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Some health information management (HIM) professionals will conduct ICD-10-CM/PCS training of coding specialists in their facilities, and many of these professionals will kick off the training in early 2013. However, in order to start ICD-10 training in 2013, these HIM professionals must do a lot of “prep work” – and that work should start now, in October 2011.

Below is a timeline for many of the most critical action items that need to be completed before ICD-10 training can start in 2013.

OCTOBER-NOVEMBER 2011

Identify all staff responsible for coding throughout the facility and document the following information for each of them:

  • Name
  • Department
  • Job title
  • Work site (in house or remote)
  • Responsibility for coding cases classified as: inpatient, observation, ambulatory surgery, clinic, emergency department and ancillary visits
  • Coding credentials (if applicable)
  • Coding education (indicating name of learning institution or whether person was “trained on the job”)
  • Number of years of experience in coding

DECEMBER 2011

Request or generate an inpatient case mix report and an outpatient case mix report for all financial classes of patients seen from Jan. 1, 2011 through Nov. 30, 2011. These reports should include, at a minimum:

  • Patient name
  • Medical record number
  • Account number
  • Date of service/discharge
  • All ICD-9-CM diagnosis codes
  • All ICD-9-CM procedure codes
  • All CPT/HCPCS codes
  • All modifiers
  • All DRG assignments

JANUARY 2012

Analyze the inpatient and outpatient case mix reports to identify high-volume conditions, procedures and codes to include in the biomedicine GAP analyses and coding training. In other words, be sure to customize analyses and training materials based on the conditions and procedures that are most common to your facility.

 


 

FEBRUARY 2012

Prepare biomedicine GAP analysis exams for medical terminology and anatomy and physiology to assess coders’ strengths and to identify opportunities for improvement.

MARCH 2012

Prepare biomedicine GAP analysis exams for pathophysiology and pharmacology to assess coders’ strengths and to identify opportunities for improvement.

APRIL – MAY 2012

Administer GAP analysis exams to all staff responsible for coding.

JUNE 2012

Grade all GAP analyses and prepare summary reports detailing the findings for each coder. Use the GAP analysis results to identify staff that will need biomedicine training in addition to ICD-10 training.

JULY 2012

Schedule training dates and reserve location(s) for the training sessions. Note: the biomedicine training may need to start in 2012 if it is not feasible to perform both biomedicine and ICD-10 coding training in 2013.

AUGUST 2012

Compile facility-specific clinical notes and reports to customize ICD-10 training exercises and tests.

SEPTEMBER 2012

Order all training materials that will be needed, such as:

  • ICD-10-CM and ICD-10-PCS code books
  • ICD-10-CM and ICD-10-PCS training materials
  • Medical terminology books
  • Anatomy and physiology books
  • Pathophysiology books
  • Pharmacology books

OCTOBER 2012

Prepare and submit continuing education (CE) prior approval applications (and fees) to the organizations that have certified coders who will be trained in ICD-10. The CE approval process may take several weeks or more, so HIM professionals should not wait until 2013 to secure CEs for the training.

These action items are not all-inclusive, but they illustrate how imperative it is for HIM professionals to start preparing for ICD-10 coding training now!

About the Author

Lolita M. Jones, RHIA, CCS, is the principal of Lolita M. Jones Consulting Services (LMJCS), founded in October 1998 in Fort Washington, MD.  Ms. Jones has over 25 years of experience in coding and consulting. She started preparing for the implementation of ICD-10-CM/PCS by going back to school. On September 12, 2010, Ms. Jones became an AHIMA-approved ICD-10-CM/PCS trainer.

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With ICD-10 on the horizon, there’s a lot to think about from a coding, reimbursement and compliance perspective. For a moment, however, let’s take a step back and a deep breath. Think big-picture: what is the goal of every healthcare provider?  Being an old vet myself, I know it’s to provide excellent, quality patient care. ICD-10 will get us there and give us the opportunity to measure how well we deliver care through the ability to focus on outcomes.

When you think ICD-10, think quality and meaningful use because it all ties together.

