ICD-10: The Gift of Time… and How to Spend It... WHITE PAPER Inside May 2014

May 2014
ICD-10: The Gift of Time… and How to Spend It Wisely
Executive Summary
Health care professionals across the spectrum are having a serious case of
déjà vu, as they find themselves, once again, a year away from the newly
extended deadline for the transition from ICD-9 to ICD-10. While there is
a wide range of opinion on the value of this delay, it cannot be argued that
this transition will impact every aspect of claims processing, reimbursement,
clinical documentation, payer relations and coding, as well as audit, compliance and risk management programs across health care organizations.
Whether or not you personally agree with the delay, the positive consequence is that organizations have the opportunity to use the extra time to
increase education and physician engagement, complete systems work and
data integration, ensure vendors are on track, improve documentation, and
ultimately ensure they get appropriately reimbursed for the care provided.
In previous whitepapers and articles , we discussed how providers can simultaneously address all of these initiatives through clinical documentation
improvement, which relies on a solid understanding of reimbursement. We
drew attention to the connection between clinical documentation, quality
measures, audit targets and ICD-10, as each of these topics is integrally
linked to the on-going industry move towards electronic health records.
We encouraged providers and payers to perform their own comprehensive
end-to-end testing to avoid multiple financial risks.
Collaboration across the
Training Your Systems: Data
Set Transitions
Vendor Challenges
Clinical Documentation
Improvement Strategy
Physician Engagement 9
Expand and Finalize
Education Plans
Payer Implications 13
Minimizing Financial Risk 14
Our Solutions
Regardless of where your organization stands on the ICD-10 preparation
continuum, any health care organization can use the delay—this gift of extra
time—to ensure readiness and reduce risk. This paper will focus on those
areas that are most likely to ensure success in completing the final transition
to ICD-10 prior to the new implementation deadline.
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1. Visit www.mediregs.com/resource-center to find all whitepapers, articles, and blog posts on
ICD-10 previously published by Wolters Kluwer Law & Business.
ICD-10: The Gift of Time… and How to Spend It Wisely
Collaboration across the Spectrum
At the time of the latest delay announcement, the health care industry was just six
months away from implementing ICD-10, with many organizations well on their
way to preparedness. Some organizations had completed initial assessments, were
engaged in implementation planning and possibly even beginning implementation
steps. Others were, perhaps, not so far along. Wherever you currently stand with
your transition plan, do not allow the delay to impact your organization’s momentum.
Leverage the investments you have made thus far and continue to work toward
the new implementation date, utilizing the next year as a gift—the gift of time.
The transition to a new code set, ICD-10 in this case, has implications that extend
throughout an entire organization, including information systems. Whether your
organization is large or small, a wide range of processes will be impacted:
• Scheduling & Registration,
• Coordination of Care,
• Delivery of Care,
• Documentation,
• Coding,
• Claims Submission & Adjudication,
• Reimbursement,
• Audit, and
• Quality Reporting.
Given the widespread impact, it is best to take a holistic implementation approach where the entire organization is engaged. While some areas will absolutely
be affected to a greater degree than others, the impact of poor implementation
planning in any of these areas will be felt throughout the organization. As such, the
organization must break down any remaining silos and work together as one to
achieve compliance, utilizing effective change management techniques.
If not already in place, establish a multidisciplinary oversight team to lead your organization through successful implementation. As a collaborative team, the team
members should be collectively knowledgeable of current processes across the
organization and how the ICD-10 code set impacts each process. Do not allow the
delay to impact your team’s engagement. In order to maintain your momentum,
continue to meet on a regular basis to ensure ICD-10 preparedness.
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Because ICD-10 is an
organization-wide issue,
the work an organization
needs to do to prepare
and sustain once ICD10 is implemented
can be daunting. All
organizations will need
to change the way they
currently do business
under ICD-9 to be
successful under ICD-10.
ICD-10: The Gift of Time… and How to Spend It Wisely
Capitalize on this time to revisit or complete a comprehensive impact analysis,
identifying all impacted departments, individuals, processes, systems, documents,
etc., and any existing gaps. Engage focus groups of impacted constituents and
subject matter experts to assist with:
• Defining new processes;
• Refining existing processes; and,
• Updating forms, templates, etc. to support ICD-10.
Use your regular meetings to collaborate on organization-wide initiatives, such as
ongoing education programs, clinical documentation improvement initiatives, EHR
implementations, and the implementation of computer assisted coding solutions.
These organization-wide initiatives will not only help you improve efficiency,
compliance, accuracy and quality of care today, but will also provide a solid basis
for ICD-10 implementation.
Working as a collaborative team across the organization is the key. Poor implementation of ICD-10 has a variety of ramifications that ultimately can impact
an organization as a whole, from the delay or denial of reimbursement to the
inevitable audit activity that is sure to follow final implementation. Solid planning
through collaboration will ensure that the organization is prepared, that no stone
is left unturned, and that when ICD-10 is finally implemented it can just be
business as usual.
Training your Systems: Data Set Transitions
ICD-10 not only impacts various information systems utilized by the organization,
requiring updates or system upgrades to accommodate, process and retain ICD-10
codes; but it also has an impact on various other data sets utilized in the industry.
