12. Implications of the Transition – Who? ● Providers ● Hospitals ● Physicians ● Outpatient facilities ● Post-acute providers (home health agencies, skilled nursing facilities, etc.) ● Health Plans or Payers ● Third party administrators ● Employers
13. Implications of the Transition – Who? ● Others ● Laboratories ● Free standing ancillaries ● Researchers ● Public health agencies et al. ● Data collection agencies/organizations (registries) ● Vendors ● Clearinghouses ● Business associates and partners ● Patients
14. Implementation – Two Systems, One or three? 5010 ICD-10- CM/PCS 01/01 2010 01/01 2011 01/01 2012 01/01 2013 10/01 2013 01/01 2014 Implementation Testing Implementation Testing ARRA Meaningful Use”
15. X12/NCPDP HIPAA Transactions Implementation Testing Compliance ICD-10-CM/ICD-10-PCS Implementation Testing Compliance New Systems (RFIs & RFPs) Implementation Education & Training
16. Remember Resources Key supporters and worker bees Systems and other resources Vendors and Consultants HIPAA transactions are important What can be done in parallel? Other systems needs Internal v external schedules New systems Business goes on as usual (?) Implementation
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35. Resources National Center for Health Statistics – CDC ICD-10-CM www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm Centers for Medicare and Medicaid Services ICD-10-PCS www.cms.hhs.gov/ICD10 ICD-10 and HIPAA Federal Register Notices www.access.gpo.gov/su_docs/fedreg/a080822c.html
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38. Dan Rode, MBA, CPHS, FHFMA Vice President, Policy and Government Relations American Health Information Management Association 1730 M Street, NW, Suite 502 Washington, DC 20036 Telephone: (202) 659-9440 E-Mail: dan.rode@ahima.org Questions ??? Comments !!! Questions ??? Q&A - Contact
Editor's Notes
Sue
SLIDE 25 Because ICD-10 is quite different from ICD-9-CM, it could be difficult to relate data coded under ICD-9-CM to data coded under ICD-10. This would severely impact reports that compile statistical data for trend analysis. Such reports may be used for rating purposes, effectiveness of care, provider profiling, actuarial analysis, etc. Ad hoc reports used to track utilization review, immunizations, maternity, transplants, disease management, cost savings, etc. will also be affected. Any activity involving comparisons of historical and current data, such as retrospective audits, would be impacted. It is possible that bad decisions may be made due to reliance on this distorted, inaccurate, or misinterpreted data, and/or due to comparability problems between data reported in ICD-9-CM and that reported in ICD-10-CM. One should exercise caution when interpreting longitudinal data as diagnoses and procedures may be classified differently if analysis crosses coding system changeover. However, it is also important to note that differences in distinctions and how diseases are currently classified are often due to outdated distinctions or classification in ICD-9-CM – so, while trends under ICD-10 may be different, that doesn’t mean ICD-9-CM data trends are clinically accurate or provide meaningful information.
SLIDE 27 General equivalence maps (GEMs) between ICD-9-CM and ICD-10-CM/PCS have been developed Backward and forward maps between ICD-9-CM and ICD-10-PCS are currently available on CMS web site Backward and forward maps between ICD-9-CM and ICD-10-CM are currently available on CMS and NCHS web sites GEMs are not crosswalks – they are reference mappings to help the user navigate the complexity of translating meaning from one code set to the other Differences between these maps arise because of differences in specificity of the classifications, especially in situations where one code in the new coding system maps to multiple codes in the previous classification and these codes are spread over multiple DRGs. Mapping from ICD-9-CM to ICD-10-CM/PCS is not a straightforward one-to-one crosswalk. Actually that is a good thing – if the two classifications were the same, and easily mapped, then we would not need a new classification system.
SLIDE 28 A reimbursement map was added to the CMS web site in 2009. This map is intended for use by payers as a temporary mechanism to allow claims to be processed by legacy systems until internal systems have been fully converted. It is important to note that maps should NOT be used for coding actual medical records, but rather as a guide to translate data. For more information about these Reimbursement maps, you may be interested in the Coding Notes article in the April issue of AHIMA Journal.
