the rationale for dual coding Dual Coding in Preparation for ICD-10: Emerging Best Practice Lisa Fink, MBA, RHIA, CPHQ Kathy M.

Transcription

1 the rationale for dual coding Dual Coding in Preparation for ICD-10: Emerging Best Practice Lisa Fink, MBA, RHIA, CPHQ Kathy M. Johnson, RHIA

2 Table of Contents 3 Introduction 4 Rationale for Dual Coding Connect with us to learn more and to help ensure a smooth transition to ICD-10 6 Dual Coding Methods and Study Design 9 Dual Coding Approach: 100 Percent Dual Coding vs. Focused Projects 11 Example Worksheets to Plan Dual Coding Projects 14 Challenges 15 Conclusion 16 About the Authors 18 Care Communications ICD-10 Services 18 Additional Online Resources 2

3 Dual Coding in Preparation for ICD-10: Emerging Best Practice An e-book by Lisa R. Fink, MBA, RHIA, CPHQ, Senior HIM Consultant and Kathy M. Johnson, RHIA, Vice President and General Manager, Data Quality and Coding Compliance. Introduction Experts in the healthcare industry suggest that dual coding in ICD-9 and ICD-10 CM/PCS (ICD-10) is an integral part of ICD-10 implementation plans. The delayed implementation date of October 1, 2014 provided organizations an additional year to work on ICD-10 plans and activities, and an opportunity to gain experience with dual coding. Coding 100 percent of patient records in both ICD-9 and ICD-10 for a period of time prior to October 1, 2014 may have initially appeared to be the ideal strategy; however, the challenges of budget constraints, coder shortages, education and training needs, and new system implementations suggest a more efficient strategy is to perform multiple dual coding projects, which are more focused and limited in scope. We will discuss this emerging best practice in this e-book. While some consultants have recommended doing dual coding for six to twelve months prior to the go-live date, at Care Communications we suggest starting dual coding projects as soon as possible and continuing as needed through post implementation evaluation. These studies will inform evolving strategies for conducting beginning and advanced ICD-10 training activities for coders and users, improving clinical documentation, developing ICD- 10 coding policies and procedures, and reengineering coding workflow as needed for a successful transition to ICD-10. a more efficient strategy is to perform multiple dual coding projects. 3

4 Rationale for Dual Coding As organizations consider how they will accomplish dual coding, they must first be clear about their reasons for dual coding. Knowing how results will be used helps planners design their dual coding projects to most efficiently achieve their objectives. Below is a list of the common reasons for including dual coding in your ICD- 10 implementation. 1. Financial Modeling and Analysis: Results of dual coding will assist with financial modeling and analysis. Coding the same records in both ICD-9 and ICD-10 code sets provides data that can be grouped to MS-DRG s to determine where reimbursement will differ between ICD-9 and ICD-10. While revenue neutrality may be the goal of the Centers for Medicare and Medicaid Services (CMS), it is not reality in every case. Identifying the potential revenue changes specific to your patient population enables your organization to more accurately prepare budgets and associated strategies. Organizations need to know how and when payers plan to change reimbursement formulas and contracts prior to the ICD-10 go live. Data from a dual coding project will assist organizations in reviewing current payment contracts and negotiating future contracts. Organizations need to know how and when payers plan to change reimbursement formulas. 2. Developing the ICD-10 Workforce: Dual coding as part of ICD-10 education and training will provide coding staff with valuable practice prior to the go live. Practice reinforces education and training, increases confidence, and improves productivity. Coding real world patient records with both code sets provides coders with valuable ICD-10 coding practice, allowing them to critically think through and apply the principles they learned in training to the types of cases they will regularly encounter in their facility after October 1, Equally important, it provides managers with an opportunity to better identify staffing needs leading up to and following the go-live date. 4

5 3. Clinical Documentation Improvement (CDI): Additional benefits will be gained by identifying opportunities for CDI. In ICD-10, the total possible diagnosis codes increase from approximately 13,000 to 68,000; possible procedures codes increase from 3,000 to 87,000, which will result in more granular data. To achieve such granularity, patient records must include significantly more specific clinical documentation. Early ICD-10 coding presents the opportunity to review the documentation for the necessary specificity. Documentation problems can be identified and solutions such as clinical documentation improvement programs can be updated, focused physician training can be developed and implemented, or documentation policies and/or data capture templates can be revised. 4. Workflow Re-engineering: Changes in workflow may be needed in the ICD-10 environment. Coding with ICD-10 prior to go-live also provides an opportunity to evaluate the workflow and adjust it as needed. Testing new workflow design is important especially at the time of implementation for new technologies, such as EHR s or Computer-Assisted CDI and Computer-Assisted Coding (CAC) software. 5. Reporting: Reporting processes may need to be adjusted. Reports used for quality reporting, research, trending, or auditing should be reviewed to determine the impact on these reports, if any, by ICD-10. Analysis of the reports affected by ICD-10 data should be modified prior to the go-live date. In ICD-10, the total possible procedure codes increase from approximately 13,000 to 68, End-to-End Testing: It is critical to the successful implementation of ICD- 10 that data flows in a timely and accurate fashion through all the internal systems as well as external systems such as those at clearinghouses and payers. The latter will determine readiness to process claims for reimbursement. 5

