running to the gate while traveling on vacation. Table 6 provides a coding summary for the external cause classification.
Table 6
ICD-9-CM | ICD-10-CM |
E849.6 Accidents occurring in public building E001.1 Activities involving running | Y92.520 Airport as the place of occurrence of the external cause Y93.02 Activity, running Y99.8 Other external status (activity)
|
This coding illustration demonstrates the expanded place of occurrence codes and an additional section called External Cause Status (Y99), which captures status. The status categories include activities performed for income, volunteerism, leisure or military service.
Summary
Although the expanded code set offers enhanced specificity in all chapters, the changes in Chapter 15 (Pregnancy, Childbirth and the Puerperium), Chapter 19 (Injury, Poisoning and Certain Other Consequences of External Cause), and Chapter 20 (External Causes of Morbidity) require more training time for HIM professionals, clinicians (for documentation improvement) and reimbursement teams, as they all want to be able to capture all to which they are entitled with ICD-10. If you fall into any of these categories, prevent the money pit from overflowing; take a good look at your service lines and turn them into money makers! Providers that currently do not report codes from these chapters will find the transition to ICD-10-CM simpler; if that’s the case, today is your lucky day!
About the Author
Maria T. Bounos, RN, MPM, CPC-H, is the Business Development Manager for Regulatory and Reimbursement software solutions for Wolters Kluwer Law & Business. Maria began her career at Wolters Kluwer Law & Business as a product manager, responsible for product development, maintenance, enhancements and business development and now solely focuses on business development. She has more than twenty years of experience in healthcare including nursing, coding, healthcare consulting, and software solutions.
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Concurrently, we are seeing an evolution in philosophy relating to the management of codes and mappings, something that will influence buyer decisions regarding the types of tools to incorporate into an ICD-10 program.
In considering mapping and crosswalk tools, leading companies are viewing the problem from an ongoing operational perspective and not simply from a transition/conversion lens. The idea is that the complexity of ICD-10 is not limited to encompassing a one-time transition or conversion. Rather, the complexity will continue to be an issue well after Oct. 1, 2014.
Here are some reasons for this:
- The number of codes, and code volatility: between the ICD–9 and ICD–10 code sets, there are roughly 160,000 codes, and they are far from static. Consider the 2012 updates (which were made during a period of a "code freeze"), which introduced about 4,800 adds/deletes/changes to codes and several thousand mapping changes. We can expect such volatility for the next several years as well.
Managing the adoption of these changes requires a lot of work, including:
- Analyzing the impact of changes/deletions;
- Determining how to apply the new codes with other identifiers;
- Mapping/relating the new codes to other enterprise artifacts (benefit tables, code lists, charge masters, medical policies, etc.);
- Notifying the “owners” of these artifacts about the changes; and
- Flowing the changes to downstream systems and processes.
Most crosswalk and mapping tools will help with navigating these changes and analyzing the impacts to mappings, but they will not help with these other analytic tasks, which represent a significant challenge without some type of assistance.
- Codes don't exist in a vacuum; in most healthcare organizations, ICD codes are incorporated into lots of artifacts with ties to lots of processes and systems, both transactional and analytical. ICD-9/ICD-10 codes also are often found in lists (used to represent aggregations of codes, such as “all diabetes codes,” etc.), benefit tables (indicating which codes are payable under various circumstances), medical policies (identifying which procedures are applicable for which diagnoses, etc.), charge masters, DRG lists and more. These artifacts also tend to require other types of codes, such as CPT and HCPCS codes, to interface with the ICD-9/ICD-10 codes.
Simply storing and managing ICD-9/ICD-10 codes and GEMs/reimbursement mappings (and value-added mappings) is necessary, but not sufficient when it comes to successfully managing ongoing operations while using the ICD-10 code set. We believe that it is imperative to centrally manage these codes in conjunction with other types of codes and interface them with other artifacts (beyond mappings) that will come into play in downstream processes and systems.
We see our more progressive clients implementing master data management systems to handle mapping and crosswalk transition needs and also to address the ongoing operational requirements of adopting code/mapping updates and relating the ICD codes to other codes and artifacts. These solutions have been labeled “enterprise code set repositories,” or “encyclopedias,” and are being established as centralized, governed, enterprise storage points for codes (ICD, HCPCS, DRG, CPT, etc.), mappings and other key artifacts comprised of codes.