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SLIDE 31 But today we will concentrate on the First Phase: Impact Assessment which we’ve divided into 7 steps. AHIMA’s ICD-10 Preparation Checklist includes greater details for each phase, and this document is a great resource to get you started. You can find it at the url listed on the last page of this slide deck.
SLIDE 32 The first stage of preparation involves developing a strategy on how to proceed by identifying key tasks and objectives. As one of the first steps, it is suggested that you establish an interdisciplinary steering committee to oversee ICD-10 implementation and to develop an organizational implementation strategy; designate a lead; get senior management buy-in and put together a multi-disciplinary team by identifying the target audience Next develop internal timeline, including any resources required. Divide responsibilities among task force members - such as coder training, physician training, IT issues. The planning phase represents an opportunity to reassess and refine operations your current operations. You can learn a great deal about the current coding process, clinical documentation improvement plan, etc.
SLIDE 33 Employ change management strategies to minimize “fear of change” factor. As with any major change facility-wide - communication is key. You may want to assign someone the job of producing periodic announcements that outline updates on ICD-10 implementation. This communication should provide a rundown on national issues and implementation dates, as well as the issues within your facility. Keep all of the key stakeholders in mind as you plan your communication strategy.
SLIDE 34 Most organizations will start by building awareness by orienting key personnel including senior management, Clinical department managers, Medical staff, and IT personnel. It is important that these individuals have basic familiarity with the structure, organization, and unique features of the new systems and the value of the new code sets, and an understanding of how ICD-10-CM/PCS fits into the electronic health record and nationwide health information infrastructure. All users of ICD data need to understand how this transition will impact their current processes. Education should also be provided on the Final Rule, the timeline and the implementation date.
SLIDE 35 Once people are up to speed you’ll need to address the organizational readiness for the 5010 electronic data standard changes. During the impact assessment, consideration needs to involve: Affected staff Information systems (affected systems, applications, databases) Documentation process and work flow Data availability and use Organizational capacity (including budget) and other key projects that will occur during this same transition timeframe.
SLIDE 37 HIM are just the first systems to change. Slide Transition The impact to billing systems will need to be considered such as the size of the data fields are changing with ICD-10. In addition, while the underlying payment methodology will remain the same, the current payment system will need to be converted to ICD-10 codes. How will new codes that did not exist in ICD-9-CM be taken into consideration? National and local coverage determinations that contain ICD-9-CM codes will need to be converted to ICD-10 codes along with all systems that utilize ICD-9-CM codes in their logic or edits. While it is the providers responsibility to update these coverage determinations, facility staff will need to be educated on these changes, and how the medical necessity edits and logic will change. Slide transition All current systems and reports that contain ICD-9-CM codes will not only need to be reprogrammed but a decision made on how to manage the legacy data from each system. For those systems that transmit the data to external sources, verification of the external system to handle ICD-10 codes will need to occur. Some of those systems are: provider profiling, quality measurement and Utilization management systems, disease management and registries, fraud management, aggregate data reporting, clinical systems, and Patient Assessment data sets such as the MDS and OASIS. Even if your systems are prepared there will be issues on how to accomplish external reporting requirements if these data bases and systems are not ready to accept ICD-10 codes. Slide Transition Beyond these systems there may be changes required in Clinical systems, other support systems and the registration systems. There will be a need to create a complete inventory then to prioritize sequence of systems changes and estimate cost of changes. This is a list of systems that may be affected for someone to get started in thinking of their own organizational needs. Every facility is different, but this may be a start at the development of your own list.