These data sets are utilized within and in conjunction with various software and
platforms within health care organizations to support their billing, reimbursement
and compliance. In order to “train” your systems and tools to handle ICD-10, you’ll
need to transition their data sets.
The delay gives providers, payers, vendors and CMS time to further create and
validate translations to ICD-10. Depending on your setting, you may need a
number of the following ICD-10 data sets outlined in the chart below along with a
description, translation status and location for translated information.
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Not all specialties are
affected equally, so
it is recommended
that immediate focus
be placed on those
specialties most
deeply impacted. This
will come from your
claims analysis, but we
generally see major
shifts in cardiology,
orthopedics, obstetrics,
and other specialties
and conditions (such
as sepsis) currently
included in the CMS
quality programs.
ICD-10: The Gift of Time… and How to Spend It Wisely
Medicare Code Edits
Diagnosis codes on Medicare claims are subject to a number of different checking rules or “edits”. These rules identify if a code is valid or “reportable”, whether the age
and gender of the patient correlates to the assigned code, and more. There are two manuals that CMS publishes that detail diagnosis code edits: the Outpatient Code
Editor (OCE) for outpatient and physician claims, and the Medicare Code Editor (MCE) for inpatient claims. The edits are subject to the public rule-making process. Key
lists of code attributes and edits include:
Age Edits:
Adult diagnoses
Newborn diagnoses
Pediatric diagnoses
Maternity diagnoses
Gender Edits:
Diagnoses for females only
Diagnoses for males only
CC/MCC Edits:
“CC List” - Diagnoses Defined as Complications or Comorbidities
“MCC List” - Diagnoses Defined as Major Complications or Complications and
Comorbidities Exclusions List
Hospital Acquired Conditions/Present on Admission Edits
Hospital Acquired Conditions List
Present on Admission Exempt Code List
CMS 2014 (v31) MS-DRG Definitions Manual with ICD-10 codes in PDF and TXT
CMS 2014 (v15.0) ICD-10 Dx Edit Code Lists in PDF format
Medicare Physician Quality Reporting
A reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals.
The reporting process includes a list of specific quality measures mapped to diagnosis and procedure codes.
2014 ICD-10-CM codes I n the CMS PQRS “Single Source Code Master” XLS file.
Medicare Coverage and Medical Necessity
Medicare and the Medicare Administrative Contractors (MACs) publish narrative “Coverage Determinations” that detail coverage specifications (including diagnoses)
for procedures and services. MAC Local Coverage Determinations (LCDs) and Coverage Articles include a coding section that is generally used to specifically list
diagnosis codes that support medical necessity. Beginning in March, 2014, MACs began releasing ICD-10 versions of their LCDs and Articles. These are given an LCD ID
number that is distinct from the ICD-9 versions, and are marked as “future” documents.
Historically, CMS publishes National Coverage Determinations (NCDs) with a discussion of the indications and limitations of coverage, but do not translate that to
specific diagnosis or procedure codes. Recently, CMS has begun issuing special transmittals with attachments that list the ICD-10 codes that would apply to a medical
necessity edit related to specific NCDs. They point out that this is an exercise, and it is unclear whether they intend to continue to publish this information so transparently. An interesting part of this exercise is the translation of the coding rules for both Medicare Part A and Part B, which includes an implied ICD-10-PCS to CPT®
crosswalk for services that are addressed by a NCD.
Local Coverage Determination & Coverage Articles
Various MAC Websites
National Coverage Determinations
Example: R1199OTN [CR 8197] dated March 15, 2013, International Classification
of Diseases (ICD)-10 Conversion from ICD-9 and Related Code Infrastructure
of the Medicare Shared Systems as They Relate to CMS National Coverage
MS-DRG Definitions and Grouper
CMS uses a Medical Severity Diagnostic Related Group (MS-DRG) methodology to determine payment for inpatient stays. This system relies on a grouping methodology where the patient diagnoses and the procedures performed during the stay are “grouped” to MS-DRG. The MS-DRG Definition Manual identifies the diagnoses &
procedures assigned to a given MS-DRG
CMS pilot 2014 (version 31) ICD-10 MS-DRG Definitions Manual
Software called the “Grouper and Medicare Code Editor”, which must be purchased separately. Inherent to this logic is a number of other data sets, including
information related to hospital acquired conditions, present on admissions, and
codes considered to be CC/MCC.
ICD-10: The Gift of Time… and How to Spend It Wisely
Medicare CMS-HCC Risk Adjustment
CMS uses a risk adjustment payment system, called the Hierarchical Condition Category (HCC) payment model, to pay Medicare Advantage (MA) and Prescription
Drug Plans (PDPs) accurately and fairly, adjusting payment for enrollees based on demographics and health status. The payment model relies on clinical coding (ICD-9CM codes) gathered by providers and submitted by the health plans to CMS. HCC’s group a large number of distinct diagnoses into about 70 diagnostic groups.