The Benefits

So, what do we need to think about? With the implementation of a new coding system, the first thing that comes to mind is money. Yes, there’s a cost to implementing ICD-10.  The Centers for Medicare & Medicaid Services (CMS), the World Health Organization (WHO), and the National Center for Health Statistics have collaborated for years to initiate ICD-10, as their focus always has been to put a system in place that improves outcomes.

Looking at the RAND Study, an ICD-10 study done for CMS in 2004, it becomes clear that the benefits of ICD-10 will outweigh the costs. As a synopsis of this study, RAND examined one-time and cumulative annual costs over 10 years. Costs included training of coders and physicians; productivity impacts on coders and physicians; and system changes affecting providers, vendors, payers and CMS.

The high-end costs averaged approximately $1.5 billion, according to RAND, but the benefits focused on outcomes; specifically, it indicated that ICD-10 will be a gateway to accurate payment for new procedures, fewer rejected claims, fewer fraudulent claims, better understanding of new procedures and improved disease management – with an estimated benefit of more than $6 billion to the healthcare industry during the aforementioned 10-year study period.

What can you, not only to be ICD-10 ready, but also to understand how you will be able to contribute to quality outcomes and excellent patient care? The answer: know your risk areas and, first and foremost, understand how you currently do business under ICD-9. This can be accomplished through analytics, specifically through analyzing your current business under ICD-9 by translating the codes to ICD-10. A few strategies would include looking at your areas of highest risk related to coding, reimbursement and compliance.

I-10 Strategies

Coding Perspective:

Look at your utilization under ICD-9. Specifically, look at the most frequently utilized ICD-9 codes at your facility. Start with the top 10percent (depending on the size of your facility, going up to 20percent). A few caveats would include that you need to understand the workflow in your organization specifically related to how ICD-9 codes are generated and to determine whether the codes are from encounter forms, order entry or HIM (just to name a few). Also, don’t forget to find out whether the interfaces are talking to one another (although, of course, that’s a completely different topic for discussion).

You can achieve understanding of your risk under ICD-10 through the CMS General Equivalent Mappings (GEMs) data. GEMs bridge the language gap between ICD-9 and ICD-10 CM and PCS to help providers understand, analyze and manage the process of moving to the new code sets. There are many translation tools on the market; just ensure that the translation tool you choose for your facility maps forwards and backward as well as offers the capability to analyze via reimbursement mappings.  Additionally, to expedite the process look for workflow tools that can batch 10-20 percent of the most utilized ICD-9 codes at your facility.

Reimbursement perspective:

Your next logical step is to analyze how you will be paid for those “most utilized” ICD-9 codes under ICD-10. This warrants gaining access to an MS-DRG grouper for ICD-10. Remember, the underlying mission for CMS was to create a system that is budget-neutral. Let’s not be foolish; do your homework. It is your fiscal responsibility to ensure that you get paid for that to which you are entitled.

 


 

This means looking at the highest-paid ICD-9 codes at your facility (and looking at the “most frequently utilized” codes doesn’t necessarily mean that they are the highest-paid). This can be accomplished by pulling your highest-paying DRGs with associated ICD-9 codes, then grouping the claims data and checking how those translate to ICD-10. This will help you understand the current case mix and also reveal a potential case mix you might want to go after – in addition to fostering understanding of your current inpatient surgical procedures and potential surgical procedures you may wish to perform at your facility in the future.

Compliance perspective:

To ensure that you stay in compliance and begin to look at the goal of quality outcomes, take the analytics a step further. Look at the most complex mapped ICD-9 codes in your current data. Alter your focus: there will be those that easily map as a one-to-one comparison via the GEMs. Instead, focus on the areas that have a one-to-many mapping to see the types of risks you are facing with ICD-10. And then, finally, focus on the areas of ICD-10 that were not present in ICD-9, which may give you the opportunity to capture great new analytics on patients by code. This includes identifying opportunities to track obstetric patient care and expenses by trimester; flagging patients who are suspected victims of domestic violence and may need additional intervention; and targeting conditions such as cardiovascular disease, cerebrovascular disease, cancer and diabetes – all conditions that are not intrinsically tied to underlying disease processes.

