- Claudia Tessier
The CMS has confirmed Oct. 1, 2014, as the date when the ICD-10-CM/PCS code sets will replace ICD-9-CM for reporting medical diagnoses and inpatient procedures. Every healthcare entity covered by HIPAA must make this transition to ICD-10-CM/PCS: no excuses, no pardons.
Current Procedural Terminology coding for outpatient procedures and services is not affected by the transition to ICD-10-CM/PCS. However, the new version of the electronic health care transactions standard (Version 5010 of the X12 standard that became effective Jan. 1, 2012) is essential to the use of ICD-10-CM/PCS codes.
ICD-9-CM, developed in the 1970s, is outdated and can't provide the precise data about patient conditions and procedures that ICD-10-CM/PCS offers. Most countries quickly adopted ICD-10 after its release in 1990, with the United States being the last major holdout. Some of our delay can be attributed to the process of adapting ICD-10 to meet our specific healthcare needs and settings and creating ICD-10-CM/PCS.
ICD-9 was developed before the widespread adoption of digital technologies. ICD-10's detailed codes allow modern technologies to provide improved analyses of evolving disease patterns and treatment outcomes, and those in turn contribute to improved quality of care and reporting, as well as reimbursement.
ICD-10-CM/PCS is expanding from ICD-9-CM's approximately 14,000 codes to roughly 150,000, with about 70,000 in ICD-10-CM and about 80,000 in ICD-10-PCS. The additional codes accommodate many more precise diagnoses and procedures that reflect advances in medicine that ICD-9 cannot accommodate, and countries that have been using ICD 10 for many years report consequent advantages in healthcare delivery and management. Compare our continued use of ICD-9 to trying to use manual or Selectric typewriters to meet the communication demands of today's world.
Keep in mind that not all 150,000 codes will be applicable in every setting. Rather, specialties and particular settings will have a range of codes (or multiple ones) that will be regularly applicable, and they only occasionally will go outside those ranges.
Why not skip ICD-10 and wait for ICD-11?
One could argue that even ICD-10 is insufficient for today's healthcare environment. The next version, ICD-11, is expected to be ready by 2016, but it doesn't make sense to wait for it because it would be like moving high-school graduates directly into master's and doctoral programs without making them first attend an undergraduate school. Further, the development of U.S. modifications to ICD-10 will take several years beyond 2016. After all, it's taken more than 20 years for the U.S. to prepare for ICD-10-CM/PCS. Also, by that time, integration with SNOMED CT is likely to be on the agenda, providing even greater functionality. Additionally, the investment to date on implementing ICD-10-CM/PCS is huge, and retreating to ICD-9-CM would not only waste that investment but also require further expenditures.
The American Medical Association (AMA), the most vocal critic of the transition, has committed itself to working with the CMS to mitigate the problems it sees with ICD-10. Further, the AMA recently acknowledged that skipping ICD-10 and going directly to ICD-11 is not advisable. Its reasons, shared by others, include: Transition to ICD-11 would cost as much as the transition to ICD-10. Its content requires more computerization, for which the industry is not prepared. Skipping ICD-10 would delay the positive impacts of ICD-10, including the anticipated reduction in payers' reliance on repeatedly asking for additional information ("attachments"), thus reducing burdens on physicians. In summary, there is no excuse to not move to ICD-10 now.
All that being said, we must acknowledge that a new threat to the October 2014 transition date for ICD-10 recently arose when two bills were introduced into Congress (one in the House, the other in the Senate) with the aim to stop or delay implementation. A consortium including the American Health Information Management Association (AHIMA) and several other organizations has spoken out strongly against these bills, for all the reasons noted above. The consensus is that, given the strong industry opposition and the usual slow process of moving bills through Congress, the healthcare world is advised not to stall preparations for its implementation.
Conduct a self-assessment of ICD-10 readiness
It's prudent for any organization to consider the following in preparing for the change to ICD 10: If a healthcare entity doesn't already have a steering committee, it's imperative to form one. Members should include both C-level executives, whose leadership signifies commitment and support, as well as those charged with implementation, in particular the heads of health IT and health information management (HIM). The latter two should serve as leaders of the project (planning and implementation) team, which should also include members of the medical staff, nursing, case management, clinical documentation improvement, quality assurance, accounting and other teams. All these team members will serve as champions and stewards of the transition within their realm of responsibility. The financial impact is especially important, both in terms of reimbursement and the costs associated with the change.