CMS preliminary ICD-10-CMS-HCC and RxHCC Models in excel format
Regulations and Regulatory Guidance
Additional information will be published by HHS, CMS, CDC, other agencies, state governments and state Medicaid agencies. Providers should monitor and track this
incoming information to incorporate into policies and procedures.
Federal Register Proposed and Final Rules provide announcements about ICD-10 as it
relates to the yearly prospective payment system updates, quality reporting requirements, code edits, and other rules that are established via the rule making process.
Medicare Internet Only Manuals (Pub 100s) – CMS has already begun revising
sections that include specific ICD-9 codes to provide the ICD-10 translation. They
tend to put the term (ICD-10) in the title. As an example, see CR 7806, which
revised Pub 100-02, -03 and -04 sections related to Extracorporeal Photopheresis.
MLN matters, Special Edition, Fact Sheets and educational materials CMS has
often simply incorporated into existing documents and in some instances specifically calls out/lists on the CMS ICD-10 page.
CMS General Equivalence Mapping (GEM) files that provide mapping between
ICD-9-CM and ICD-10-CM.
The Center for Disease Control (CDC) publishes outreach, education and advocacy
materials; data repository information; and shared ICD-10 training resources with
other HHS agencies.
Health Resources and Services Administration (HRSA) produces webinars and
newsletters to HRSA grantees related to ICD-10 adoption.
National Institute of Health (NIH) Surveillance Epidemiology and End Results
(SEER) program creates mappings for key ICD-10 impact areas including registries
and research databases.
Indian Health Services (IHS) produces resources for I.H.S. institutions including
“Have No Fear of ICD-10” boot camp, clinical rounds, full-blown communications
The Medicare Administrative Contractors (MACs) have started to produce ICD-10
guidance in various locations on their web-sites.
Various MAC Websites
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ICD-10: The Gift of Time… and How to Spend It Wisely
Vendor Challenges
Most organizations do not go it alone, but engage vendors in a variety of capacities
to augment their day-to-day processes. As such, vendor readiness becomes a key
component to overall organization-wide ICD-10 readiness.
Part of an organization’s initial assessment or organizational impact analysis
should identify existing processes where vendors are engaged, as well as how they
are engaged. Organizations must gain an understanding of:
• The systems utilized by the vendor;
• The status of vendor system updates to support the ICD-10 code set;
• How vendor systems and data are integrated into the organization’s systems;
• The vendors’ overall preparedness plans;
• The inclusion of comprehensive ICD-10 education in the vendor’s
preparedness plan; and,
• For system vendors, the ability of the system to support ICD-10 (the new
code set, incorporation into edits, rule translation, etc.) and maximize the
use of technology.
Don’t make the mistake of assuming that a vendor has comprehensive plans.
Instead, utilize the additional time to obtain validation of specific vendor readiness
and work toward preparedness. While most are prepared to engage in ICD-10
and related processes, you shouldn’t allow preparation activities to stop.
Communicate regularly with your existing vendors and require written feedback
related to their ICD-10 readiness status. For those still preparing, gain an understanding of their preparation plans and require routine status updates. Don’t
forget to include your system vendors to keep testing on the radar, as the delay
may push back end to end testing. Engage the vendor in testing discussions and
schedule formal testing activities.
Incorporate ICD-10 readiness and performance standards as a requirement for any
new vendor relationships and update existing vendor contracts accordingly. As we
have recently experienced, sudden changes in requirements can occur, so be sure
to include force majeure language in your vendor contracts moving forward with
provisions to address changes in governmental legislation.
Lastly, include vendors in the internal organization preparedness plans. This may
mean including them in planned ICD-10 education and organization-specific
process training. As vendors serve as an extension of the organization, it is imperative that they are a consideration in the organization’s implementation plans.
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ICD-10: The Gift of Time… and How to Spend It Wisely
Clinical Document Improvement Strategy
With an additional year to prepare for ICD-10, organizations should take this time
to thoroughly train physicians and coders to operate in the new environment.
Included in this should be clinical documentation improvement (CDI) strategies to
improve physician documentation and ensure that diagnoses and procedures are
captured with the level of specificity required under the new code set.
The reality is that ICD-10 will dramatically change the way that clinical information is captured. With more than 69,000 unique diagnostic codes and 72,000
procedure codes, ICD-10 contains more than eight times the number of codes
used in ICD-9 and will require greater specificity than ever before. In addition,
ICD-10 introduces alpha characters and can include anywhere from three to seven
digits—a stark contrast from the numeric ICD-9 code set, which contains no more
than five digit codes.
As a result, the manner in which procedures and diagnoses are captured will
greatly change. For instance, in ICD-10-CM atherosclerotic heart disease of native
coronary artery with unstable angina is a single code (I25.110). However, in ICD-9
CM this requires two codes: Coronary atherosclerosis of native coronary artery
(414.01) and intermediate coronary syndrome (411.1).
Preparation and Training
To prepare for this change, physicians must not only learn the new code set, but
also learn to document in a manner that will justify the selection of one specific
code rather than two broader codes. Yet, learning to adapt documentation to the
new code set will prove to be an uphill battle. To that end, CDI strategies must
include extensive preparation and training for both physicians and coders.
