How To Transition From Icd 9 To Icd 10

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1 1 TRANSITION FROM ICD-9 TO ICD-10: MANAGING THE PROCESS Joy Burnette, RN, BSN, AACC, HITPro-IM, CPHIMS July 29, 2013

2 2 TRANSITION FROM ICD-9 TO ICD-10: MANAGING THE PROCESS By October 14, 2014 the transition from International Classification of Disease (ICD) version 9 to ICD version 10 will be mandatory for health care billing of clinician and facility services. The impending transition can be met with confidence with the right plan, responsive and prepared vendors, training, and electronic tools. In addition to robust electronic tools, healthcare organizations are encouraged to take advantage of vendor consulting expertise for workflow and revenue cycle solutions, and the variety of training programs to address the workflow needs of all stakeholders. All of the experts concur that planning is paramount to transition success and that providers and provider organizations should begin now in order to meet this non-negotiable deadline for transition.(centers for Medicare and Medicaid Services, n.d.)( HIMSS Advisory Report 2012, 2012, p. 3)(McNicholas, 2011, p. 345) BACKGROUND A systematic classification of diseases associated with mortality and morbidity has been used as early as Up until 1948 the United States (US) used the International Lists of Causes of Diseases created by the US, Canada and Mexico. The US then adopted the current International Statistical Classification of Disease (ICD) created and maintained by the World Health Organization.(Jette et al., 2010, p. 1105) The ICD-9-CM code set contains approximately 18,000 codes and that number will expand to more than 68,000 with the transition and the number of ICD-10 codes continues to rise. Many revisions and country specific modifications have ensued with the last comprehensive US revision in 1979 to include inpatient procedure codes. Unfortunately, the ICD-9 list no longer supports the proliferation of advances in medical diagnoses and treatment plans witnessed in the patient care arena over the past 30 years.(harris & Zeng, 2012, p ) The new robust list will allow clinicians to further classify diseases, capture patient acuity with improved accuracy, and allowing for more discrete data analytics that will assist in improved patient care, safety, and clinical outcomes.

3 3 BENEFITS OF TRANSITION There are several benefits to the transition from ICD-9 to ICD-10 resulting in a positive impact for patients, clinicians, the health care industry, and the general population at large. The transition to ICD-10 has been accomplished by several countries including Canada, Australia, Thailand, and Germany with modifications from each country to meet their population health reporting needs. The benefit of improved health and well-being of millions of individuals worldwide is anticipated with the transition.(mcnicholas, 2011, p. 352) The Centers for Medicare and Medicaid Services (CMS) believes the increased specificity of the ICD-10 coding will improve patient outcomes, decrease medical errors, decrease unnecessary or repeated procedures, provide more meaningful data for quality of care analysis and population health reporting(centers for Medicare and Medicaid Services, n.d.) The ICD-10 codes will also provide data for a more accurate physician case-mix presentation, result in fewer billing errors, decrease requests for additional documentation and decrease the frequency of rejected claims.(centers for Medicare Services, n.d.) The adoption of ICD-10 coding is expected to decrease medical errors and unnecessary or repeated procedure, improve patient outcomes, add depth to population health reporting, and prevent fraud and abuse by improving the accuracy of medical billing. Graphic reference: (Harris & Zeng, 2012, p. 324)(McNicholas, 2011, p. 352)

4 4 STAKEHOLDER PROGRESS FOR TRANSITION Health care arena stakeholders are many ranging from patients to clinicians, payers, regulatory agencies and industry vendors. Each of these entities will play a pivotal role in the coordination of a smooth transition. The progress with which stakeholders are preparing for the transition varies widely. To assess readiness and advise the Secretary of Health and Human Services the Workgroup for Electronic Data Interchange Group (WEDI) was formed under the Health Insurance Portability and Accountability Act of The group is charged with periodically briefing the Department of Health and Human Services on issues related to the Administrative Simplification. Based on their advisement, the issues are considered for review by the Secretary of Health and Human Services.(J. Daley, personal communication, April 11, 2013, 2013) In 2009, WEDI began surveys to assess the ICD-9 to ICD-10 transition readiness of stakeholders in the healthcare industry and completed the most recent survey in March The results indicate many stakeholders are behind in meeting milestones along the transition timeline. One in ten providers is prepared for external testing in 2013 and nearly half do not have definitive plans for external testing. More than 40% of providers are uncertain of the timing for completing the first step of impact assessment, indicating significantly slow progression leading up to the transition. Close to half of the health plans have completed their assessment and another quarter are near assessment completion. The survey results clearly indicate the healthcare industry at large is behind according to the proposed WEDI/NSHICA timeline.(j. Daley personal communication, April 11, 2013, 2013) Most providers and health plans identified competing priorities as a major barrier to a smooth transition to ICD-10. In addition, health plans cite other regulatory requirements while providers refer to staffing, budgetary restraints, IT impact and vendor readiness.(j. Daley personal communication, April 11, 2013, 2013) The transition will require stakeholders to transition directly to ICD-10 coding or use a crosswalk from ICD9 to ICD-10. Of the WEDI respondents, nearly two-thirds of providers will elect to use cross-walking as their primary method of transition. Some are utilizing the General

