September 11, 2012

ICD-10 Implementation: Healthcare’s Slow-Moving Train

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Editor’s Note: Talk-Ten-Tuesday produced a live three-part series called “ICD-10: Back on Track,” which aired Aug. 28 through Aug. 30. The following touches on Part I, which focuses on getting physicians back on track with ICD-10.

 

For a fully loaded freight train of about 1.5 miles in length, with 120 hopper cars weighing 100 tons each, it will take up to two minutes for the train’s last car to start moving. Amazingly, railroad folks who know will tell you, when the engine starts up, the train will move up to one inch before the second car is pulled and the “slack” is drawn out of the couplers — and this process continues down the line, literally one car at a time, in a carefully calculated process.

Healthcare facilities, like slow-moving freight trains, have plenty of moving parts and interconnectivity. And with so many departments and settings to be impacted by ICD-10, getting everyone engaged, especially physicians, was foremost on the minds of a number of listeners to the recent Talk-Ten-Tuesday three-part series about getting the healthcare industry back on track.

Getting the Momentum Back

One listener acknowledged that their facility had stopped training while awaiting the Centers for Medicare & Medicaid Services’ recently unveiled final rule, which moves the compliance date from October 2013 to October 2014. The listener wanted to know what to do to “get the momentum back.”

“What we believe needs to happen first is the same measured, phased approach where, first and foremost, you have to educate the docs,” said Denny Flint, president of Complete Practice Resources and one of the panelists for the first of three broadcasts. “Because after speaking in front of literally thousands of docs over the last year and a half, most of our providers don’t have a clear sense of what ICD-10 really is, or what it means in practice. So we think you have to start there, and that becomes the prerequisite for all phases that follow.”

Getting physicians engaged seems to be the appropriate starting point for getting back on track with ICD-10.

“I couldn’t agree more with that (getting docs engaged makes sense),” said Rudy Braccili, executive director of revenue cycle services for Boca Raton Regional Hospital. “There’s no reason to delay that physician education in documentation whatsoever.  When we first approached that, it seemed like a huge undertaking, but then wisely we’ve … (focused) it on specialties that are most likely impacted with the I-10 change.”

Braccili explained that in his facility, some specialties are more impacted than others. He recommended that facilities focus on specific specialties and then perform analysis on physicians within those specialties that provide most of the hospital’s business.

“When you focus it in by specialty and then run reports to show (which) physicians within that specialty … provide us with say, 80 percent of our business, you can really get it down to a target of, say, five or six or a dozen or so physicians and really focus and target your documentation efforts towards them,” Braccili said. “Suddenly, it becomes much more of an approachable undertaking than thinking ‘how am I going to educate (the) 700-plus (members of my) medical staff?’

The question one listener asked about finding an easy way to determine which specialties would be impacted most in terms of the number of new codes drew a grin from Rhonda Buckholtz, AAPC’s vice president of ICD-10 Training and Education program.

“That one makes me chuckle because every specialty will be impacted,” Buckholtz said. “There are really very few that won’t see some type of impact.”

Physician Education

A recurring concern among listeners was physician education, especially as it relates to clinical documentation. One listener wanted to know the best way to help physicians understand the documentation requirements needed for ICD-10, particularly as it pertains to the kinds of specific information needed for coding.

“We see that the changes in the coding (are) different based on the different specialties in the different chapters in the CM code books,” said Melanie Endicott, director of HIM Solutions for the American Health Information Management Association (AHIMA). “We recommend that you do small, little focus sessions with the different specialties instead of trying to overwhelm them and teach them the whole book at once.”

One listener suggested that the best way to help physicians is for facilities to continue to train them on high-quality, compliant documentation –- not necessarily focusing on the fact that it is for ICD-10. Ensuring the creation of high-quality documentation serves multiple purposes, the listener added.

“Absolutely, I agree,” Endicott replied. “In fact, clinical documentation improvement specialists right now …gearing up for ICD-10 are beginning to query and look for documentation within the health record that meets the needs of ICD-10, even two years in advance.”

Endicott explained that facilities should be looking at improving clinical documentation from multiple perspectives.

“So it is very important that we don’t look at this as just as a dollar sign, but … as improving the quality of the documentation, which in turn improves the quality of care.”