SLIDE 38 It will be necessary to determine the length of time both legacy and new coding systems will need to be supported and whether current system storage capacity will need to be increased. <<Types of support to be considered include: Systems vendors--is support for both legacy and new coding systems addressed in the contract? How long is support for both coding systems anticipated? What kind of support is needed? Internal IT department--how long will the ICD-9-CM coding system continue to be accessible and to whom will it be accessible (e.g., data analysis personnel may require access for a longer period of time than the coding or billing staff)? Is system storage capacity adequate or will it need to be increased? Data users--how long will legacy data need to be available for data analysis, research, etc.? Billing--legacy system will still be needed for old claims and re-bills. Coding professionals--knowledge of both coding systems will continue to be needed. >> In addition, it will be required to determine which reports will require a modification of format or layout change, and which forms will require a redesign. Identify new or upgraded hardware/software requirements and determine budgetary implications (e.g., larger computer monitors, more powerful hard drive) <<If the coding process is currently manual (use of hard-copy code books), consideration should be given to using electronic tools (such as an encoder) when ICD-10 is implemented, which will result in additional hardware and software requirements; although it would be technically possible for coding professionals to use a paper-based version of ICD-10, given the size and structure of these systems, they would be easiest to use in an electronic format. Will hardware upgrades be needed to ensure optimal system performance? It may be necessary to conduct a data mapping overview. >> Vendor readiness and those timelines are crucial. Determine vendor readiness and timelines for upgrading software to new coding systems and determine if upgrades are covered by any existing contracts. If necessary, include costs of the upgrade in ICD-10 budget. Consideration should be given to contract renewals. <<Determine the anticipated timeline for testing the performance of the new code sets in your systems environment. Work with vendors to coordinate installation of new or upgraded software. Actively participate in any vendor user group meetings regarding ICD-10 implementation. Build flexibility into systems currently under development to ensure ICD-10 and, when possible, the next version of ICD compatibility.>>
SLIDE 39 Orient IS personnel on the specifications of the code sets that they will need to know to implement systems changes, including the logic and hierarchical structure of ICD-10-CM and ICD-10-PCS. <<The following questions should be addressed: What is the character-length specification for ICD-10-CM and ICD-10-PCS codes? Is it alphabetic, numeric, or a combination of both? Are the alphabetic characters case-sensitive? Does the code format include a decimal? Can codes, descriptions, and applicable support documentation and guidelines be obtained in a machine-readable form? What coding systems will it replace and when will it replace them? Are forward and backward maps available between the legacy and new coding systems? If so what is the defined use case for each? How many data management systems will be affected and what types of systems changes will need to be made?>> Perform a comprehensive systems audit for ICD-10 compatibility. Inventory all databases and systems applications that use ICD-9-CM codes. <<Give consideration to: Use of application service provider vs. internally developed system interface and other affected software programs How are ICD-9-CM codes used in each system? Will ICD-10-CM or ICD-10-PCS codes serve the same purpose and will a change in code sets impact the results? Where do the codes come from (e.g., manually entered versus imported from another system)? How quality of data is checked Interfaces between systems >> In addition, map electronic data flow to inventory all reports that contain ICD-9-CM codes, and perform a detailed analysis of systems changes that need to occur. The next slide has more detail.
SLIDE 40 Prioritize sequence of systems changes and estimate cost of changes. Refine previous budgetary estimates as necessary. Here is a list of software changes that will need to be changed or verified they are ready for ICD-10.
