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Sample high-value claims before ICD-10 implementation date

With the heat on physician practices to prepare for the impending ICD-10 implementation date, two analysts discuss how best to avoid negative outcomes.

The ICD-10 implementation date is coming and there's no avoiding it. As healthcare organizations try to prepare themselves the best they can, physician practices in particular may be feeling the pressure. Two experts weigh in on how physician practices can ensure readiness and offer some ideas for ways to prepare.

Clinical documentation improvement (CDI) is critical to being prepared for ICD-10 and avoiding potentially troublesome outcomes.

"If insufficient [information] is gathered at the time of service, then the granular ICD-10 code cannot be assigned," said Robert Tennant, a senior policy advisor of government affairs at the Medical Group Management Association (MGMA) based in Englewood, Colo. "So what we suggest to folks … even if your software has not been upgraded yet, you can still do what I would call CDI testing."

Physician practices can accomplish such testing in two ways: sampling and creating code subsets.

Sample high-dollar claims

In the first approach, take a sample of 25 to 30 claims -- "usually the high-dollar, high-volume claims that the practice traditionally submits to health plans," Tennant said -- or 50 to 100 claims if it is a bigger practice or you're dealing with claims that have already been adjudicated and paid.

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Then look at the documentation and see if the appropriate level of granularity for an ICD-10 code can be assigned. Note any mistakes, and from there educate physicians and clinicians about these missteps, Tennant said.

"For example, let's say that a claim was paid for a sprained wrist but you notice that in the documentation, the physicians never wrote down whether it was the left wrist or right wrist," Tennant said. "[That's] an opportunity then to educate clinicians and say, 'OK, everything looks good but you forgot to put laterality. So let's start to incorporate laterality into all our clinical documentation'."

Create ICD-10 subsets

Another way to improve clinical documentation:  As claims are being developed, create a subset of those claims and try to assign both ICD-9 and ICD-10 codes, Tennant said.

"Now you wouldn't include the 10 code actually on the bill but it could literally be on a sticky note that you attached … The goal here is to identify any gaps in documentation which might prevent a downstream coder from assigning the right ICD-10 code," he said.

Making sure clinical documentation is thorough and specific so that a high level ICD-10 code can be assigned will not only make the transition to ICD-10 smoother, but it will also help keep organizations from losing money, said Harsh Dhundia, director at Pace Harmon, a consulting firm with offices in Washington, D.C., San Francisco and Chicago.

"If there isn't enough supporting documentation, you're going to be forced into a lower-value code so you get compensated lower," Dhundia said. This will lead to loss in revenue, he added.

What CIOs can do to better prepare for ICD-10

With so much at stake for healthcare organizations when it comes to ICD-10 preparedness, hospital CIOs can do a few things to lower the risk of a negative outcome.

According to Harsh Dhundia, director at consulting firm Pace Harmon, CIOs should focus on three areas in preparation for the ICD-10 implementation date of Oct. 1, 2015:

  • Governance: "You're going to see changes not just in the system but in how people deal with the information that's going through the system and how information itself is created," Dhundia said. Therefore, CIOs need to take many factors into consideration, such as the user population that will be affected by ICD-10 and how to educate them to prepare for the change.

    "That is broader than just looking at your vendor or your IT system test working; that's actually understanding your user population," Dhundia said. He suggests CIOs set up a cross-functional team including everyone from the chief medical officer to the revenue cycle team.
  • Education: At present, much ICD-10 education is focused on clinicians, leaving everyone else in the healthcare organization who will inevitably also be affected out of the loop -- another reason why CIOs need to bring in the entire chain of people.

    "[They] are going to have to deal with this when they start looking at … or understanding whether a certain procedure was coded correctly or not for them to be able to get compensated correctly," Dhundia said. "Those individuals today are not … the target for education."
  • Prepare for a longer adjustment period after October 1: It is unlikely that one or two months after the October 1 implementation date all the kinks will be ironed out and everything will be progressing smoothly, Dhundia said.

    "We should not just be preparing for two months or three months after October," he said. "We should really be looking at a year to a year and half."

Upgrading EHRs and billing software: An expensive necessity?

Hand in hand with the ICD-10 implementation date comes the need for billing software to sync with the new codes, which could be an expensive task for healthcare organizations.

"Practices will need to have their billing software -- and I think for the most part probably their EHR -- upgraded or replaced prior to October 1," Tennant said.

In a survey done in February, MGMA found that about 40% of practices that responded have the cost to upgrade or replace EHRs and billing software built into their maintenance agreement. The remainder, however, do not. Tennant estimates that practices that do not have the costs factored into their maintenance agreement, are looking at around a quarter million dollars in software costs.

"Now that's not including training or workflow redesign, lost productivity, changes to super bills; all the other costs are separate," he said. "These are just costs related to the software."

Let us know what you think about the story and the ICD-10 implementation date; email Kristen Lee, news writer, or find her on Twitter @Kristen_Lee_34.

Next Steps

Learn more about ICD-10:

ICD-10 conversion: AMA, CMS plan to help providers

CMS readies for ICD-10

WEDI urges action from HHS, foresees unsteady transition to ICD-10

This was last published in August 2015

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