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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As soon as the ICD-10 slide with that latter figure appears, the resulting gasps, guffaws and outbursts are loud, no matter the location of the seminar. I am particularly struck by the similarity of these responses as they pertain to the Kubler-Ross model, perhaps better known as the “Five Stages of Grief.” While manifestations of grief and other responses to emotional trauma are as individual as a fingerprint, and therefore not uniform, ICD-10 nonetheless inevitably evokes these kinds of uniformly strong emotions in even the most jaded physicians. So in this article we’ll take a closer look at how reactions triggered by the ICD-10 mandate correspond to the various stages of grief.
Denial
Denial is a conscious or unconscious refusal to accept facts, information, reality, etc. relating to a certain situation. In the case of ICD-10, there existed (and still exists, if truth be told) many providers who refused to believe that ICD-10 would actually be implemented. Many still believe a “skip” to ICD-11 will happen, but this conclusion is reached without taking into account the years it will take to develop clinical modifications necessary to make ICD-11 feasible under our country’s payer model. Let’s be clear: the government’s mishandling of the announcement that ICD-10 implementation will be delayed didn’t help. ICD-10 is the “law,” and it literally would take an act of Congress to derail us from the path we’re currently on. Being in denial isn’t going to make this go away.
Anger
Anger can manifest itself in many different ways. With ICD-10, anger seems to be directed at those who “ are shoving this ridiculous waste of time and resources down our throats.” At my workshops I routinely hear such comments as “well, I now know my retirement date,” or “this is yet another instance of government intrusion” or “I don’t care what they say; I’m not going to do it.” Again, ICD-10 is the law. No matter how angry you get, it ain’t going away.
Bargaining
Once it became clear that ICD-10 implementation seemed inevitable, bargaining came about through numerous requests from various entities pleading for or demanding delays. Don’t forget, ICD-10 already was delayed by two years before recently being delayed by yet another year. Expect the bargaining to continue. Unfortunately, bargaining rarely provides a sustainable solution, especially if the outcome is inevitable anyway.
Depression
This phase of the grief cycle is the most dangerous, in my opinion. Now that it appears ICD-10 is truly inevitable, what becomes “depressed” is the will to heed the call to prepare. This inaction will lead many providers to “wait and see” until the switch is thrown (on what looks to be Oct. 1, 2014). Experts and early implementers agree: there will be a significant drop in both productivity and revenue for even the well-prepared practice.
Acceptance
The rate at which acceptance of ICD-10 is reached is key. The sooner a provider understands and accepts that ICD-10 demands a concerted effort to navigate, the better. When emotional detachment and objectivity are reached, solid work can be achieved.
So how do we mitigate these five phases of the grief cycle? It certainly helps if you take an emotionally detached, objective look at what ICD-10 is really all about. Think back to the fracture-of-the-patella example I used earlier. Simply adding laterality drops the number of ICD-10 codes to 160. Looking at the X-ray and knowing, for example, that it is a “transverse” fracture reduces the results to 32. Adding the type of visit, in this case let’s say “initial,” drops the number of results to only six.
I urge everyone to take a closer look at what ICD-10 truly means. A physician wouldn’t pronounce a diagnosis without performing a thorough exam on a patient. Taking such an objective view of ICD-10 will help mitigate and reduce the need for having to endure the five stages of grief. The sooner the “acceptance” stage is reached, the sooner productive work can occur.
About the Author
Denny is the president of Complete Practice Resources, a health care education, consulting, and software company headquartered in Slidell, Louisiana. He formerly served as the CEO of a large, multi-specialty physician group, full service MSO and was certified as a CPC through AAPC. He has authored or co-authored numerous “common sense” practice management books and implementation manuals. He is an award-winning, nationally known consultant, speaker, and educator bringing his expertise to making the complex “simple.” He currently serves on the editorial board of ICD10 Monitor.
Educated at the United States Air Force Academy, Denny had a distinguished career as an Air Force pilot and has a long history of commitment to excellence and dedication to his clients’ success.