5 5 Equivalence Mappings to assist in mapping from ICD9 to ICD10. Stakeholders need to be aware that the GEMs are not a direct cross walk but rather tools to help the user understand and make decisions based on complexity and create their own mappings.( Diagnosis Code Set GEMs, 2013, p. 6) This requires planning and extensive testing followed by training and implementation. The transition will require a higher degree of specificity in provider documentation to support the ICD-10 reporting for billing and reimbursement. The longstanding approach of if it is not documented it was not done will be more critical to reduce the time it takes for coders to prepare billing submissions. Many physicians struggle to adequately document with ICD-9 coding and will require robust training, coding support, and surveillance to ensure there is very specific documentation supporting the diagnoses selection.(mcnicholas, 2011, p. 351) Proper diagnosis specificity documentation will potentially decrease biller time, shorten the revenue cycle time, decrease reimbursement risk, and support the compliance burden.( HIMSS Advisory Report 2012, 2012, p. 7) METHODS OF TRANSITION There are two basic transition approaches for the adoption of ICD-10 coding. Providers may elect to continue with manual coding using a paper superbill or move to an electronic charge capture process. While paper superbills have been used a large portion of the time, there are drawbacks to the continued use of manual coding. With the increased specificity billing personnel will spend additional time abstracting data to complete the more complex diagnoses. A lack of specificity in the clinical documentation will result in an increase in communication between the biller and clinician to determine the proper diagnoses.

6 6 The review of current superbills to remove seldom used codes, as well as cross walking using the General Equivalence Mappings (GEMS) from common ICD-9 codes to ICD-10 codes, may require additional time according to some accounts. However, CMS indicates ICD-10 paper superbills will not require additional time, despite the tremendous increase in diagnosis codes. ( ICD-10 Myths and Facts, 2013, p. 4) Electronic charge capture (ECC) provides a standardized approach and format across multiple medical specialties and will decrease the need for biller interpretation of hand written diagnoses and procedure code. The move to ECC is rapidly becoming the preferred method of generating and processing medical claims. This is mostly due in part to the clinician determining and documenting diagnoses, and receiving decision support to capture billing at the time of care. Documentation of the accurate diagnosis specificity is even more important with ICD-10 coding as CMS and other agencies use this administrative data to measure physician and hospital quality of care. Proper didactic and interactive learning prepares the clinician to more accurately select diagnoses that reflect not only the disease or condition but also the severity and sequelae to the primary injury or illness. Biller training in anatomy and physiology terminology will provide a better understanding of clinical documentation that supports the specific diagnoses. Training for all stakeholders is critical to a smooth transition. Meticulously designed software and cloud applications with powerful medical informatics, coupled with the specificity of ICD-10 codes, will assist in tracking disease patterns and clinical outcomes. This is most important as we move from the intervention model of care to population preventive medicine model. TRANSITION, BARRIERS, AND TIME The sheer number of ICD-10 codes will require specific training for billers and clinicians which will take time, thorough training, and teamwork. Training of clinicians on documentation requirements will be a key component in a smooth transition. Billing personnel will require additional training and familiarity with clinical diagnoses, sequelae and anatomical terminology in order to maintain coding productivity. Training will be complex and time consuming for most

7 7 providers. This can be mitigated by the employment of highly skilled expert trainers to teach and guide the health care team to accomplish timely and accurate ICD-10 coding. Proper clinician training and ECC will also allow project managers to evaluate the ICD-10 transition process in real-time for timely interventions. Competing priorities is a regular concern for health care. Compliance with other federally mandated regulations, Joint Commission guidelines, and computer physician ordering systems implementations are just a few of the competing priorities for most all healthcare providers. An integrated timeline will assist in planning and navigating multiple projects at one time. The ICD- 10 migration and cutover should have multiple milestones and hard deadlines in order to meet the October 1, 2014 transition. The ability to simultaneously code with ICD-9 and ICD-10 in a parallel ECC process provides an option other than an abrupt transition to ICD-10 coding. Electronic billing integration will also experience hurdles during the transition. The new code set will require adequate testing and validation prior to the cutover to ICD-10 coding. Reaching out to stakeholder vendors now will be critical to successful electronic submission of claims and to maintain the revenue cycle. ECC combined with excellent clinician documentation and electronic billing integration undoubtedly will decrease the billing revenue cycle length over time. RECOMMENDATIONS All of the experts, regulatory agencies, and professional organizations generally agree on several recommended steps in preparation for the transition to ICD10. Clinicians, healthcare providers, and other stakeholders should begin the transition process now if not already in progress. An impact assessment should include clinicians, administrative staff, IT resources, billing transaction processing, reimbursements, contract negotiations, and payers. The first, and probably the most important step, is the impact assessment on current systems, workflow and personnel followed by communication with the participating vendors. Create a general timeline with specific milestones for all stakeholders and anticipate additional barriers such as budgetary requirements and staffing shortage.