Many physicians will find it necessary to change their current documentation
habits and this cannot and will not happen overnight. Training should be progressive and spread over the months leading up to the transition if organizations hope
to begin coding in ICD-10 on the new implementation date.
Training should include hands-on practice in the new code set, allowing physicians
to identify where codes have changed and where they must alter documentation
in order to meet these changes. To accommodate physician training, a growing
number of facilities are or soon will be coding in a dual ICD-9/ICD-10 environment
to ensure coders and systems are fully ready for the transition, and to assess staff
productivity, financial impact and other issues.
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The effects of poor
documentation within
your EHR ripples out to
produce payment delays,
challenges with meeting
quality reporting
requirements, and
increased risk of audit
and review.
ICD-10: The Gift of Time… and How to Spend It Wisely
This level of training will play a key role in organizations’ planning initiatives, as
provider education will ultimately translate to improvements in clinical documentation, which will be key to a successful transition. In addition, these improvements will also mitigate the risk of miscoded, rejected and improper reimbursement claims, thus improving the revenue cycle and enhancing the bottom line.
Automated Documentation and Coding
Leveraging structured reporting technology to automate procedure documentation and coding is also recommended as part of organizations’ broader CDI
strategy, as this can streamline the transition and shorten the learning curve
for physicians.
By guiding physicians through the procedure documentation process, these systems ensure that each procedure is documented with the level of specificity and
granularity required to ensure appropriate coding under ICD-10 and allow physicians to efficiently capture robust detail from even the most complex procedures.
In addition, automation eliminates the human errors that often lead to incomplete
documentation and incorrect coding.
This will be important as the impact and trickle-down effect of the transition
will touch nearly every department within the organization—from clinical documentation and coding to claims processing and reimbursement, as well as audit,
compliance and risk management programs. Thus, the accuracy and specificity of
physician documentation will also impact multiple software systems.
Because of the wide-reaching impact of ICD-10, CDI strategies which include
physician documentation improvement and structured reporting must be implemented now, if they have not already. For those in the midst of these programs,
it is important that all efforts are continued over the next year to ensure that
information is retained and physicians are ready for the implementation date.
The reality is that whether ICD-10 is implemented in 2015 or 2025, physicians
must make changes to their current processes and this is not possible without a
strong CDI strategy in place.
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ICD-10: The Gift of Time… and How to Spend It Wisely
Physician Engagement
ICD-10 will usher in new opportunities and challenges for physicians. The transition to the new coding system presents unprecedented opportunities to capture
the granularity needed to enhance patient care initiatives. At the same time, the
uphill resource battle associated with training and infrastructure costs presents a
daunting scenario for many physicians and health care organizations.
Simply put, physician engagement strategies that begin early in the transition
effort will be paramount to compliance success. Unlike the motivation behind
Meaningful Use (MU) to increase EMR adoption in recent years, ICD-10 implementations are not backed by financial incentives. Physicians must be engaged in
the process and educated on the far-reaching impact that delayed or ineffective
implementation strategies will have on the bottom line.
While physician groups affiliated with hospitals and health systems have the
advantage of aligning with systems implementations that are backed by shared
resources, research conducted by the American Medical Association suggests that
the average private physician practice could be facing costs as high as $80,000
if they already have an EMR in place. Practices without an existing EMR may be
looking at financial investments upwards of $250,000.
These figures represent staggering costs and hindrances to engagement for physicians already faced with multiple regulatory initiatives wreaking havoc on budgets;
but when considering the long-term impact of poor or failed transition efforts,
these costs pale in comparison.
Getting Buy-In Early
Time is an important element of an effective physician engagement strategy, and
private practices, clinics and other health care organizations should leverage the
extra time available to achieve buy-in now.
When considering the best approach to education and training going forward, start
small and allow initiatives to grow at a reasonable pace to minimize the potential
for overload and push-back. Identification of physician champions early in the
process will also provide a beginning point for discussion and a natural course for
breaking down barriers and pulling others into the implementation process.
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For each of your
different specialties,
you will need to review
the differences between
ICD-9 CM and ICD-10
CM with the physicians.
How you will train your
Orthopedic physicians
will be different from
how you educate
the Oncologists or
ICD-10: The Gift of Time… and How to Spend It Wisely
Once identified, these champions can build an ICD-10 task force that further
engages clinicians. Consider that the engagement does not start and stop with
physicians. Because the new coding systems is expected to impact every aspect of
operations (IT, HIM, billing, reimbursement and clinical), change management will
need to occur across an entire enterprise.
Once key implementation leaders are identified, strategies should be thoughtfully
laid out to make the most of a physician’s time. Be specific and purposeful with
meetings and training sessions such that whoever attends finds value in the discussion and take away information relevant to a particular specialty or practice.
Physician champions should be leveraged to promote the positives of the new
coding system as well as encourage physicians in their day-to-day workflows.