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Thank goodness for the pre-summit announcement, as the April event was well received with great attendance! I had the distinct pleasure and honor to speak at the ICD-10 Summit with Dr. Louis Rossiter on the subject of “Predicting Payment Impact of ICD-10 through Analytics.” Of the roomful of more than 200 attendees, more than half had begun their risk assessment, and the others were taking it all in so that they could have the tools to begin.
We understand that ICD-10 will have a major impact on the documentation expected from clinicians, and an even bigger effect on the coding staff within your organization; but because Centers for Medicare and Medicaid Services (CMS) has also reassigned combination of codes in ICD-10 to define diagnostic related groups (DRGs) for payment, a change in Medicare and commercial reimbursements is inevitable. As part of the risk assessment process, it will be vital for hospitals to get a handle on the financial impacts of ICD-10.
Our presentation discussed the methodology behind informatics and the opportunity to address the impact of ICD-10 through analytics. We believe the key for information management specialists is to monetize the impact of ICD-10 through modeling tools. These tools can help you better communicate and get the attention of your CEO and CFO to take action, properly resource your efforts, and stimulate change for all who need to be involved in the transition. By modeling tools, we recommend using your own hospital data to simulate payments under ICD-9 compared to payments under ICD-10. Please note that they will be different. You can trend this information over time and find variances between before and after transition by service line, DRG, and major diagnostic category (MDC).
Naturally, your hospital’s recent claims data is a rich source of information. It is possible to translate your ICD-9 claims files for a recent period of time into ICD-10. Then use your hospital’s current Medicare payments by DRG to simulate the reimbursement impact for all payers in order to get a pure ICD-10 impact. Summarize the payments by various factors such as DRG, MDC, and service line so that you can see which areas of the hospital will be affected the most, and the least, or not at all.
We utilized the terminology “Medicare Estimated Payment” (MEP) throughout our presentation to indicate your hospital’s current payment rate by DRG under Medicare, which can be used to simulate payments for all payers. In the traditional approach, we have natively coded patient discharge records that can be assigned a DRG and an MEP to give you an estimate of what the hospital will be paid. It is possible to take the same records and the information they already contain to assign the ICD-10 codes. You can then translate those to DRGs and again assign the MEP just as before.
Two important observations to note about this process:
1. The ICD-9 code(s) was assigned by a coder thinking and using ICD-9 (we call this native coding). The ICD-10 is simulated based upon this natively coded ICD-9. The simulation was not natively coded in ICD-10. In our experience, this does not seem to make a difference, specifically since CMS does not know the impact of natively coding ICD-10.
2. The reason the payments will be different is the way CMS has used the ICDs differently in 9 versus 10 to assign the DRG. For example, many cardiovascular and orthopedics services have been grouped to a lower DRG payment, but in other instances, some have a higher DRG payment.
When the MEP has been assigned to each claim, it is possible to look at each claim and understand what DRG will be assigned under ICD-9 or ICD-10 and what the resultant payment is likely to be. They can be further analyzed by average or aggregate payments. We recommend that when you do your analyses, you consider calculating payments specific to your institution (your own wage index, unique DSH payment, and unique IME/GME). You can work with your CFO to obtain this information.
An ICD-10 Payment Impact Analysis solution should translate ICD-9 hospital claims data into ICD-10 and use Medicare expected payment so that hospitals can simulate the reimbursement impact by MS-DRG for a recent period of time. Hospitals should be able to drill down into the data and assess financial impact by MDC, MS-DRG, and major service lines. The bottom line is that you must be able to view hospital claims with the ICD-9, the translated ICD-10, and the Medicare payment at a glance. The goal is to leverage the financial impact analysis data to galvanize change across your organization.
It is critical for every organization to understand how they do business under ICD-9 as well as ICD-10. Predictive analytics is the gateway to analyzing large amounts of data in a clear and concise manner. A payment impact analysis pinpoints the winning and losing service lines so that an organization can plan and implement strategies for fiscal success. Even with a one-year delay, it will be imperative for all organizations to have the best analytic tools at their disposal.
