EDITOR’S NOTE: This is the ninth in a series of articles on fast-tracking ICD-10 implementation.

This month marks the beginning of the “Countdown to ICD-10.” We have only 10 months left to get ready. Many of my clients have been asking, “What are the top four areas of implementation that are the most critical, and what should we focus on right now if we have to pick and choose what gets finished by the go-live date?” That is an excellent question. I believe the most critical issues are:


  1. System upgrades implemented to achieve ICD-10 compliance (an electronic health record and other critical applications that use diagnosis codes or descriptions)

  2. Interfaces between the electronic health record (EHR) and other software applications

  3. Medical record documentation

  4. Template and workflow rebuilds

Many hospital systems and physician practices won’t meet the deadline if they do not take a look at these critical tasks and prioritize them in case not every element of their action plans can be completed by Oct. 1, 2014. So, let’s talk about some of the challenges.

Many currently are right in the middle of system upgrades for all software applications that affect ICD-10. One of the concerns is this: How will the upgrades work with ICD-10? It is important to maintain a testing environment prior to going live with the new version. However, some hospitals and physician practices do not have a testing environment (sometimes referred to as a “sandbox”) to test the new version. That can be concerning, as we all know that some upgrades don’t go smoothly and errors must be found and corrected. Once the new, ICD-10-compliant versions of software are running smoothly, it is important that your information system staff makes certain that all upgraded software that will interface with the electronic health record is tested and able to interface. This might be the easiest issue to deal with, even though we know that upgrades are complex issues to address and often must be completed quickly.

Now for arguably the largest area of concern in a medical practice, and for hospitals that employ physicians: How do we ensure that the physicians will a) document with the specificity demanded by ICD-10 and b) select specific ICD-10 codes? This is a challenging problem. For physicians still working with paper, the superbill will not work for ICD-10. The superbill (charge ticket, encounter form, or whatever you call it in your medical practice) is outdated and won’t accommodate the full volume of ICD-10 codes that will need to be on the forms. You won’t find any practitioner who will look through a seven-page superbill to make a code selection. That is inefficient and takes away time from patient care.

So, what is the solution? There are a couple of them. Many vendors now are developing or have developed an “electronic superbill” that can interface with some of the electronic health records or be used as a standalone product. This might provide an electronic solution, which is the method I would prefer if a practitioner is remaining on paper until after the ICD-10 transition. The other method is to train your physicians to write the diagnoses (with specificity) on the superbills, with someone else coding it. Many physician groups will begin using their coders as hospitals currently use coders. The coders will abstract the coding from the documentation, and this will free the practitioners to focus on patient care – but they still will need to be involved somewhat, since it is their responsibility. Keep in mind, however, that this may be costly if you need to hire qualified coders. But think of it this way. If productivity is reduced by 50 percent during the first year of implementation, how much money will the practice lose if a practitioner only can see 50 percent of his or her patients due to the additional documentation burden? And what about the reduction in access to patient care? This could really affect quality of such care. Maybe it actually would be more cost-efficient to have coders abstract from the medical record and select the codes that way.

Now let’s look at the electronic health record. The first issue that must be addressed is rebuilding the templates that once were customized by the hospital and/or medical practice. Let me give you an example. In a physician EHR, it might take 8-10 templates to build the E/M level for an office visit in the electronic record. That can take hours to accomplish. Yet what if your templates are set up based on the chief complaint, assessment, or plan of care? This could equate to many more template rebuilds. And what if you have more than one specialty? Now your complex issues multiply. Yes, you must rebuild the templates, but if you have not begun this process, can you accomplish this in just 10 short months? You will have to rebuild the templates for ICD-10 in most cases, and finding experienced people to help may be the challenge.

What about if the practitioner is selecting his or her procedure and diagnosis codes within the EHR? We know that all certified electronic health records will be updated for ICD-10, and that many are using IMO, which has the capability to drill down to the required specificity. But is the EHR vendor using it? In many instances, they are not, and instead are mapping from ICD-9 to ICD-10, in which case the provider will need to select a diagnosis from a “pick list.” What problem do you see here?

What is the solution? There are a few. The first is to begin training practitioners now to document in ICD-10 and to use their EHR upgrade efficiently. It is always helpful within the training to provide snapshots of what the EHR coding screen will look like. Another solution is to begin using scribes to document the patient encounters in the medical record. A scribe can free up the physician to manage more patients and potentially could reduce losses of productivity. Medical assistants and nursing staff would be perfect candidates to act as scribes as long as both the scribe and practitioner are trained to communicate during the patient encounters. The last solution, of course, is to utilize coders to abstract the coding and code from the documentation. With both of these solutions, there potentially will be the need to increase staffing, but again, look at the potential loss of productivity. Using scribes and/or coders might reduce the loss of productivity long-term and may even increase revenue in the future to allow the practitioners to manage more patients efficiently. However, regardless of which method you might choose, the practitioner still will need to understand how to document for ICD-10 based on his or her specialty.

The last issue that should be addressed is clinical documentation improvement. I feel strongly that, even in a medical practice, clinical documentation improvement processes would be of great benefit for coding, documentation, and revenue – not only in the hospital, but in the medical practice.

It is time to bring these issues to the forefront, discuss them with your steering committee and find your own solutions.

About the Author

Ms. Grider, a Clinical Documentation Improvement Practitioner, is an AHIMA-approved ICD-10 trainer and an American Medical Association coding author. She is a senior healthcare consultant for Blue & Co., LLC, and has more than 30 years of experience in coding, reimbursement, practice management, billing compliance, accounts receivable, revenue cycle management and compliance across many specialties. Her specific areas of expertise include medical documentation reviews, accounts receivable analysis and coding and billing education. She is the Indiana Health Information Management President-elect.

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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.
Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner

Deborah Grider has 34 years of industry experience and a recognized national speaker, consultant and American Medical Association Author who has been working with ICD-10 since 1990 and is the author or Preparing for ICD-10, Making the Transition Manageable, Principles of ICD-10 and the ICD-10 Workbook, Medical Record Auditor, and Coding with Modifiers for the AMA.  She is a senior healthcare consultant with Karen Zupko & Associates.  Deborah is also the 2017 American Health Information Management Literacy Legacy Award Recipient. She is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.