8 8 Initiate standards for documentation and charge capture. Consider employing ECC as a means to decrease errors in coding. Coordinate with payers on the electronic transmission of claims and create lines of communication between billing staff and payers. Address any special considerations such as replacement of legacy systems, adding new software, and evaluation of the claims submission process. Clinicians will require training that stresses the need for much higher specificity in documentation. Many clinicians currently struggle to fully document diagnoses and conditions to support the current ICD-9 code set. Scheduling and conducting training sessions will require time and additional resources. Planning now for the number of clinicians and personnel that will need to be trained is paramount to success. Allot additional funding for in-house training or outsource trainers. Several hospital departments will be impacted by the ICD-10 transition including information systems, finance and revenue cycle, medical records, and electronic or paper patient health records. Prepare additional IT resources for technical support for both during and after the initial cutover. Have billing personnel available to answer coding questions. With the proper technology and billing support, the transition will be less difficult and frustrations will be decreased for all. The Centers for Medicare and Medicaid Services (CMS) estimate the ICD-10 transition may reach $640 million in 2013 with small hospitals of less than 100 beds $100,000 to $250,000 cost and larger healthcare facilities with more than 400 beds costs could range between $1.5 million and $5 million in expenses. Individual physician costs are estimated to be $28,500. (Centers for Medicare and Medicaid Services, n.d.) Budgetary demands will be the highest in 2013.( HIMSS ICD-10 Cost Predictive Modeling Tool, 2011) Many factors will impact the amount of anticipated costs including the number of systems affected, the size and complexity of the organization, number of out sourcing of technical assistance, the number of applications and interfaces to be updated; and how many people need to be trained, and the training needs based on coding knowledge and experience.(nguyen, 2011, p. 15)

9 9 Finally, plan for the regular monitoring of productivity and revenue cycle, and identify barriers to success early. After the transition, it will be important to evaluate the impact on the clinician workflow, claims processing workflow, and biller productivity, as well as requests for additional documentation, and the quality and specificity in clinician documentation. Initiate interventions to maintain the timely clinical and business aspects of the transition. CONCLUSION A smooth transition to ICD-10 coding can be accomplished with the appropriate planning and implementation. Adoption of increased clinical specificity documentation will be a significant process requiring clinician training, support and guidance. Increasingly, providers are moving to ECC for robust disease severity and sequelae data, powerful informatics analysis, and administrative strategic planning. All of these activities play an important role in the effort to improve patient care, safety, clinical outcomes and disease prevention in the health care arena.

10 10 RESOURCES Center for Medicare Services: CMS Resources for ICD-10 Transition: index.html?redirect=/icd10 Provider Resources: html American Medical Association:

11 11 REFERENCES CMS Column: Cost Considerations for the ICD-10 Transition. (2011). Retrieved from newsletters.ahima.org/newsletters/icdten/2011/december/costconsiderations.html Centers for Medicare and Medicaid Services. (n.d.). Diagnosis Code Set General Equivalence Mappings ICD-10-CM to ICD-9-CM and ICD-9 to ICD-10-CM 2013 Version Documentation and User s Guide. (2013). Retrieved from Diagnosis_Code_Set_General_Equivalence_Mappings.pdf HIMSS Adviosory Report Implementing ICD-10 by the compliance Date: A Call to Action. (2012). Retrieved from soryreportimplementingicd-10compliancedate.pdf Harris, S. T., & Zeng, X. (2012). How to Set Up an International Classification of Diseases, 10th Revision Training Workshop. The Health Care Manager, 31, Retrieved from Healthcare Information and Management Systems Society ICD-10 Cost Predictive Modeling Tool\. (2011). Retrieved from aspx?itemnumber=11207 ICD-10-CM/PCS Myths and Facts. (2013). Retrieved from ing/icd10/downloads/icd-10mythsandfacts.pdf Jette, N., Quan, H., Hemmelgarn, B., Drosler, S., Maass, C., Oec, D.,... Ghali, W. A. (2010, December). The Development, Evolution, and Modifications of ICD-10 Challenges to the International Comparability of Morbidity Data. Medical Care, 48, Retrieved from McNicholas, F. C. (2011). Getting Ready for International Classification of Diseases, 10th Revision (ICD-10-CM). Journal of Dermatology Nurses Association, 3, dx.doi.org/ /jdn.0b013e318231d00e Nguyen, L. (Producer). (2011, November 17, 2011). ICD-10 Implementation Strategies and

12 12 Planning National Provider Call. Retrieved from ICD10/downloads/ICD-10_NPC_111711_written_transcript.pdf S, J. (2012). Bearing the cost of ICD-10 transition. Retrieved from bearing-the-cost-of-icd-10-transition/