About the Author
Maria T. Bounos, RN, MPM, CPC-H, is the Business Development Manager for Regulatory and Reimbursement software solutions for Wolters Kluwer. Maria began her career at Wolters Kluwer as a product manager, responsible for product development, maintenance, enhancements and business development and now solely focuses on business development. She has more than twenty years of experience in healthcare including nursing, coding, healthcare consulting, and software solutions.
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Delay or No Delay, This is No Time to Put Your Feet Up!
By Maria Bounos, RN, MPH, CPC-H
Hypothetically, if a delay was announced, it would affect each sector of the industry differently. Whether you are affiliated with a vendor, institution, physician practice, educator, consultant or payer, a delay could mean lost jobs, affecting employment, possibly inducing bankruptcy or eliminating any opportunity to get “caught up.” For some, it could mean complete devastation, while to others it could be a blessing in disguise.
Whether or not a delay is announced, a prudent recommendation is to maintain your momentum if you are in the midst of analysis – and if you have not started, get started now! This article is a synopsis of an ICD-10 whitepaper Wolters Kluwer Law and Business wrote, a piece urging organizations to act now, regardless of implementation date.
ICD-10 requires organization-wide change management simply because it is a change that involves every aspect of an organization, with the possible exception of housekeeping. ICD-10 is not just a coding issue; it is a concept that involves assessment of, and implementation planning for, clinical documentation improvement (CDI), education, reimbursement impact, payer relations, information systems and vendor readiness. The change management potentially will involve both internal and external resources. It is time to think holistically and to get out of your silos, as well as a time for understanding that this process is fluid and may require tweaking along the way.
ICD-10 assessment and implementation planning involves the following:
- CDI – The adoption of improved clinical documentation is not new for healthcare professionals, as it is one of the most basic concepts manyclinicians learn on day one – specifically, “if you didn’t document it, you didn’t do it.” This phrase speaks volumes as it pertains to ICD-10, specifically because improved and complete documentation will render improved coding and accurate data for optimal reimbursement.
- Education – Understanding how ICD-10 will affect you and your institution is extremely important at every professional level. Coder and clinician education is a critical part of the assessment and implementation process, but not all-encompassing. If you keep in mind that all training should be job- and role-specific, perform assessments based on where gaps are identified, and remain transparent and resolute, you will have a successful ICD-10 educational program.
- Reimbursement – Take the time to understand your business and perform an impact analysis at your facility. An impact analysis will help you understand how you are performing under ICD-9 as well as help you understand the projected impact of ICD-10. Throughout this process you will learn which service lines are winners and losers, but more importantly, delay or no delay, your business deserves a thorough review and analysis to ensure optimal reimbursement.
- Payer Relations – Take inventory of your payer contracts, as “negotiation time” is now. Specifically, take a moment to reflect on this statement: there will be no one stopping the commercial payers from going live with ICD-10 on Oct. 1, 2013.
- Information Systems – Turn over every system and interface so you can better understand your internal IT systems. Assess whether external systems, such as payer interfaces or vendor tools, influence your plan for implementation. Keeping in mind that IT systems are dynamic, it is important to learn the system gaps and redundancies, and work toward process improvements.
- Vendor Readiness – It is extremely important to know whether your vendors will be ready for ICD-10 and how much it will cost for your vendors to make your systems ICD-10 ready. Working one-on-one with the budget team will be imperative for financial planning, as will taking the opportunity to look for new vendors, if warranted.
In the referenced Wolters Kluwer whitepaper, you will find that the points noted above are discussed thoroughly and provide ample ICD-10 readiness assistance. In times of uncertainty it is important to understand what is at stake – in this case, with or without an implementation delay. There are many opinions and insights floating around as they relates to the potential ICD-10 delay, and in my opinion now is not the time to take a break and put your feet up. Now is the time to understand how you are doing business, regardless of the implementation date.
About the Author
Maria T. Bounos, RN, MPM, CPC-H, is the Business Development Manager for Regulatory and Reimbursement software solutions for Wolters Kluwer. Maria began her career at Wolters Kluwer as a product manager, responsible for product development, maintenance, enhancements and business development and now solely focuses on business development. She has more than twenty years of experience in healthcare including nursing, coding, healthcare consulting, and software solutions.
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What can I possibly write that hasn’t already been written?
