Strategies for successful ICD-10 implementation

Jeffrey Goldstein, M.D., MS, FACHE Clinical Transformation Consultant, Allscripts

Healthcare organizations are preparing for a huge task: moving from 13,000 ICD-9 codes to 68,000 ICD-10 codes. It will require specific strategies that apply to any organizational change of this size. The International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management, and clinical purposes. Clinicians use this code set to monitor the incidence and prevalence of diseases and other health problems, providing a picture of the general health situation of countries and populations.¹ On Oct. 1, the United States will join 25 other countries who are already using ICD-10.

The Centers for Medicare & Medicaid Services (CMS) delayed ICD-10 implementation to 2015 to further readiness, but much of the industry has not used the extra time wisely. Half of the physicians who answered a Medical Economics’ 2014 physician survey said they are not ready for ICD-10.²

There are many reasons for this, but essentially, it primarily comes down to cost, productivity, and technology hurdles – and lack of certainty in the transition. The U.S. Department of Health and Human Services (HHS) estimated that the cost of transitioning from ICD-9 diagnosis and medical procedure codes to ICD-10 codes would be $1.64 billion.³

But smart healthcare organizations recognize that delaying ICD-10 preparations means risking a huge financial hit. While many physicians are not ready, the number who are prepared is up significantly from a large-scale survey in 2013 by the Medical Group Management Association in which fewer than 5 percent of practices reported having had made significant progress toward ICD-10 readiness.⁴

CMS has twice pushed back the compliance date for ICD-10 implementation, from October 2013 to October 2014, and then to 2015. However, physicians, health plans, and electronic health record (EHR) vendors would be wrong to assume another delay. Stanley Nachimson, principal of Nachimson Advisors and an expert on ICD-10, estimates there is a 75 percent chance that the ICD-10 transition will actually take place Oct. 1.

With estimates ranging between $1 billion and $6 billion in additional costs resulting from this delay, any further extension would only result in additional costs and, as such, the healthcare industry should not expect to see this date moved again,⁵ especially this late in the game. The U.S. healthcare industry will require diligent, comprehensive actions to be fully prepared for the transition.

Using time wisely

No coding system commands that you have to use an electronic documentation system. However, with more than 68,000 clinical modifications codes and 76,000 procedure coding system codes, an EHR greatly simplifies aligning the correct code to the services provided. The problem many organizations face is that, no matter how comprehensive an EHR is, it is only as good as the information entered into it. Coding and billing teams must be able to work together to retrieve clinical information and produce a clean and accurate claim.

There is a wide range of diversity in how hospitals and health systems respond to the task. Perhaps the biggest challenge is that few organizations have truly embraced the concept that ICD-10 affects every part of the organization. ICD-10 workflows start at registration and continue up to the moment the patient is discharged from the hospital or goes home from the physician’s office. Too often organizations consider ICD-10 as an “IT problem” or a “medical records matter,” when in fact the touch points involved in ICD-10 are significantly greater.

Leading a successful change

For a project as vast and complex as ICD-10, a successful organization needs a strong governance structure assigned specifically to this endeavor. Leadership needs to define the operational structure required for ICD-10 readiness. It’s essential to have an ICD-10 executive sponsor and a designated ICD-10 person responsible for maintaining the project on a steady and consistent path.

The next step is to establish an operational committee with representation from the key areas affected by ICD-10. This committee’s charter defines its roles and responsibilities and should provide specific guidelines, such as weekly meetings, a defined agenda, and a mechanism for apprising the C-suite of both current and upcoming milestones. Leadership should empower this committee to recommend changes to the project’s overall structure and advise course corrections.

With the governance structure in place, effective communication provides the underpinning for a project of this size and importance. Regardless of when a transition begins, leadership must immediately show its involvement and dedication to a successful transition to ICD-10 by informing everyone that this is a top organizational priority. The organization can use various channels, such as meetings, newsletters, and even an ICD-10 blog that speaks to the project’s goals, objectives, milestones, and successes.

Many organizations soon come to realize that a project such as this relies heavily on having sufficient resources available. For ICD-10, this means people, money, and perhaps the most important element of all: time. Staff will require training, that in itself will require identifying trainers not only for those who provide care, but for billers and coders. This will result in budgeting the money both for these resources and for upgrades and modifications to your existing IT systems so that ICD-10 can successfully operate within your environment.

Training for clinical staff has slowed to a halt

With delays in ICD-10 implementation, many organizations have openly stated that educational activities came to an abrupt halt. With the deadline fast approaching, hospitals, clinics, and ambulatory practices are looking to evaluate just how ready they are to move to ICD-10 and how best to address critical gaps in education and training. Physician ICD-10 education is often not viewed as a priority, and instead of aligning physician education to high-volume, high-value care, physician training is most often addressed with generic online or brief classroom sessions.

Physicians, nurses, coders, and billers are the people that have suffered the most. But other groups clearly need to understand what is needed for ICD-10, such as those involved in registration, patient access, case management, and social work. Yet, they are no longer being trained in the fundamentals of the new coding system, either. Any other areas that need to understand how ICD-10 operates have all but been ignored for education. They need to understand how this will impact not only their work, but how it will also negatively affect collections through delays and denials. The effect on patient satisfaction and quality of care can be devastating.

Consistent documentation

Unfortunately for ICD-10 readiness across the entire industry, the major issue tends to be the lack of uniform documentation. Concise, thorough, and comprehensive documentation is essential, and it is the required basis for not only ICD-10 but for value-based purchasing, bundled payments, pay-for-outcomes reimbursement, and managing episodes of care. Without solid documentation, hospitals and physicians alike will soon find themselves challenged to validate their work, which could lead to undervalued or denied payments.

Lack of consistency in documentation takes on many forms. It can be a hospital that allows its clinicians to document both on paper and in an electronic medical record. Or it can manifest itself as relying on free text or dictated notes that do not follow a consistent format. Poor documentation can have potentially grave clinical effects. In a 2013 study that examined the financial impact of clinical documentation improvement (CDI), there are significant increases in length of stay, cost of care, and readmissions when documentation falls short of expectations for consistency and content.⁶

Summary

The transition to ICD-10 is the largest mandate in U.S. healthcare history. Full ICD-10 implementation will require diligent, comprehensive actions. The three pillars to ICD-10 success are the same with any enormous organizational change: governance, education, and documentation.

Many organizations have called for additional delays before full implementation, while other organizations across the United States have already made significant strides to prepare for the change. But is another delay of ICD-10 the solution? Many believe not, because any further delays can hinder forward momentum. Organizations that fell behind before the delay haven’t taken the extra time to get up to speed, and therefore additional time to prepare isn’t likely to motivate them any more than the first delay did.

ICD-10 readiness is a journey, but unless the fundamentals are in place, moving toward an Oct. 1 launch is an uphill journey on a very steep slope. But with a solid strategy in place, healthcare organizations can complete the transition, even if they’re a little late at the start.