July 31, 2012

Do Not Underestimate the Time Needed to Prepare for ICD-10 Implementation, says HIM Consultant

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How productive are your coders? Do your current business processes aid, or impede, their productivity? These are just two of the questions hospital managers may want to investigate now—before it’s time to implement the new ICD-10 coding system.

“Look at the percentage of time coders spend actually coding and dropping bills versus performing other chart activities and tweak your work flow processes to get your coders coding correctly and dropping the bill quickly too,” advises Karen Youmans, MPA, RHIA, CCS, president of YES HIM Consulting, Inc., Largo, Florida.

 

Youmans also recommends that the healthcare industry take a lesson from our neighbors to the North, which implemented ICD-10 between 2001 and 2005.  “The greatest risk to this program is the underestimation of what it will take to implement successfully,” she says.  For example, Canadian healthcare leaders underestimated the magnitude of the changes needed in business processes and the need to identify variations, process redundancies, and inefficiencies.

In addition to business processes, it’s essential to recognize the impact that ICD-10 will have on clinical workflow and interpretation. Training certified coders only in ICD-10 is not enough; they also must understand the underlying medical conditions and surgical procedures documented and what constitutes accurate and detailed physician documentation.

Most importantly, Youmans says, “Physicians need to be able to assist us with the change and have acceptance of ICD-10. They are a critical factor in the success of implementation.”

Identifying Level of Productivity

The number of records coded per hour will, of course, vary depending upon several factors, including the individual coder and his or her clinical knowledge and experience and, as mentioned below, the amount of time spent waiting for physician documentation. Another thing to consider is the type of documentation (for example, paper-based, electronic, or hybrid), which may affect how coders review the documentation. Even the site of the coding—remote or onsite—could make a difference in productivity.

As Youmans says, “All of these qualities should be taken into consideration during an analysis of productivity and the training that will be needed.” Slow turnaround “doesn’t necessarily mean coders aren’t doing their jobs fast enough,” she adds. It could very well be some inefficient processes in place.

To “tweak your business processes,” Youmans says, you must follow a patient chart workflow step-by-step and identify where roadblocks and delays may occur in your business processes. Identifying the problem slowdowns, and then solving them, puts you on your way to higher coder productivity and decreased billing time.

Analysis of One Hospital’s Process

In the fall of 2010, Youmans and her colleagues analyzed one entire healthcare system’s inpatient and outpatient coding and business processes in order to differentiate the amount of time spent finalizing the coding of a chart versus time spent on the following:

  • Other chart activities, such as reviewing charts and writing queries, processing completed queries, and working DNFB (discharged but not final billed) reports
  • Other non-chart-related activities, such as researching clinical techniques and coding guidelines; resolving computer downtime and system issues; and attending meetings, seminars, webinars etc.

On the inpatient side, they found that 74.65 percent of coders’ time was, in fact, spent on coding, and 93 percent of the coded charts related to inpatient stays of 10 or fewer days. Coders averaged 3.86 charts per hour (or 30.8 per day). This particular healthcare system’s coders exceeded the industry productivity standards established by the American Health Information Management Association (AHIMA) and the Healthcare Financial Management Association (HFMA). For inpatient charts, AHIMA averages the number per day at 24, and HFMA averages the range between 23 and 26.

Not surprisingly, as the length of stay (LOS) increased, the number of charts finalized per hour decreased. For example, an average of 1.78 charts per hour (14.2 per day) could be completed for an average LOS of 10 to 30 days.

Consultants investigated the reasons why bills could not be finalized and found that “bill hold” accounted for almost 44 percent of the delay. Reasons for holding the bill included lack of the operative reports required for coding in addition to missing discharge summaries or other physician documentation.

On the outpatient side, 57 percent of coders’ time was spent on coding and 26 percent spent on other chart activities and 17 percent for other non-chart-related activities. Youmans’ team broke out outpatient services into ambulatory surgery, emergency department, and ancillary services. However, in hindsight, she says, outpatient ancillary services, which are the most diverse hospital services provided, should have been divided into even smaller groups to make analysis easier.

Other factors also must be considered, and major ones are the national correct coding initiative (CCI) edits and the DNFB reports. Youmans says, “The types of CCI edits and the number of accounts on DNFB need to be quantified.”

On both the inpatient and outpatient side, missing physician documentation was the biggest roadblock to finalizing a claim. Part of the problem rested with new coders—those with one or two years of experience—who, says Youmans, “often lack the confidence that the existing documentation was enough” or hold the claim instead of sending a query or listening to the dictated report for information.


Taking Action to Improve Delays

In the fall of 2011—one year after the baseline study, Youmans’ team returned to the healthcare system for a follow-up review and discovered that hospital leaders had made several improvements in their processes to ensure prompt coding and billing.

For example, to counter the issue of variances in skill levels, the healthcare system developed a mentoring program where a more experienced coder was partnered with a new coder. Each day the two met via a brief conference call to review the new coder’s questions or deal with other problematic issues. In addition to studying their business processes and changing inefficient ones, the hospital implemented physician education to improve documentation and increased education for coders to widen their clinical knowledge base and increase their confidence. They also initiated a process where coders checked the CCI edits upfront instead of on the backend in the business office.

Youmans reported that “by tweaking the processes,” the hospital showed “an incredible increase” of 5 percent in coder productivity for inpatient claims. Coding productivity also increased on the outpatient claims as follows:

  • Ambulatory surgery coding increased from 6.17 to 6.49 charts per hour.
  • Observation visit coding increased from 4.43 to 5.98 charts per hour.
  • Ancillary services’ coding increased from 22.58 to 26.96 charts per hour.

Getting Ready for ICD-10

Experts in the field repeatedly state that now is the time to begin preparing for the implementation of the ICD-10 coding system, and the example above shows that an analysis of coding productivity and business processes can provide valuable information. Youmans also provides the following tips.

  • Begin by building staff (physicians, coders, etc.) awareness about the imminent implementation of ICD-10.
  • Make education a priority—for physicians and for coders. For physicians, emphasize the need for more detailed, specific documentation and timely submission of it. In addition to training coders in ICD-10 diagnosis and procedure coding, make sure they also receive education related to anatomy and physiology plus a clinical overview of the most commonly performed procedures.
  • Allow enough time for coders and physicians to work together to practice coding and documentation, respectively, with ICD-10 and, in fact, implement dual coding to ensure coders and systems are ready for the switch.

To repeat the most important lesson of all: Listen to the advice provided above from our northern neighbors, and do not underestimate what it takes (timelines, effort and budget) to implement the new system successfully.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Janis Oppelt

Janis keeps the wheel of words rolling for Panacea®'s publishing division. Her roles include researching, writing, and editing newsletters, special reports, and articles for RACMonitor.com and ICD10Monitor.com; coordinating the compliance question of the week; and contributing to the annual book-update process. She has 20 years of experience in topics related to Medicare regulations and compliance.