This problem is aggravated by the fact that, honestly, ICD-10 is really quite boring.
So, we typically write or talk about:
- Costs of conversion
- Crosswalks
- Education of staff
- Why ICD-10 is better
- How to bring physicians on board
- Who must comply (and who need not)
- How many more codes there are
- How late the U.S. is compared to other industrialized countries
- And so on, and so forth, ad infinitum
As I was creating this list, it occurred to me that perhaps I should take all the usual topics and ignore them. And so it shall be.
History
We all know when the World Health Organization published ICD-10, because that’s another one of the “usual topics.” But let’s consider the following multi-choice question:
When did ICD-10 start to be used in the United States?
- Jan. 1, 2012.
- Umm…it hasn’t happened yet.
- 1999.
If you answered “a” or “b,” you’re wrong. The question was not “When will HIPAA-covered entities start using ICD-10-CM and ICD-10-PCS?” ICD-10 (with no additional letters) started to be used for coding and classifying mortality data on death certificates in 1999. (There are no more questions in the quiz, so you either earned a zero or 100 percent).
Physician Education
Last year I wrote an article titled “What’s Up (With the) Docs?” in which I described several approaches to securing physician support of a hospital’s ICD-10 implementation. As one would expect, it was a collection of practical arguments that could be presented one on one or via a group presentation. However, what it didn’t address was a key issue: simply put, a tiny minority of doctors are just jerks, and a few are nice people but aren’t quite open-minded enough to follow even a simple argument supporting something they dislike.
“Don’t confuse me with the facts,” they say. “My mind’s made up!”
So I have an addendum to that article, which is this:
When you hit a brick wall, go around it or over it – but don’t try to go through it. Don’t let the one out of 100 control your life or compromise your success. They will get their karma in time.
What Comes Between?
Here’s something I found interesting, and if you are not a coder or a comparable HIM professional, it might be news to you as well:
- ICD-10-CM and ICD-10-PCS (along with CPT/HCPCS) will be used to code the care patients receive.
- ICD-10 (the WHO version) already is being used to code and classify causes of death.
But what happens in between? Is there any coding system for that period of minutes to years between a patient’s final hospitalization and their “ultimate exit”? Actually, there is.
(Drumroll).
Let me introduce ICF, the International Classification of Functioning, Disability and Health. It is managed by the WHO Collaborating Center for the Family of International Classifications for North America (WCCFICNA?) and is used to code and classify the consequences of disease. How cool is that?
Of course, just because a coding system exists doesn’t necessarily mean anyone uses it, but wouldn’t it be interesting if they did? Imagine that a patient is admitted, cared for by several physicians, subsequently discharged with a relatively clean bill of health, and then tracked (via physician office visits, hospital follow-up and so forth) to see how they are progressing and managing the activities of daily life.
With CMS’s focus on avoidable readmissions beginning on Oct. 1, 2012, this might be a very good way for hospitals to manage patients after they no longer are patients. It’s something hospitals must do if they are to prosper under the new Readmissions Reduction program ordered by Section 3025 of the Patient Protection and Affordable Care Act (PPACA) of 2010.
The Solution for All Our Problems?
Proponents of ICD-10 – myself included – take great joy in noting that ICD-10-CM and PCS address all the shortcomings of ICD-9: there are many more codes, much more flexibility and a more logical overall coding system. But we also usually include an argument as to why this is so good, when, in reality, it’s only good for certain segments of the population and the industry. For everyone else, it may be innocuous or neutral, but it’s neither good nor bad; it’s just there. Let’s face the facts:
As a patient, I very likely will see no benefit from ICD-10. After all, most coding is done after I’m discharged.
As a physician, I expect to see little benefit from ICD-10, unless I happen to be doing research or am really dedicated to the practice of high-quality defensive medicine. But most of what I see is that this new system is expensive and is likely to make me poorer, not richer.
As a hospital executive, I recognize that ICD-10 brings higher costs to HIM, including some employee turnover. And it also provides a multitude of new loopholes that payers can use to deny my claims, in whole or in part. I mean, really: is there any true value in going from one code for a broken finger (ICD-9) to 276 codes (ICD-10)? Doesn’t that just raise the potential for 276 questions?