This means recognizing what physicians are doing right as well as areas needing
Improving Documentation Workflows
As new industry standards are introduced through MU (SNOMED CT®, RxNORM
and LOINC) alongside other national initiatives such as HL7 and ICD-10, one
universal challenge is lack of a common medical vocabulary, an issue that can add
complexities to the documentation experience. Improving physician workflows
prior to transitioning to ICD-10 can go a long way towards physician engagement
and adoption.
Industry research suggests that physicians are already discouraged that newlyadopted EMR workflows are not producing the workflow efficiencies that were
originally expected. When physicians have to search out multiple codes to comply
with MU and ICD-10, the negative impacts to documentation workflows are only
exacerbated. Additionally, there is often a language gap between familiar terms
that physicians are accustomed to using and the terminology found within new
classification systems.
Research from the HIMSS/WEDI ICD-10 National Pilot Program confirms the
complexities of ICD-10, revealing that accurate coding occurs only 63% of the
time with key offenses associated with specificity and laterality falling much
shorter. A 50% drop in productivity was also noted. Consider that a SNOMED CT
code may be required for a problem list, but the ICD-10 code could require further
granularity of data such as the laterality of a fracture.
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ICD-10: The Gift of Time… and How to Spend It Wisely
Effective terminology management strategies are paramount to laying the best
foundation to support documentation efficiency and accuracy under ICD-10.
When information from disparate sources can be normalized to achieve semantic
interoperability across health systems, patient data can be mapped to standardized code sets such as ICD-10, reducing the number of “clicks” required during
the documentation process. Effective terminology management can also enable
clinicians to use familiar clinical terms—such as afib, ank fx or elevated BP—to
streamline the process and improve accuracy.
Mapping initiatives are complex, and while these strategies will prove effective to
physician engagement, achieving this foundation of automated mapping can be
daunting for resource-strapped IT departments. Many health care organizations
are turning to provider-friendly terminology conversion tools to do the work for them.
When considering the value proposition of health IT investments and the need
to lay foundations that best engage physicians, the business case for terminology management strategies—and specifically third-party tools to support these
efforts—is an easy one.
Expand and Finalize Education Plans
Now is the time to expand and finalize your ICD-10 education plans. Whether you
have a small or large organization, physician practice, or you are a payer, ICD-10
education must be an ongoing process. Additionally, knowing how ICD-10 affects
your staff’s or your audience’s daily workflow as this will help tailor your training
and your training will be more effective in the long run. In reality, everyone works
and learns differently and each at their own pace.
The cost of training and potential loss of productivity has been a concern for most.
The recent delay in implementation has allowed providers to take a step back and
ease up on productivity for a while knowing that experts have predicted a loss of
productivity between 10-50%. “Recruiting and retaining qualified coding professionals can be a challenge, but know that there is not a ‘one size fits all’ approach
to training for ICD-10-CM and ICD-10-PCS.”2
With ICD-10-CM, coders can transfer their ICD-9-CM knowledge and skill set and
can easily assign code(s) in ICD-10-CM without major educational efforts. Because
the coding process and principles have not changed, if a coder has good working
knowledge of ICD-9-CM, ICD-10-CM should be fairly easy to learn. Conversely, if a
coder uses a cheat sheet and has had minimal training in ICD-9-CM, the transition
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2. AHIMA ICD-10/CAC Summit, April 23, 2014, Rose T. Dunn, MBA, RHIA, CPA, FACHE: “ICD‐10 Readiness: What
Should Be on Your Agenda for the Next 18 Months”.
In our experience,
one of the biggest
CDI challenges
involves vocabulary.
The terminology that
the clinician uses in
the medical record
to describe a patient
condition, the language
of the diagnosis coding
system, and the wording
of the regulatory
requirements can differ
significantly. ICD-10-CM
uses a much richer and
descriptive vocabulary,
which should mitigate
some of this disparity
in terminology, but
providers can and
should start to run
translations now.
ICD-10: The Gift of Time… and How to Spend It Wisely
will be more difficult. An assessment process will support efforts to provide training for the different levels of knowledge and skill for coding professionals.
Unlike ICD-10-CM, ICD-10-PCS is an entirely new system for coding inpatient
procedures. Coding professionals must have a strong knowledge of anatomy, be
able to analyze documentation to support coding decisions and have working
knowledge of how surgical procedures are performed.
It has been communicated by many professionals that organizations should adopt
ICD-10 as the “gold standard” to prevent productivity issues. If providers continue
the course with ICD-10 training and education, this, in turn, can shorten the learning curve, improve documentation across the spectrum, as well as collect data
through “dual coding”. Whereas the data can be trended and studied to improve
business and clinical operations rendering better patient care, quality outcomes
and hopefully, reduce denials and improve reimbursement.
AHIMA has published excellent resources3 regarding a successful ICD-10 training plan. Even with the recent
delay in implementation announcement, the following concepts are concise and relevant, no matter where you
are in understanding how ICD-10 affects your organization. As you plan, design or need to evaluate/re-evaluate
your ICD-10 educational training blueprint, know that the following will consistently apply as you move
toward implementation date and onward.
• On-going and focused on the highest risk areas specific to your organization. Hit the top five this
quarter, the next top five will emerge for your attention next quarter.