SLIDE 41 Identify the personnel who will need education: HIM professionals Physicians Anyone who uses ICD-9-CM codes will need education in ICD-10 Determine the type and level of education they will need: Coders need to increase their medical knowledge and will need an in-depth knowledge of ICD-10. Keep in mind ICD-10-PCS will be used for inpatient procedures only (but is a completely new coding system) Physicians need to understand the requirements for documentation The medical staff needs to be aware of the challenges to physicians and be supportive of processes that allow greater interaction between the coding staff and physicians. Determine whether education will be provided internally or externally (or both) and what media will be utilized. <<Traditional face-to-face classroom teaching, audio conferences, CD-ROM or downloadable materials (self-directed learning) or various forms of web-based instruction (self-directed or instructor led).>> HIM managers and coding professionals should: Educate themselves on the benefits and value of ICD-10 and learn how ICD-10 fits within the overall electronic health record (EHR) and data quality initiatives. It is important to learn the structure, organization, and unique features of ICD-10-CM and ICD-10-PCS and gain a moderate level of familiarity with the coding systems. The web sites at NCHS and CMS are vital resources, as well as the AHIMA site for ICD – www.ahima.org/icd10 (furnished on your resource slide)
SLIDE 42 Here are areas that coding professionals should consider when preparing to transition to ICD-10. This will assess areas of strengths and weaknesses to determine training needs: Anatomy and physiology Medical terminology (ICD-10 contains up to date terminology) Official coding guidelines Attention to Documentation and current physician query practices Reference look up skills because the coding professional may be doing more research during the learning curve of ICD-10 So the bottom line is start with Education, Education, Education
SLIDE 43 As previously stated, various categories of users will require varying levels of training. In the impact assessment, it will be important to identify those levels. It has been suggested that intense training for coders on how to actually code in the systems, (as opposed to the training we have been discussing on the differences in the systems, etc.) should occur not more than 6-9 months prior to implementation in order to retain the information. The final rule has recommended 50 hours of training for hospital inpatient coding professionals and 8 to 10 for other coding professionals. And training will vary depending on the setting – coders in the hospital inpatient setting will require education on ICD-10-CM AND ICD-10-PCS, while all others will only require training on ICD-10-CM. Those in the physician setting may only require training on a certain specialty are, such as OB, ENT, Cardiology. <<Since ICD-10-CM has the same hierarchical structure, the same basic organization, and many of the same conventions as ICD-9-CM, experienced coding professionals will not require the level of extensive training that would be necessary for an entirely new coding system. They will already be familiar with the logical hierarchy and the basic ICD rules. Experienced coding professionals will primarily need to be educated on changes in structure, disease classification, definitions, and guidelines. (ICD-10-PCS is a different matter) For ICD-10-PCS, a strong background in anatomy and physiology, medical terminology, pharmacology, and medical science is needed.>>
SLIDE 44 This slide provides a start at list of data users who will need some level of training. This list can assist in developing your own list. <<Additional notes if time>> <<Coders and other HIM – for example Release of information personnel will need to be aware of the codes for sensitive information, such as drug abuse or AIDS, psychiatric conditions Clinicians - educate them on documentation requirements Senior management - regarding implementation dates - outline impact on organization -provide overview of differences between code sets - identify time, effort, and resources that will be required to implement changes, as well as potential costs to the organization. Quality management, Utilization review personnel - need to know differences in system, impact on their work (such as documentation requirements, longitudinal reporting), time frames involved in changeover Data analysis and retrieval personnel - need to be oriented to new codes (for longitudinal studies or reports) - particularly, crosswalks, maps. Data security personnel will need to be aware of new codes if security software uses ICD-9-CM codes to flag records. Vendors - ensure that vendor(s) are preparing for the transition - if possible, try to get it written into current and new contracts that these updates and changes will be provided at no additional cost (or limited cost) - if you are purchasing a system, will vendor include crosswalk and change history? Provide information to other departments on how HIM can help them in the transition.
SLIDE 45 Make use of the time before implementation by conducting a gap analysis of coding and documentation practices. You can start now to measure coders’ baseline knowledge of anatomy, physiology, pharmacology, and medical terminology so that education can be targeted at the areas of weakness. Measuring the coders’ baseline knowledge now will shorten the learning curve, improve coding accuracy and productivity and accelerate the realization of benefits. Review of ICD-10-CM guidelines, ICD-10-PCS guidelines and training manual, and other “preview” products, etc. can help to identify any areas of weakness (including areas where documentation needs to be improved) ICD-10, plus other recent initiatives such as MS-DRGs and Hospital Acquired Conditions and Present on Admission reporting have brought Clinical Documentation Improvement (CDI) programs to the forefront. Use this lead time to work on documentation improvement strategies as necessary.