Impact on Coding

In addition to engaging physicians regarding greater specificity in the  clinical documentation required with ICD-10, Braccili said that coder education is extremely important. He noted that anatomy and physiology are high on his list of subjects upon which coders should focus.

 


 

“I think you can’t do enough of that, quickly enough,” Braccili said. “So I would definitely get started if you haven’t already on coder training, everything (including) anatomy and physiology. These courses take months and months for the professional coders to go through, so I would not hold back on the coder training whatsoever.”

Some listeners spoke of how hospitals could audit their own ICD-10 coding. Of particular concern was making sure that commercial payers as well as Medicare would accept their coding.

“You could, of course, hire a consultant to come in and do that,” suggested Endicott, acknowledging that doing so might prove costly. “Other ways that you could do it is just (through) some peer review within your facility, so that one coder reviews another coder’s charts and (they) learn that way. That’s a cost-effective way to do it.”

Voicing an academic’s point of view, Brooke Palkie, assistant professor of HIM at the College of St. Scholatica, said she too liked the “train the trainer” approach. And while Palkie said she appreciates the classroom setting for education, she believes a more fitting environment for coder education is a hospital department.

“The perfect place (is) in a department, to be able to have people who specialize beforehand and who continue to work with the rest of their department until there is a continuous audit,” Palkie said. “If there’s not application, you’re going to lose it. So there’s that chance for people to apply, to assess, and that’s when you can improve and focus on the different specialties and areas that need more training, more A&P.”

Dual Coding

 

There has been much discussion centered on dual coding, in which facilities code in both ICD-9 and ICD-10 for a period of time. One listener asked if dual coding would help them prepare for ICD-10 and whether dual coding might impede current levels of coder productivity.

“I’ve heard (that) when the implementation date was 2013, there were some organizations that were going to begin dual coding in January of 2013,” Endicott said. “That may now be pushed out a year, but I think that six to nine months ahead of time is a good time to look at that.”

Endicott stressed that it would not be necessary to dual-code every chart. She suggested that facilities might consider dual coding only on some charts so that productivity doesn’t decline.

“I think that doing … dual coding will help you once implementation is in,” she said. “You’ll be ready for ICD-10 and you’ll have less of a learning curve at that time.”

I-10’s Impact on Quality

In light of the notion that the pervasiveness of ICD-10’s impact is expected to extend throughout organizations, as well as in different provider settings, the new code set’s impact on quality is of concern to some. One listener wanted to know about ICD-10’s impact on patient safety indicators and core measures, especially its projected impact prior to the Agency for Healthcare Research and Quality’s (AHRQ) pending updates of its diagnostic list for case selection.

“I think that (what) you could possibly do is take a look at the ICD-9 codes now and the diagnostics that are attached to them, and see how those begin to translate into ICD-10,” Buckholtz said. “(You can) see whatever changes you might need to make.”

Palkie again made the case for dual coding in response to the listener’s question.

“I think this also circles back to the question about the dual coding,” Palkie said. “And I think there are multiple purposes for dual coding, and in fact if you look at the final rule, one of their (U.S. Department of Health and Human Services’) justifications for the delay was a cost avoidance of $3.6 to $8 billion in delayed payments. So one reason, of course, is payments, but there (are) multiple other reasons why you would want to do the dual coding.”

Breathing Room

Recognizing that the 2014 compliance date has given providers some breathing room, speakers were quick to mention that the extra two years could be used to everyone’s advantage.

“I think now that we’ve got over two years, take advantage of that time and help educate the physicians on what has changed with the coding,” Endicott said. “Then also have the coders and other HIM professionals learn from the physicians to better understand the clinical terms and what’s being done in those operations so that they can better code it. So it’s kind of a two-way street.”

Beyond using the extended deadline period to advance physician and coder education, Palkie said the additional time would encourage engagement of the new code set and the data it will yield.

“You absolutely have to take advantage of this opportunity to leverage the data and how it is going to affect the whole entire organization, thinking in terms of enterprise information management,” Palkie said. “How is it (data) going to affect quality? What is it going to mean for meaningful use? What is it going to mean for reimbursement? Take advantage of this time; make sure it’s not just an implementation, (but also) really leverage this opportunity.”

 

Chuck Buck

Chuck Buck is the publisher of ICD10monitor and is the executive producer and program host of Talk Ten Tuesdays.