Analytics can be very powerful from a coding, reimbursement and compliance perspective. The specificity required with ICD-10 will allow us to better understand how we do business and give us the reporting mechanisms we need to better focus on quality and meaningful use. ICD-10 will be a financial investment, but the benefits will outweigh the costs when we have the opportunity to improve patient care through analytics.

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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As we prepare and progress in our understanding of the future ICD-10 coding system, we continue to uncover the differences from the ICD-9 system. This article will review the difference between the current procedural coding guidelines of ICD-9-CM and the ICD-10-PCS as they relate to the coding of a percutaneous transluminal coronary angioplasty (PTCA) procedure with insertion of coronary artery stents.

Editor’s Note: On a recent Talk-Ten-Tuesday podcast, the ever-popular Billy K. Richburg
described the perils of mapping. His segment is transcribed below.

 

I’ve been accused of being somewhat cynical when it comes to anything the federal and state governments do, and I’ll confess there’s considerable truth in that. But today I want to talk about the kinds of things non-government payers do – apparently with the sole purpose of irritating the rest of us.

ICD-10 has all sorts of advantages, one of which is that it’s the same everywhere, thanks to the feds. “Mom and Pop’s Health” out of some backwater burg in rural America can’t make up their own codes unless they really thrive on violating the HIPAA Transaction Rule, which is illegal.

But what about the things related to ICD-10 not addressed by the Transaction Rule? How about a specific example: crosswalks!

Crosswalks are a critical component of our transition to ICD-10, but as incomprehensible as it seems, there isn’t a single mandated crosswalk. Yes, CMS publishes GEMs, but right on its website they say the mappings can be used to develop “alternative mapping systems” for specific purposes. In other words, “Mom and Pop’s Health” can make up their own mapping.

So how exactly is this a problem?

For most hospitals, larger clinic groups and the like, it probably means very little. But using multiple mapping systems would make it impossible to reliably model ICD-9 and ICD-10 versions of the same claims to see how DRG grouping would compare, for example. “Mom and Pop’s Health” claims might map right one time and wrong the next.

But the greatest risk is to smaller providers – small clinics, small home health agencies, mid-level independent practitioners such as therapists and nutritionists – that think they cannot afford to have their claims professionally coded, so they instead depend on crosswalks to simulate proper coding. For those people, multiple crosswalks may be their ultimate nightmare: they’ll never know how they’re going to be paid. It’s bad enough to use one flawed system (like GEMs), but it’s a bona fide disaster-in-the-making to try to use several of them simultaneously.

So no matter who you are, no matter how large or small your practice or your organization, do not think for a moment about using GEMs or any “how gullible are you?” alternatives to code claims. It’s just not worth it.

About the Author

Billy K. Richburg, MS, FHFMA, is HFMA-certified in accounting and finance, patient accounting and managed care. Bill graduated from the University of Alaska in Anchorage and earned his MS in healthcare administration from Trinity University in San Antonio, Texas. During a career spanning more than 40 years, Bill has held positions including CEO, COO, CFO and CIO in hospitals ranging from 75 beds to more than 300 beds, and in home health agencies, DME stores and a home infusion company. Bill is a board member of the Lone Star Chapter of the HFMA and is director of government programs for the Revenue Cycle Management business segment of MedAssets Inc. His office is in Plano, Texas.

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Sound advice and solid guidance formed the foundation of the recent HIMSS Virtual Briefing: Critical Factors of the ICD-10 Conversion. The audio included five inter-related topics presented by 12 speakers with expertise in the steps required to make the transition to the ICD-10 system. Highlights of the briefing are provided below, but, first, here are a few important sound-bites delivered by speakers that emphasized the need to get started on the transition now, not later.

Editor’s Note: On a recent Talk-Ten-Tuesday podcast, the ever-popular Billy K. Richburg used the Rubik’s Cube as an analogy for ICD-10 compliance. His segment is transcribed below.

Rubik’s Cube is a puzzle invented by a Hungarian engineer and teacher in 1974. Subsequently it was marketed worldwide beginning in 1980 by Ideal Toy Corporation.

When you buy a (Rubik’s) Cube, it’s “solved.” That is, each face is all one color and you mess it up by twisting the layers. Once the colors are mixed on each face, you then solve it – making the faces a solid color again – by twisting the layers around the central core. Sounds simple enough … until you actually try it.