The project team must ensure that all those who will be affected are thoroughly informed about the transition. A transitional assessment should evaluate policies, procedures, computer systems, and other data and systems inventories. Internal stakeholders, as well as vendors and payers, must participate in an effort to align all parties in this effort. Health IT and HIM must work closely together to ensure that all necessary integrations and upgrades are identified and implemented; this includes not just equipment and software, but also policies, procedures, applications and databases.
The transition is also a valuable stimulus to evaluate and improve workflows, including replacing manual processes with electronic ones, eliminating redundancies and improving communications. It is a great opportunity to introduce or upgrade an institution's clinical documentation improvement program and to reinforce the links between documentation and coding and their influence on quality of care and reimbursement.
Coder recruitment required
Personnel needs for the new coding system must be assessed. Industry experts estimate that productivity will drop by as much as 50% initially, and although this will improve over time, it will never match the productivity associated with ICD-9-CM. Does that mean you'll need twice as many coders?
Well, it's not as simple or stark as that. Determine which of your coders are willing and qualified to learn the new system. Widespread anecdotal reports indicate that some very experienced coders are choosing not to stay in the profession -- some because they are approaching retirement anyway, and others because they don't want to make the effort to learn a very different system. Many who are willing to learn the new system recognize that they are in a very good negotiating position with their current or future employer regarding pay and working conditions. Most institutions will have to recruit coders, especially those who can code in both ICD-9 and ICD-10. Dual coding is recommended at least initially because analytics will require data from both systems in order to compare the impact on case mix, reimbursement, and so forth.
So, how do providers retain and recruit coders in this very competitive market? Contracts, retention bonuses and improved benefits are among the answers. Still, retaining coders won't be sufficient to fill the gap created by the drop in productivity, and recruitment may be difficult. Some providers are turning to Coding-as-a-Service companies (similar to medical transcription businesses), the number of which is growing both in the U.S. and offshore.
Internal and external training will also be necessary. Consider ICD-10-CM/PCS to be a new language, based on knowledge of anatomy and physiology, pathophysiology, pharmacology, disease processes, and surgery, as well as the health record's content and organization. Many professionals have these skills already and can be trained for coding ICD-10. Coding courses are available through community colleges, four-year college programs and online courses.
The pool for additional coders includes not just newly trained coders, but also existing healthcare professionals. Nurses, medical transcriptionists, medical students, HIM and health IT graduates, foreign-trained nurses, and doctors who can't find work in their own profession or are looking for better opportunities, as are retiring clinicians -- all have the right experience. Some coding programs, such as Coding for Healthcare Professionals, which I co-founded, are aimed specifically at healthcare personnel seeking an alternative career, as well as at clinicians who want to learn coding themselves, both to be free of their dependence on coders and to better understand reimbursement.
Update software and identify documentation weaknesses now
The need for coders must be coupled with systems changes and supporting software. Healthcare documentation is the primary source for identifying the appropriate codes and, therefore, reimbursement. This is the time to identify weaknesses in documentation, whether related to the electronic medical record, transcription or other systems, and to address policies and procedures and make necessary changes. A clinical documentation improvement program can be especially valuable, even essential, for successful implementation.
Coding software developments are coming of age. Medical encoders identify possible codes based on the diagnosis or procedure entered, reducing the time spent in looking up codes manually. Computer-assisted coding (CAC) reads and interprets documentation and generates the most likely codes by utilizing natural language processing (NLP) to analyze the syntax and semantics of patient documentation. Even more than encoders, CAC can reduce productivity loss, particularly as coders become adept at using the new system.
Most of these systems support dual coding, that is, they identify both ICD-9-CM and ICD-10-CM/PCS codes, which can be valuable in business analytics regarding the impact of the change on reimbursement and case mix. Keep in mind that, even with encoders and CAC, special knowledge is needed to select the appropriate codes among the possibilities presented, and additional searching and researching might be required to assure accuracy. Computer-assisted coding with NLP software can be compared to the use of speech recognition with NLP in documenting care: These systems don't completely eliminate the need for human review or confirmation of their results, but great hopes persist that in time they will do so.
The transition to ICD-10-CM/PCS holds great potential to improve documentation and reimbursement, while at the same time contributing to improved quality of care and public health data. The transition is challenging, however, and demands early attention to its potential impact on finances, personnel, workflow, documentation, systems, communication, relationships with vendors and payers, and so forth. That said, the transition remains an important component to success in the new digital age of healthcare.
About the author
Claudia Tessier RHIA MEd is a consultant, author, and speaker on healthcare documentation and coding. The co-founder of Coding for Healthcare Professionals, she can be reached at firstname.lastname@example.org. Let us know what you think about the story; email email@example.com or contact @SearchHealthIT on Twitter.