SLIDE 46 During the impact assessment, it is important to identify the specific departmental budget(s) that will be responsible for the cost of systems changes, hardware and software upgrades, and education. For a period of time, productivity and accuracy will suffer, as people become familiar with using the new coding system. <<Questions to consider during the transition: Will the increased number of codes impact the coding error rate? Will the increased number of codes impact the ability to detect errors? How long is the learning curve expected to be? How long will it take for coders to achieve proficiency – at least a proficiency level equal to before ICD-10-CM implementation? What will be the impact on quality of data during the learning curve? Decreased coding accuracy will impact data quality. >> The length of this transition period, and the impact on data quality, will be less for ICD-10-CM than for ICD-10-PCS due to the similarities to ICD-9-CM. But certainly there will be a short-term learning curve for coders to become proficient in the new systems. Ultimately, in the long-term, it is expected that coding errors will decrease to a level below ICD-9-CM because of the improved logic and standardized definitions in ICD-10-PCS, the more accurate clinical terms in ICD-10-CM, and the more specific code descriptions in both systems. The additional detail/specificity will assist in advancing more sophisticated computer-assisted coding technology, so in the long term it is expected that improved productivity and accuracy will be realized. In addition, a determination must be made of whether there will be a need for increased staffing or consulting services to assist with IT changes, coding backlogs, monitoring of coding accuracy, or to support other aspects of implementation or testing. The total implementation costs should be allocated over the implementation time frame to allow for the absorption of the costs.
SLIDE 48 Because other countries have implemented ICD-10 already, there are some lessons that we can learn. Other countries tell us to begin now – don’t wait! Use the time between the transition to plan and prepare because organizations that have planned strategically will make the smoothest transition and reap the largest benefits. An initial productivity decline should be expected, with a gradual improvement over 3-6 months. Implementation variables that can affect productivity are the amount and level of dedicated preparation, program management, interdisciplinary team participation, extent of coder education and credentials, coder experience and understanding of anatomy and disease processes, extent of training, documentation status, and organization size and complexity As previously discussed, vendor and payer readiness is extremely important. The single most important measure of a smooth and successful transition is clear, concise, and regular communication to all functional areas within the organization. Consistent and accurate education and training provided to the appropriate groups at the key times is also critical. As previously stated, there will be comparability issues to contend with between the two systems because they are different. The change to ICD-10 is major, but must be confronted if classification system is to be a credible basis for reimbursement and other purposes (statement from Australia).
SLIDE 49 We have talked about the impact assessment and the importance of taking advantage of these years before the actual transition. So what is the bottom line on preparation? For a period of time, productivity and accuracy will suffer, as staff become familiar with using the new coding system. But adequate training and testing can reinstate coder productivity and potentially enhance it as the coding system should enable fewer problem codes. <<The impact on coding accuracy may uncover these issues– will the increased number of codes impact the coding error rate? Will the increased number of codes impact the ability to detect errors? How will coding productivity be affected? Will decreased accuracy and productivity be limited to the transition period (or learning curve)? – with improved accuracy and productivity occurring in the long-term, due to the increased specificity of the codes? How long is the learning curve expected to be? How long will it take for coders to achieve proficiency – at least a proficiency level equal to or before ICD-10-CM implementation? What will be the impact on quality of data during the learning curve? >> A decrease in coding accuracy will certainly impact data quality. Remember that the length of this transition period, and the impact on data quality, will be less for ICD-10-CM than for ICD-10-PCS due to the similarities to ICD-9-CM. Again, adequate training and evaluation of competence will be critical. During this time, an increase in claims rejections and denials is likely, leading to delays in processing claims. This leads to improper claims payment, which impacts compliance. But the attention to accuracy and an improved system of handling rejections and denials could be put into place prior to transition. Bad decisions may be made due to reliance on distorted, inaccurate, or misinterpreted data, due to comparability problems between data reported in ICD-9-CM and that reported in ICD-10-CM/PCS - - exercise caution when interpreting longitudinal data as diagnoses and procedures may be classified differently. To offset this chain of events, it is important to start early to prepare, educate and test.
SLIDE 50 So what are your next steps???? If you have not already done so, you should read both Final Rules that were discussed at the beginning of this presentation. Don’t wait – use the extra two years provided in the Final Rule to begin preparation. (especially since the industry stated in comments that it was needed) You want to begin preparing NOW.
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