July 19, 2015

ICD-10 – Managing in the Storm: How External Political Events, Surveys, and Cost Add to Stress for Project Managers

By Paresh Shah

Project managers (PMs) understand that the key elements of the ICD-10 project—making a plan, training your clinical staff, updating internal processes, communicating with vendors and payers, testing internal systems, and testing externally are all table stakes: Doing well in these areas is no guarantee of success, regardless of the facility size.

There are three major constraints and challenges facing ICD-10 compliance deadline. The risk and the associated mitigation will be key for providers to meet the compliance deadline.

External Events

Over the past few weeks, there has been a lot of news about ICD-10:

  • During the first week of July, the Centers for Medicare & Medicaid Services (CMS) announced it would work with the AMA to ease the transition to ICD-10. CMS has adopted the AMA’s suggestion regarding the code set. (See www.cms.gov for details)
  • Legislation proposed in the U.S. House of Representatives would permit providers/coders to code in both ICD-9 and ICD-10 formats for a fixed period of time after Oct. 1, 2015.
  • Legislation proposed in the U.S. House of Representatives—Coding Flexibility in the HealthCare Act of 2015 (Bill introduced by Rep. Marsha Blackburn, R-Tenn. and Rep. Tom Price, D-NC) would require HHS/CMS to report to the U.S. Congress 90 days after the ICD-10 Implementation date (Oct. 1, 2015) on the impact the ICD-10 codes are having on providers and the industry stakeholders.

Based on the external events, the key things to remember are:

  • Washington, D.C. has been following the ICD-10 and its impact.
  • Due to the number of days the U.S. Congress is in session before Oct.1, the passage of the bills is uncertain.
  • The CMS/AMA announced “Medicare will not deny the claims solely on the specificity,” but there has been no similar announcement from the private plans on the CMS/AMA announcement. CMS does need providers to submit claims in ICD-10 beginning Oct. 1.

Industry Survey(s) and the Risk 

There are various industry survey results completed and more sectors are in the process of collecting results, but there are already key findings:

  • Provider organization(s) have made forward progress with the implementation but are behind in testing.
  • Many organization(s) believe that ICD-10 adoption will reduce revenues.

The survey identifies key risk(s) to the industry, but as a PM the survey results need to be filtered down to the provider’s organization.

There is no one solution as each and every healthcare institution is unique (Provider A has more than 50 percent of its clients on Medicare/Medicaid while Provider B has 50 percent of its clients on private insurance plans, etc.).

Table 1.0 is an example of a matrix derived from the industry survey(s) and its applicability to the PM institution.

Event

Occurrence

Impact on Schedule

Impact on Cost

Remediation

Vendor fails to deliver compliant software/Vendor readiness

Likely

Slip in date

Monetary issue

Work with vendor; alternatives to software

Coding (Skills, Training, etc)

Likely

Slip in date

Medium–huge

In-house training; online training; practice exercises

Testing – Internal

Likely

Delay

Impact on revenue and cost

Scenario-based testing; ability to work on paper

Testing – External

Likely

Delay

High

Time & cost to remediate (more line of credit, etc.)

 

Other ….

 

 

 

 

Table 1.0 can be expanded to other risk(s) as part of ICD-10, and the risk(s) can be grouped together so they can be handled together with the same level of effort (for example, training for coders and the training for clinical documentation may be grouped so that if there is clean clinical documentation, it will be easier to code). Similarly, if there is a lack of coding expertise, it can be grouped together with the coding training and an alternative to coding—automation, etc.

Based on the risk(s) at the organization level, it’s critical for the PM to avoid risk (lack of coding expertise will not affect us), transfer the risk (if the IT system does not work, transfer the risk of making the software compliant onto the vendor), mitigate risk (if a payer is not ready, work with them and trust them), or accept risk (if a payer is not ready, accept it as it is).

The risk(s) are there because no other organization in the U.S. has implemented such an elaborate change before.

The Challenge of Meeting Targets

The PMs and their organizations want to look good on both the cost and the schedule simultaneously. Meeting the ICD-10 deadline is critical to the organization—meaning that the PM and the team must spend time to meet the schedule (October 1). In addition, cost is critical to the organization and the CFO.

As a PM, there is a conflict between schedule and cost, which could lead to alternative compromises. For example, to achieve compliance, additional training/coders (outsourcing) might be needed. From a cost perspective, if the decision is made to put live training on hold and have online training, this may succeed in reducing cost. There are additional considerations:

  • Meeting the Oct.1 deadline is the goal, but at what cost?
  • If cost is the priority, what is the critical path to meet the deadline in the shortest period of time?
  • Does the PM have data on the cost to date, schedule to date, and the status of sub-tasks on a real-time weekly basis to make informed decisions?
  • Based on the information, can the PM make adjustment(s)—do they have decision-making authority?

In addition, if a PM is attempting to improve on cost (lower price for outside trainers/coders, resulting in mediocre-quality consultants) and schedule (more resources for testing) simultaneously, it neither guarantees nor ensures that the cost and schedule may improve. Shortcuts may lead to other problems, like poor coding and claims being denied.

Moving Forward

The constraints/challenges help to make stress in ICD-10 project management a huge issue. For the PM, burnout is an issue, turnover of coders (after they are trained) is understandable, and easy solutions are hard to find. Bringing in new resources to bail out the organization, with varied backgrounds (experience with large hospital/IDN while the organization is a small hospital, etc.) adds stress. Will they be able to assist or hinder the deadline?

The PM needs to understand all the pieces of the puzzle but needs to move forward (as per his project plan) and sort his priorities based on the hospital’s mission (patient safety, patient care, etc.). A regular meeting with the CFO to discuss the project status and the trade-offs to be made is critical.

For example:

  • Hiring an ICD-10 coder or a trainer to train existing coders and do practice sessions (overtime for practice).
  • Being non–compliant on Oct. 1 versus being compliant one week late, and the trade-offs.
    • (At the time of Y2K there was a situation at a firm where I did consulting, where an application was hardly used—less than 5 percent of the time. Nobody knew about this application not being Y2K-compliant until November 1999. The CFO made a gutsy call to proceed with Y2K compliance on all major applications and then work on that application after Jan. 1, 2000. There was no disruption or any disaster on Jan. 1, 2000, or after, when we brought the application on-line. The reason for the success was the CFO simulated all the scenarios. He was able to meet the schedule at the controlled costs.)

Due to the unknowns, the post-ICD-10 risks need to be accounted for. What if significant claims are getting denied or rejected, and the tradeoffs?

As Janet O’Malley, director of the ICD-10 & Clinical Documentation Improvement Program at Boston Children’s Hospital, says, “The role of the project manager is to lead people, ensuring that they complete the required tasks to make the project successful. We don’t provide value when we don’t do that, and with ICD-10, a mandate that no one wants to comply with, that is a difficult role.”

About the Author

Paresh K. Shah, President of MindLeaf Technologies, Inc., Bedford, Mass. Mr.  is a member of HIMSS –ICD10 Taskforce and Co-chair of the HIMSS Playbook.

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