6 Dual Coding Methods and Study Design Dual coding is labor intensive and thus an expensive undertaking for organizations. To be as efficient and effective as possible, some organizations have moved away from planning for 100 percent dual coding for a specified period of time, towards developing meaningful, limited scope dual coding projects with clearly define the goals, methods and study design appropriate to each project s objectives. For example, dual coding projects that provide the opportunity for coders to practice as part of training, would look different from ones done to determine the adequacy of clinical documentation. Planners would choose a dual coding method, and determine the sample size, time period to cover, and how records would be sampled, i.e., random sample, by physician, by specialty, by diagnoses, procedures, or MS-DRG. Coding the record in both code sets simultaneously is most efficient. The following are examples of methods being used in dual coding projects. 1. Simultaneous Dual Coding by an Individual Coder: Using this method each coder would first use the ICD-9 code set and then the ICD-10 code set to assign codes to a record. Coding the record in both code sets in the same sitting is most efficient, and is a good choice when the goals of the project include accomplishing a reasonable volume of production coding as coders practice ICD-10 skills. 6

7 2. Dual Coding of One Record by Two Coders: If one of the goals of the organization is to assess additional resources required in the coding of ICD-10, production time should be measured by using two coders to do the dual coding, one coding with ICD-9 and one with ICD-10. This method will reduce the bias of reviewing the same record twice. 3. Dual Coding and Inter-rater Reliability: With this method several coders code the same record in ICD-10. This method allows for coders to practice, but it also enables the study results to be used to establish a measure of inter-rater reliability. When several coders code the same record, followed by an educational discussion about the matching and mismatching codes selected, the degree of agreement among coders can be measured. Results from inter-rater reliability studies can be used for developing an organization s ICD-10 policies and procedures, as well as the quality and productivity standards that the coders will be expected to meet. This method is a good choice if the goals of the project are more educational in nature, and in the long term should lead to better data quality as evidenced by a high rate of inter-rater reliability. 4. Use of Temporary Staff for Dual Coding: Use temporary or outsourced staff to code in ICD-9 and submit claims while regular coding staff code 100 percent of discharges in ICD-10 for three to six months prior to the October 1, This approach has the potential to make the transition a smoother process for the coders and physicians as they will have worked out the challenges prior to the go-live date. This method provides data for multiple uses to include financial modeling, testing and reporting. Regardless of method chosen, if sampling, care should be taken to stratify the sample of cases to ensure that all major diagnostic and procedure categories are included. <<<<< 7

8 Caution: Methods not recommended based on lessons learned Using claims data for dual coding, or using CMS General Equivalence Mappings (GEMs) of ICD-10 to ICD-9 codes are tempting methods being used in some organizations, but not recommended. Coding from claims data without reviewing source documents in the patient record does not allow for the specificity necessary for accuracy. Using claims data can lead to coding errors as a result of guessing the appropriate code in the absence of clinical documentation. Coding in ICD-9 and GEMs mapping to ICD-10 may seem like a time saver but can compromise data quality as many codes lack true one-to-one matches. These methods make analysis of the data for dual coding purposes flawed. GEMs are intended to assist users to understand, analyze, and manage the translation of one code set to the other. The GEMs help users manage large data sets and are not intended to replace using ICD-9 and ICD- 10 directly. An excellent reference for the appropriate use of GEMs is offered by the American Health Information Management Association (AHIMA) in their 2009 Practice Brief, Putting the ICD-10-CM/PCS GEMs into Practice. Using claims data for dual coding can lead to coding errors. Limited use of mapping can potentially improve efficiency of the process if the coder maps ICD-10 to ICD-9 codes and the edits the ICD-9 by reviewing the chart as needed. Mapping from the more granular ICD-10 to the less granular ICD-9 is more accurate than mapping from ICD-9 to ICD-10. 8