• Job role-specific rather than one-size fits all. Doctors and coders learn differently, and your plan should
respect this learning process.
• Task-related not just conceptual. Provide specific “what to do” training in the software and systems
available to each staff member.
• Evidence-based and referenced, to give staff reasons to “buy in.” Provide statistical data about patient
outcomes, financial facts about impact to reimbursement, and/or specific risk to the organization
(likelihood of audit, remediation) if best practices aren’t followed.
• Assessment-based. Understand what each staff member already knows by performing a knowledge gap
assessment, and teach according to their “gaps.”
• Respectful. You’ve got a great team of very smart and capable professionals who want to learn. Assume
they can and give them the opportunity to provide feed- back on the process.
• Transparent. Avoid forming teams who are the knowledge keepers. Once you have completed training on
an issue, allow your staff to take ownership for staying up-to-date by providing them with access to payer
and Medicare policies.
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3. http://www.ahima.org/topics/icd10
ICD-10: The Gift of Time… and How to Spend It Wisely
Payer Implications
Parts of your ICD-10 readiness efforts to date have no doubt included a review of
payer contracts. This extra time affords your organization the ability to capitalize
on that work to focus on stop loss and carve-outs, new payment models (e.g.,
paid-for-performance, bundles) and to implement strategies to maximize revenues
through renegotiating contract terms.
As an organization begins to create an inventory of all existing contracts, it may
be prudent to consider an online solution to efficiently and effectively manage
contract information. The ability to manage contracts and relationships allow for
a risk management and compliance program to organize and manage all contractual and arms-length relationships in your organization from a single location. A
one-stop compliance program management tool makes it easy for organizations
to closely monitor and track critical relationship activity and maintain detailed records that meet regulatory requirements. It may also be helpful to obtain accurate
fee schedules specific to your region or provider.
During the contract evaluation, assure that the following due diligence is
• Solidly understand payer relationships, including Medicare and
all commercial payers.
• Utilize patient data and informatics, and published fee schedules to
negotiate optimal contracts.
• Inventory anticipated future contracts.
• Consolidate payer contract database.
• Maintain good communication with payers.
• Understand how payer systems integrate with internal systems.
Once your evaluation and analysis is completed, update payer contracts to incorporate ICD-10 language. Given the timing of this delay, incorporation of ICD-10
requirements effective in October of 2014 may have already been included; therefore, be sure to include force majeure language in your payer contracts moving
forward with provisions to address changes in governmental legislation. Don’t let a
change outside of your control to impact your processes and bottom line.
As mentioned related to vendors, end-to-end payer testing is critical. While
testing may be pushed back with the recent implementation date change, do keep
end-to-end testing on your radar. Update processes and re-educate as appropriate
based on the lessons learned during testing as well.
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While the industry has
a tendency to fear the
possibility of negative
financial impact from
the transition, many
may find that forwardlooking strategies
using ICD-10’s focus on
capturing more granular
detail may actually
improve revenue
streams in some areas.
Consider that if analytics
software reveals that
a certain highly-used
DRG poses potential
risk for an organization
under ICD-10, a number
of strategies can be put
into place to mitigate
that risk.
ICD-10: The Gift of Time… and How to Spend It Wisely
Minimizing Financial Risk
The key to achieving fiscal success with ICD-10 is to minimize your financial risk.
The recent delay in ICD-10 implementation not only provides more time to prepare, but also, unfortunately, leads to more money spent as the project expands
to fill the time provided. But if you are smart about your expenses moving forward
and focus your planning, you can understand your business today under ICD-9 as
a core foundation for minimizing your financial risk while maximizing reimbursement moving forward.
Take the extra time to evaluate your ICD-10 work plan, assure you are on the right
track, and take the time to take additional steps to assure you have a successful
transition. Re-evaluate the gap analysis performed in your organization. Look for
potential lost revenue opportunities and don’t limit your attention to inpatients.
Some opportunities of focus can be:
• Missing technical (hospital)component for emergency department
and bedside procedures;
• Maintain and keep current your charge description master (CDM);
• System issues (look at every component of the revenue cycle and assess
its operational effectiveness);
• Assess your denials under ICD-9, including what exists today and what will
exist with ICD-10; and
• Common denials typically relate to pre-authorization, medical necessity
and lack of supportive documentation.
It is important to note that external auditors are not going away. For example, the
Recovery Audit National program reflects $3.8 billion in corrections for FY 2013.
Since its’ inception in 2010, the RAC program’s total corrections equal $7.2 billion.4
Based on these statistics and as you set out to determine your highest risk areas,
it would be wise to include the focus areas published by the Recovery Audit
Contractors (RACs) over the last year. Additionally, assess your top 20% paid
DRGs, top utilized DRGs and cases associated with medical necessity and/or other
denial/re-bill issues.
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4. Medicare Fee-for-Service Recovery Audit Program National Program Corrections Q3 FY 2013, CMS
Because ICD-10 is an
organization-wide issue,
the work an organization
needs to do to prepare
and sustain once ICD10 is implemented
can be daunting. All
organizations will need
to change the way they
currently do business
under ICD-9 to be
successful under ICD-10.