Yes, the great irony of ICD-10-CM and PCS is that it will help researchers, governments and other payers almost beyond measure … although none of those parties provide patient care.
The End
No, it’s not the end of ICD-10-CM/PCS; we’ve only begun.
And yes, I still support the conversion, but let’s stop pretending that it’s a good thing for everyone. It simply isn’t.
But … is anything the government does good for everyone?
About the Author
Billy K. Richburg, M.S., FHFMA is HFMA-Certified in Accounting and Finance, Patient Accounting and Managed Care. Bill graduated from the U. of Alaska, Anchorage and earned his M.S. in Health Care Administration from Trinity University, San Antonio, TX. Over a career spanning more than 40 years, Bill has held positions including CEO, COO, CFO, and CIO in hospitals ranging from 75 beds to over 300 beds, and in home health agencies, DME stores, and a home infusion company. Bill is a Board Member of the Lone Star Chapter, HFMA, and is Director of Government Programs for the Revenue Cycle Technologies business segment of MedAssets, Inc. His office is in Plano, Texas.
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There is a sense of frustration among many of us, as the announcement of a delay decreases the sense of urgency for providers to move forward with ICD-10. Many of us have invested crazy amounts of time and money in preparation and development of software, implementation planning, and educational programs to assist our customers in understanding the vast impact of ICD-10 on their organizations.
The amount of rework and funding associated with the delay is overwhelming. Let’s also not forget the impact of jobs created to focus on ICD-10 and the career schools and other schools alike that have created ICD-10 coding programs to prepare students who will graduate in 2013. Our country needs to take every advantage to create sustainable jobs to support a viable economy.
Just one week after the announcement I attended the HIMSS12 conference in Las Vegas and had the privilege to participate in the ICD-10 knowledge center. It was a great opportunity for ICD-10 collaboration, networking and education among industry leaders. As I reflect on the experience, I believe that many attendees did not take advantage of this opportunity – and I can only believe that the decrease in attendance had to do with the announcement of the delay. If the announcement had occurred after the conference, there would have been great buzz about ICD-10, and providers would have been more engaged. In my opinion, the delay is truly a “buzzkill.”
History does repeat itself. I saw the same “buzzkill” when the implementation date for Ambulatory Payment Classifications (APCs) was delayed for years. In the late 1990s providers had no sense of urgency to get their organizations prepared for a new outpatient prospective payment system. Once CMS announced an implementation date of August 2000, providers laughed and brushed it off, believing that there would just be another delay. CMS had the last laugh when the new payment system went into effect and providers were not prepared, as accounts receivables went through the roof and revenue opportunities were lost due to lack of system readiness. This cannot happen with ICD-10, especially since the United States ties the new coding set to reimbursement.
My recommendation to our customers and colleagues is to keep the momentum that you had just a few weeks ago. For many, this is an opportunity to “catch up” and be fully prepared for a new coding system that will affect every aspect of an organization. Any assessments that have been done should be seen as a positive. The delay should not be seen as an opportunity to stop scrutinizing your current business practices under ICD-9, regardless of when ICD-10 will arrive. Preparing your organization for major change takes time. Take advantage of the delay and take this time to get to know your vendors, understand your contracts, inventory your IT systems, understand your coders’ knowledge gaps, and create a sustainable clinical documentation improvement program. These steps will only make organizations stronger under ICD-9 and help them become better prepared for the inevitable that is ICD-10.
Don’t let the buzzkill get the best of you, and most of all, don’t let CMS have the last laugh yet again. Do your due diligence and move forward, acknowledging that ICD-10 is right around the corner. No matter how long of a delay occurs, it will go into effect and organizations will need to be ready.
For those of you who have maintained momentum and have not let the delay announcement halt your efforts, I applaud you.
About the Author
Maria T. Bounos, RN, MPM, CPC-H, is the Business Development Manager for Regulatory and Reimbursement software solutions for Wolters Kluwer. Maria began her career at Wolters Kluwer as a product manager, responsible for product development, maintenance, enhancements and business development and now solely focuses on business development. She has more than twenty years of experience in healthcare including nursing, coding, healthcare consulting, and software solutions.
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