9 Dual Coding Approach: 100 Percent Dual Coding vs. Focused Projects There is no cookie cutter approach to dual coding that will work for all organizations. Coding 100 percent of patient accounts in both ICD-9 and ICD-10 code sets for a period of time prior to October 1, 2014 will produce ICD-10 coded data that can be used in a multitude of ways and provides coders practice time with records. While this process may be a perfectly acceptable approach in some organizations, the biggest drawback for other organizations is the cost and availability of the human resources needed. It is estimated that organizations that choose a 100 percent dual coding approach will need to double their coding staff to dual code all accounts for the period of the study. While the estimated productivity loss at ICD-10 go-live is 30 percent, early work with predictive staffing models demonstrated 100 percent coding productivity loss during periods of dual coding. There is no cookie cutter approach to dual coding that will work for all organizations. 9

10 A more efficient use of coding staff resources is planning for a series of dual coding projects, designed to fit the specific needs of your organization. The following questions can be used to help plan and prioritize dual coding projects. What are your goals or biggest coding concerns? What are your documentation concerns or documentation improvement challenges? What are the types of cases most impacted by the ICD-10 change (i.e., Orthopedics)? What data elements should be collected from each dual coded case in the project? How will you define your sample, and how will it be stratified; will random or systematic sampling be applied to each stratum? What time periods should the samples cover? What dual coding method is the best fit to obtain the data needed to address your goal or concern? What is your timeline for conducting the projects? What dual coding projects should be done closer to the October 1, 2014 go-live date, and what dual coding projects could be done in advance of the go-live date? For each project, prepare a worksheet with the answers to the relevant questions above. 10

11 Example Worksheets to Plan Dual Coding Projects Example 1 Project Planning Worksheet for ABC Hospital Reimbursement Analysis Orthopedic DRG s Goals 1. Determine possible changes to reimbursement. 2. Test claims with payers. Data Collection Sample Coding Method Timeline Use ICD-10 codes for testing natively from actual records rather than relying on a translation tool. Select sample from ABC Hospital s top 5 high-volume Orthopedic DRG s. Include records from every member of Orthopedic Department; to further define the sample, one or two of the higher volume payers will be included in the sample. ICD-10 trained coders will code 5 records per day in both ICD-9 and ICD-10 per the sample selected. The project will begin in the third quarter of 2013 and continue until ICD-10 go-live for ample analysis time. 11

12 <<<<< Example 2 Project Planning Worksheet for ABC Hospital Coder Education Goals 1. Provide all coders the opportunity to practice coding in ICD-10 following training. 2. Reinforce concepts learned in training. Data Collection Sample Coding Method Timeline Obtain ICD-10 codes natively from medical records. A sample of 5 records per high volume DRG s per month will be included. Because this is an educational goal the inter-rater reliability method will be used. Record(s) will be selected and each coder will individually code the record and code selection will be discussed. Following ICD-10 training for all coding staff this process will be implemented by the second quarter of 2014 and will continue until ICD-10 go-live. 12

13 Example 3 Project Planning Worksheet for ABC Hospital CDI Practice Goals 1. Provide CDI staff with the opportunity to practice being more specific in the query process. 2. Reinforce concepts learned in training. 3. Work with physicians to help them understand the level of detail that will be queried. Data Collection Sample Coding Method Obtain ICD-10 codes natively from medical records. Focus will be high dollar cardiac surgery accounts. Any account that demonstrates a preliminary DRG in the range will re-coded in ICD-10 for query practice purposes. CDI staff will code records in ICD-10 to determine if more documentation specificity is necessary to correctly code in ICD-10. If not, the physician query process will be initiated. Timeline A three month test of this process will occur first quarter Results will be analyzed to determine if further testing is needed. 13

14 Challenges Completing dual coding projects is not without its challenges. As payers are not accepting claims with both ICD-9 and ICD-10 code sets, dual coding for purposes of actual reimbursement is unrealistic. However, if anticipating reimbursement and making budget preparations is the goal, dual coding has value for these internal preparedness purposes. After October 1, 2014, dual coding operations may still be needed to submit claims to payers who are not HIPAA covered entities, such as Worker s Compensation and Automobile Insurance, or other payers who may not be ready for the ICD-10 environment. Having dual coding strategies in place will assist in this workflow going forward. The sheer volume of accounts to be dual coded may present a challenge. As discussed above, a well-designed sample can provide valuable information to organizations. Utilizing the top 10 to 20 MS-DRG s, principal diagnoses, and principal procedures is one effective way to determine a sample. Another way is to review current issues the organization may be having with denials or other reimbursement delays. This focus allows the organization to select a meaningful sample and start working to correct problems. Software challenges may need to be addressed. 14