ICD-10: The Gift of Time… and How to Spend It Wisely
For each of the risk areas, pull historical claims data and compare them to the
medical records for those cases.
Perform a self-assessment that is in line with a complex review; typical of a RAC.
—— Confirm that the documentation supports the ICD-9 coding.
—— Validate that the principal diagnosis was appropriately assigned.
—— Confirm that the CC/MCC secondary diagnoses are well documented.
—— Review Present On Admission coding and documentation as part of the
Natively assign codes in ICD-10 as if it is post-implementation, and
then confirm the ICD-10 to MS-DRG grouping logic to assess if
payment is consistent.
Reviews of this type provide the basis to help organizations understand current
performance under ICD-9 and provide specific information about what is required
to prepare for ICD-10. In a single review, you can glean important lessons
regarding medical necessity, coding, documentation, DRG validation and other
audit issues.
As each organization assesses the risks associated with ICD-10, we have learned
that it will have a major impact on the documentation expected from the clinicians and an even bigger effect on the coding staff in your organization. But
because CMS has also reassigned combination of codes in ICD-10 to define
diagnostic related groups (DRGs) for payment, a change in Medicare and commercial reimbursements is inevitable. It is vital for organizations to get a handle on the
financial risks associated with ICD-10 and communicate the risks to the steering
committees, to include the executive staff. Specifically, it will be prudent for every
organization to understand how they will do business in ICD-9 and assess their
financial risk as they transition to ICD-10.
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ICD-10: The Gift of Time… and How to Spend It Wisely
Our Solutions
Wolters Kluwer understands the challenges that small and
large healthcare providers, payers and vendors face and
has solutions to support your successful implementation
of ICD-10.
With over a decade of experience in medical terminology
management, we have the in-depth knowledge around
the critical healthcare IT challenges that you face, leading
the industry with data normalization solutions, including software, content, and services that map, translate,
update, and manage standard medical vocabularies and
administrative codes.
Confidently manage audit, risk, and drive compliance
with our customized, scalable SaaS solutions created and
supported by experts in healthcare audit, risk, compliance
and reimbursement.
And finally, ensure hyper-accurate procedure documentation with our award-winning computer-assisted coding
Risk Management
ICD-10 Impact Analysis
Of the many competing initiatives vying for providers’
time, money and attention, ICD-10 carries the largest risk
to the financial health of a hospital. All reimbursement
schemes for hospital inpatient procedures currently based
on ICD-9 will be directly affected by the ICD-10 transition.
New Health Analytics and Wolters Kluwer have collaborated to develop the ICD-10 Payment Impact Analysis
solution to help providers understand and gain insight
on how ICD-10 payment will impact the organization’s
bottom line. Leveraging existing state and commercial
databases, the revenue impact is determined by MDC,
MS-DRG and major service line to give organizations an
online view of their claims data for a recent period of time
translated into ICD-10 with Medicare expected payment
data applied.
Information Systems & Data Sets
Health Language Enterprise Terminology Management
The Health Language Enterprise Terminology Management
Platform provides providers, payers and vendors with the
software, content, and consulting solutions that map,
translate, update, and manage standard and enhanced
clinical terminologies on an enterprise scale—enabling
the information liquidity required to support some of
healthcare’s toughest challenges, such as meaningful use
compliance, ICD-10 conversion, population health management, analytics, ACOs, and semantic interoperability
among systems.
To ensure ICD-10 readiness, healthcare organizations are
encouraged to leverage Health Language solutions and
expertise to support the key aspects of transition planning:
protecting the revenue cycle, ensuring a clinically complete translation, preparing for post ICD-10 updates, and
optimizing clinical workflow.
ICD-10: The Gift of Time… and How to Spend It Wisely
Data Sets
Healthcare organizations, providers, consultants, life science companies, payers and software vendors struggle to
understand and keep up-to-date with complex Medicare
expected payment information. Analyzing published CMS
information, which can be confusing, incomplete and difficult to aggregate into consistent format, is a major burden
that eats through staff time. And, once they have the data
in hand, they still have to calculate provider-specific or
location-specific rates.
Medicare Payment System Data Files, powered by New
Health Analytics, are accurate, consistent and versioned
provider-specific data sets packaged “to go”—for reporting, analysis and to populate your software and IT systems
with the essential data for projecting financial outcomes
and strategic planning. Available data files include:
Inpatient PPS, Outpatient PPS, Ambulatory Surgical
Center Fee Schedule, Physician Fee Schedule, Clinical
Laboratory Diagnostic Fee Schedule, Durable Medical
Equipment Fee Schedule, and Long Term Care Hospital PPS.
Policy and Procedure Revisions
ComplyTrack Document & Policy Manager
Part of your Clinical Documentation Improvement and
Education Program will include revising and introducing new policy documents for staff members. Use the
ComplyTrack Document & Policy Manager to provide staff
with an easy-to-access location for policies and version
tracking with a streamlined revision and approval process.
It can even be integrated with links to primary source
regulations within any of our research products, such as
the Coding Suite.