How difficult is it to solve? Well, there are 43.25 quintillion possible solutions, unless you take it apart. … To put that in perspective, 43.25 quintillion Rubik’s Cubes – which are roughly 2-1/4 inches on each side – would cover the earth to a depth of 52 feet – roughly 5 stories.

The current record time for solving the cube is 5.66 seconds, set by Feliks Zemdegs in Melbourne just this year. Feliks also holds the record for “average solution times,” at 7.64 seconds.

“So what’s your point,” you ask? Glad you asked!

The process of preparing for ICD-10 actually has a lot in common with (solving a) Rubik’s Cube.

If each diagnosis code could be used with any procedure code and vice-versa – which is not the case, but stay with me here – then there are approximately 5-1/2 billion combinations, and that’s only using one procedure code and one diagnosis code at a time.

And how many ways are there to implement ICD-10 in your organization – hospital, payer, clearinghouse, or vendor? Actually, the number probably is infinite, because each individual involved in the process will influence how it is done, and let’s be honest: we each think our way is best.

There is a grand irony in all this.

In the final analysis, and with apologies to Carl Sagan, there are “billions and billions” of ways to implement ICD-10, but – like the Cube – there is only one correct implementation. No matter how you approach the problem, your implementation of ICD-10 has to look pretty much like every other one.

That’s the beauty of the HIPAA Transaction Rule, you see: How we comply is up to us and is infinitely variable. There is no “best way” to implement ICD-10. But the final solution is specified, mandated, forced, compelled, coerced: pick your verb. It must look the same everywhere.

And that’s okay, because if it didn’t, it wouldn’t be a “standard,” and it would have no value. A primary purpose of ICD-10 is to allow comparison, statistical analysis, trending and other data manipulation – and if it doesn’t look the same everywhere, those goals are meaningless.

So, smile, hold your head up high, pursue your solution to the problem even though you must tolerate those other people in your organization who think they have a better idea, and take some comfort in knowing that several hundred thousand other people are doing exactly the same thing – but you’ll all end up in the same place. After all, anything less is failure.

About the Author

Billy K. Richburg, MS, FHFMA, is HFMA-certified in accounting and finance, patient accounting and managed care. Bill graduated from the University of Alaska in Anchorage and earned his MS in healthcare administration from Trinity University in San Antonio, Texas. During a career spanning more than 40 years, Bill has held positions including CEO, COO, CFO, and CIO, in hospitals ranging from 75 beds to more than 300 beds, and in home health agencies, DME stores and a home infusion company. Bill is a board member of the Lone Star Chapter of the 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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THE PROBLEM

The key to success with ICD-10 is the same as it is with ICD-9: documentation is everything. Unfortunately, ICD-10 is significantly more complex than ICD-9, and this begs the number one question related to the entire ICD-10 implementation experience:

How do I convince a recalcitrant physician to document their care adequately so we (the hospital, ASC or other institution) can optimize ICD-10 coding and realize the greatest possible benefit from this system?

The ICD-10 countdown continues, as all certified coders are facing the task of familiarizing themselves with the new coding system.

With Oct. 1, 2013 on the horizon, many will be preparing to take ICD-10 certification exams as part of certain coding association requirements. Paper and electronic methods are the two paths coders face as they begin to think about an attack on ICD-10 – so which path should you choose?

The use of the word “attack” is widespread, as every U.S. organization is faced with transitioning from roughly 60,000 codes in ICD-9 to more than 150,000 in ICD-10. The numbers are overwhelming; so overwhelming, in fact, that many seasoned coders have stated that they will retire before ICD-10 is implemented. Being that many coders are visual thinkers, many believe that paper is the only option, specifically since those sitting down to take the ICD-10 certification exam will need to use a paper ICD-10 code book.

Whether you are a coder, a HIM director with coding staff or part of an ICD-10 risk assessment committee, do you know how you, your team and/or your organization are going to attack learning the ICD-10-CM and PCS coding systems? Many may default to paper code books, but if you think about coding from a workflow perspective, it makes the most sense to take advantage of modern technology. Still, there is no need to choose one or the other. You can pair them together as a single plan of attack and look for electronic tools that can assist coders in learning how to use the required paper code book.