15 Software challenges may need to be addressed. In particular, test environments may not be as robust as full production environments. In order to perform full-scale end-to-end testing of ICD-10 claims, all test systems in the process should be able to handle the claims with minimal manual intervention. Any identified problems will need to be amended in both the test and production environment to ensure smooth, accurate processing of data. Conclusion Dual coding as a series of well thought out projects will enable organizations to accomplish a variety of ICD-10 preparation and implementation goals in a cost effective and efficient approach. Planning for these projects should begin as soon as possible. Well thought out dual coding projects will enable orgaizations to meet ICD-10 goals cost effectively. 15

16 ABOUT THE AUTHORS Lisa Fink, MBA, RHIA, CPHQ, Senior HIM Consultant, Care Communications, Inc. As a Senior HIM Consultant, Fink has performed multiple ICD-10 engagements to include readiness assessments and implementation planning. She has also supported hospital coding functions and post go live system implementations through interim management. In previous roles, Fink directed HIM departments, QI departments and managed an IT department. Managing change was inherent in these roles to include complete retooling of medical record filing systems, development and training quality improvement processes, development of a systematic approach to successful accreditation, and implementation and support of electronic documentation systems. Fink has held adjunct faculty positions in the business college setting, the community college setting, and with two AHIMA accredited schools. Her teaching focus has been ICD-9 coding and other health information management courses. Fink is a member of AHIMA, the National Association for Healthcare Quality, and the Wyoming Health Information Management Association (WYHIMA). Currently the President-Elect, Fink has held all seats on the Board of WYHIMA multiple times. She received a bachelor s degree in HIM from Carroll College in Helena, Montana and a master s degree in business administration from Regis University in Denver. 16

17 ABOUT THE AUTHORS Kathy M. Johnson, RHIA, is Vice President and General Manager, Data Quality and Coding Compliance for Care Communications, Inc. (CARE) a national health information management consulting company based in Chicago. Johnson joined the CARE team in 1997 as a coding consultant with primary duties of completing coding quality reviews, delivering coding education (one-onone training as well as small and large group settings), conducting operations assessments and evaluating client coding compliance programs. Accepting a CARE director position in 2003, Johnson oversaw consulting engagements focused on data capture, coding classification, compliance and education. In her present role, she provides strategic guidance as adaptation to the future state of coding and the changing needs in the healthcare industry are underway. Johnson is a veteran health information management professional with more than 30 years of experience in a variety of positions, including health information management department director, classroom and practicum educator and post secondary health information program director, independent consultant and quality improvement leader in the acute care setting. Johnson s articles have been published by the American Health Information Management Association (AHIMA), Advance for Health Information Professionals, HCPro and the Healthcare Financial Management Association, and include: Regulatory Alphabet Soup: Financial Implications of RAC, MAC and HAC POA Coding Requirements Create a Chilling Effect for Hospitals Effectively Managing RAC 5010 and ICD-10 Is It Too Early to Begin ICD-10 CM & PCS Education? Johnson possesses a bachelor s degree in health information management and is an active member of AHIMA and has served on the association s Practice Councils. 17

18 Prepare for ICD-10 with Care Communications Customizable Services. Visit us online today to request more information about how our services can help ensure a successful ICD-10 transition at your facility, including: Clinical Documentation and Revenue Risk Assessment We determine your facility s Medicare revenue impact and help define strategies to reduce risk. Utilizing CARE s proprietary ICD-10 Code Predictor SM (GEMs) technology, we identify all cases that may be problematic in ICD-10. An all-important case-by-case review to validate documentation needs and develop a customized action plan for clinical documentation improvement. Skills Assessments, Planning and Training Analysis of coding staff skills deficiencies. Comprehensive and facility-specific coding education and training programs. E-learning platform or on-site training options. ICD-9/ICD-10 parallel and production coding support and planning for transition staff levels. ICD-10 Directors/Leaders Assistance of an ICD-10 expert to ensure thorough planning, project management and efficiency in execution. Visit our website: carecommunications.com/icd10 For questions and assistance with your ICD-10 implementation, contact Roberta Peters at , extension 153 or rpeters@care-communications.com. Connect with Care Communications to learn more about ICD-10: LinkedIn Twitter Facebook Google+ YouTube Additional Online Resources. Here are additional resources that may be useful in making the transition to ICD-10: ICD-10 Monitor ICD-10 Watch CMS ICD-10 web page AHIMA ICD-10 web page ICD-10-PCS Reference Manual ICD-10-CM National Center for Health Statistics AHA Central Office ICD-10 Resource Center 18

19 PMS Red Black - 35% or PMS W. Wacker Drive, Suite 1900, Chicago, IL phone: Care Communications, Inc. 2013