For your Medical Policy Documents, you can work concurrently in the ICD-10 Explorer and Document & Policy
Manager to translate your policies from ICD-9 to ICD-10,
and include links to automatically updated manuals, LCDs,
and coding/payment tools within your subscription.
Coding Suite
With the ever-increasing pace of health care regulatory
change that includes the ongoing adoption of ICD-10, it’s
harder than ever for coding and reimbursement professionals to ensure proper code assignment up front. In order
to minimize claim denials and secure your bottom line,
you need quick, easy access to the comprehensive information and tools that are necessary for effective revenue
cycle management.
Our Coding Suite, designed specifically for health care
professionals, combines expert legal and regulatory
information, web-enabled research, and the specialized
content of the CCH Medicare & Medicaid Guide to offer
the most robust coding, reimbursement, and compliance
solution available today. Search on multiple terms simultaneously or utilize automatic alerts to inform you of new
documents containing your targeted search terms. Name
your stored searches after the related internal policy to
prompt you to review new information and to point you to
any necessary updates.
ICD-10: The Gift of Time… and How to Spend It Wisely
ICD-10 Resource Center
ProVation MD – Structured Reporting and Coding
ProVation MD is the only dedicated structured reporting and coding solution that provides clinically relevant,
intuitive software that ensures hyper-accurate procedure
documentation. Covering 11 medical specialties, including
Cardiology, Gastroenterology and Orthopedics, ProVation
MD allows physicians to efficiently capture robust detail
from even the most complex procedures, and then automatically generates clear, complete procedure notes and
appropriate reimbursement codes—quickly, easily and
without dictation. By automatically applying the reimbursement codes and disseminating critical procedural
information, ProVation MD ensures appropriate payment,
reduces costs and streamlines quality reporting while
improving clinical communication and care coordination.
Built for health care providers and payers who need intense
focus on ICD-10, the ICD-10 Resource Center is a complete,
easy-to-use solution for coding staff across the organization.
ProVation Coding Plus
A companion to ProVation MD, ProVation Coding Plus
provides coding, coverage, payment information and
guidance for surgical coders, enabling them to confirm the
accuracy of reimbursement, utilize primary source material to confirm accurate code selection, confirm medical
necessity for both local and national coverage determinations, assess code edits prior to claim submission (national
correct coding initiatives or NCCI), and keep up to date on
ever-changing Medicare rules and guidelines.
ICD-10-CM Electronic Codebook
Get to know the new ICD-10 diagnosis system with this comprehensive, up-to-date codebook that connects ICD-10 coding to
Medicare rules, with:
• Comprehensive with guidelines and indexes;
• Easy to navigate tabular pages; and
• Additional Wolters Kluwer coding, coverage, reimbursement
and compliance content and tools.
ICD-10-PCS Electronic Codebook
Master the new ICD-10 procedure coding system with this
comprehensive, up-to-date codebook that connects to MS-DRG
coding resources and Medicare rules, with:
• Easy to use tables that demystify procedure code assignment;
• Comprehensive guidelines, index, and reference manual; and
• Connection to companion MS-DRG/ICD-10 Coding Manual.
ICD-10 Explorer
Search for and compare ICD-9 and ICD-10 clinical terminology
and related codes using GEMs in one simple tool!
• Interactive interface provides simple, user-friendly approach
for training, translation and professional coding.
• Simultaneously search in both I-9 and I-10 for direct comparison.
• Instantly map any code using GEMs forward & backward
mapping and CMS reimbursement mapping.
• Connect instantly to related documents, coding instructions
and guidelines.
ICD-10 Regulatory Resources, Data and Archives
Find all the resources necessary within the solution, including
coding, coverage, payment and regulatory compliance resources
for ICD-10 such as:
• Download Center, CMS notifications and training materials;
• HHS regulatory requirements for ICD-10;
• Payer contractors related to ICD-10; and
• CMS Manuals and policies related to ICD-10.
ICD-10: The Gift of Time… and How to Spend It Wisely
Of the many competing initiatives vying for providers’ time, money and attention,
ICD-10 carries the largest risk to the financial health of a hospital. If your organization is not ready to submit clean claims by the new deadline, it will be subject to
multiple cascading financial risks, including enormous direct impact to the timing
and amount of your reimbursements and audit outcomes and, thus, your bottom
line. And if CMS sticks with its original position to carry out no end-to-end testing,
you can add the strong likelihood of an exponential increase in post-deadline RAC
audit activity for years following the initial transition.
Use the extra gift of time you have wisely to ensure that your team is collaborating
across the enterprise and that your systems teams, your vendors, your documentation, your payers, your physicians and reimbursement professionals are fully
engaged and completely prepared. Through the prudent combination of education,
process improvement and utilization of technology you can be prepared for the
change and will minimize your risk.
About Wolters Kluwer
Wolters Kluwer is a market-leading global information services company.
Professionals in the areas of legal, business, tax, accounting, finance, audit, risk,
compliance, and healthcare rely on Wolters Kluwer’s leading, information-enabled
tools and solutions to manage their business efficiently, deliver results to their
clients, and succeed in an ever more dynamic world.
Copyright CCH. All rights reserved.