Considering Workflow Tools

From a broader perspective, aside from the paper code book option, other types of ICD-10 workflow tools to consider obtaining include any that will assist in learning the actual code sets, assist in current workflow activity to translate codes from I-9 to I-10 and assist in learning ICD-10 from a regulatory standpoint. These tools possibly could include a subscription to electronic educational courseware, specifically sources with a strong focus in anatomy and physiology.

There are options out there in the marketplace, and many organizations already have multiple tools that may help them accomplish some of these objectives. Also, take a moment to assess the coding workflow. You soon will realize how your organization easily can limit coder apprehension about learning the new coding system, increase coder longevity and productivity and save money at the end of the day if you choose coding workflow tools wisely.

Workflow coding tools should provide the following in one easy-to-use format:

Coding – Ensure that electronic code books are available and contain both ICD-10-CM and PCS. The CM electronic code book should be comprehensive, featuring guidelines and indexes, and the PCS e-code book should include guidelines, indexes and a reference manual. The electronic code books should be paired with some type of ICD-9-to-ICD-10 translation tool. This tool should assist the coder in analyzing current code sets under ICD-9 in comparison to those in ICD-10.

Regulatory Resources – Correct coding is driven by regulatory information. Providing access to CMS notifications and regulatory issuances such as The Federal Register and CFR will be key to a coder’s success. Additionally, a quality coding workflow tool should have the capability to highlight and anticipate the addition of local and national coverage determinations as well as updates to the ICD-10 coding system in the form of CMS manuals and transmittals. Be prepared, as payers and CMS soon will provide direction for accurate claims submission as we continue to move forward towards ICD-10.

Education - Electronic educational courses paired with coding and regulatory information can be very powerful in helping the coder tie it all together. Courses should include not only a comprehensive overview of the ICD-10 coding system but also components related to anatomy and physiology, clinical implications, and medical terminology: items to help coders adjust to the specificity required by coding with ICD-10.

 


 

The Role of Technology

Evaluating technology used to facilitate learning of ICD-10 code sets is not an easy task, yet the technology should be able to do the following from a coding workflow perspective:

I. Offer an electronic translation tool that allows the user to perform a simultaneous keyword search of ICD-9 and ICD-10 for direct comparison (and not just by code searching).

II. Provide transparent access to the General Equivalent Mappings (GEMs) and reimbursement maps so that the search results are obvious and direct, including forward and backward mapping.*

*Many have argued that coders should not use GEMs to code or even have access to the reimbursement maps. The GEMs and reimbursement maps should serve solely as a guide for coders, and should not be seen as a replacement to actually learning the new coding system.

III. Provide understanding of the implications of ICD-10 on MS-DRGs via an interactive MS-DRG grouper.

IV. Present current and archived guidance to assist coders in understanding how ICD-10 impacts other coding areas such as claims processing, Medicare benefit policy rules and national and local coverage determinations.

V. Include free training and support; this is an unfunded mandate from the government. Although development is an incurred cost by vendors for these workflow tools, institutions should not be burdened with software installation and training costs.

Choose to be a leader in learning ICD-10, and pair paper code books with electronic tools to facilitate the transition. The use of electronic coding workflow tools not only will improve efficiencies and lower administrative costs, but also reduce coding errors and claim rejections. It will lead to achieving an organizational enterprise goal to be in compliance and submit clean claims correctly the first time.

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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“Embrace it; don’t postpone it.” That’s one key piece of advice that Dr. Daniel Duvall, medical officer for the hospital and ambulatory policy group at the Center for Medicare, gave to those who listened to an August 3 national provider call sponsored by the Centers for Medicare & Medicaid Services.

The presentation by Duvall and others from CMS, entitled ICD-10 Implementation Strategies for Physicians, seemed to be designed as a way to replace providers’ fears about the new system with information about what they need to do to get ready for the October 1, 2013, implementation date.

That’s not a particularly shocking statement; most of you probably agree. But let’s consider one small example of what it means.

Have you ever noticed how every time someone comes up with some change in payment systems, coding systems, cost containment systems or whatever, consultants (me, for example) seem to come out of the woodwork?