December 11, 2012

ICD-10 Risk Mitigation for Compliance Officers and HIM Professionals

By Cindy Doyon, RHIA

Realizing the opportunities and avoiding the risks associated with the migration to ICD-10 will depend fundamentally on the individuals within each healthcare organization and their ability to thrive within this changing environment.

What is required is an organization-wide approach that:

  • Shows the impact of the ICD-10 migration across the organization;
  • Assesses the readiness of impacted populations to accept a changing environment, and thrive in it;
  • Distributes responsibility appropriately; and
  • Pulls together the comprehensive training efforts required for success.

Specifically, some must-dos include:

PEOPLE

PROCESSES

TECHNOLOGY

Create ICD-10 impact awareness throughout the organization.

 

Define your change management approach to ensure that you have determined the proper structure and sponsorship.

Ensure that your foundational information systems (IS) structure is preparing for the transition.

Develop projections of operational needs, including staffing and internal educational training needs.

Identify specific documentation gaps to determine where to focus educational resources.

 

Review existing software, including interfaces, to ensure its ability to successfully transition to ICD-10.

Train clinical and administrative staff on new code sets and technological changes, as well as fraud, waste and abuse regulations and reporting.

Calculate potential impact on financial results.

 

 

 

Review third-party agreements to ensure that any vendors involved in billing processes will be compliant with ICD-10 requirements.

 

 

Ensure that clinical documentation procedures reflect the increased level of detail required by ICD-10.

 

 


 

To ensure an accurate and unbiased evaluation of medical records, many providers will seek to contract with outside entities to conduct an independent audit. Third-party audits can be instrumental in diagnosing documentation gaps and coding compliance issues.

Some risk mitigation advice specific to documentation includes:

  • Focus on good documentation, which directly impacts accurate coding and billing, as well as payment timing;
  • Be aware of new ICD-10 documentation requirements in order to evaluate provider documentation for appropriateness and completeness;
  • Take great care to document all procedures, labs and other diagnostic and therapeutic tests and treatments in order to capture the essence of the care provided during hospital admissions;
  • Enhance collaboration, transparency and communication between payers and providers; and
  • Train and problem-solve through the use of task forces.

It is important for healthcare organizations to identify all of the changes required to systems and processes. Many payers and providers are approaching this as merely a code or system change, but it is vital to consider how and where accurate coding will come into play in all processes and workflows, and to determine the potential organizational impacts of coding errors that ultimately could lead to fraud and abuse accusations or compliance risks.

During this process, communication and candid discussions between healthcare organizations and primary third-party payers are essential. Healthcare organizations need to share plans for implementing ICD-10 code changes, including system changes and timing as well as staff training.

Payers also need to explain any changes they are implementing in their claims submission or resubmission policies and procedures. By keeping lines of communication open and identifying shared goals and objectives, both healthcare organizations and third-party payers can minimize compliance and financial risks posed by ICD-10.

About the Author

Cindy Doyon, RHIA, is vice president of coding and client audit services with Precyse, a leader in health information management (HIM) technology and services.

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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.