Get Ready for Industry-Wide Impact of ICD-10 By Bess Ann Bredemeyer, BSN, RN, CHC, CPC, PCSDirector of Compliance Consulting

Preparing for Widespread Organizational Change

While some hospitals, practices and vendors are focused exclusively on the heavy lift of qualifying for stimulus funds and achieving meaningful use, foundational regulatory change is on its way. The change to an expanded code set for diagnoses and procedures, ICD-10-CM and ICD-10-PCS, will bring sweeping changes to the processes and IT solutions used by providers and payers, clearinghouses and software vendors. The Oct.1, 2013 mandate will affect all aspects of a provider’s operations since the provision of care, along with the appropriate diagnosis and procedure codes, drive the delivery and business of healthcare.

Benefits from the Change to an ICD-10 Code Set

Already in use by other developed countries around the world, the code sets are expanding from an approximate total of 20,000 to more than 155,000 — almost an eight-fold increase. The expansion may benefit the delivery of

care by indicating more precisely the diagnosis, and will better match the payment for care to the care delivered. In time, it will promote greater efficiencies in care documentation and claims processing.

In some cases, providers will receive more appropriate reimbursement for complex procedures that couldn’t be differentiated with the previous ICD-9 code set. What used to be one code in ICD-9 may be multiple or even many codes in ICD-10 that provide greater clinical specificity and can better indicate levels of complexity. For example, the codes differentiate body parts, surgical approaches and devices used.

There should be fewer requests for more procedure information to validate reimbursement because of the greater specificity of the code set. However, knowledge and application of the correct code becomes even more critical. Protecting reimbursement will require extensive training not only of coders, but also of physicians and other code users, who must provide the

detail in clinical documentation that will identify and support the diagnosis or procedure.

The specificity and expanded data will enable improved analysis of care delivery for quality and regulatory reporting. Increased detail for analysis also can be leveraged for process improvement and pay for performance.

The Centers for Medicare & Medicaid Services (CMS) reports that coding professionals are advising organizations to begin training six months prior to the compliance date. The American Health Information Management Association (AHIMA) suggests starting three to six months prior to the date.

All Care Stakeholders Will Be Affected

The ICD-10 code set will have far-reaching impact on inpatient and ambulatory provider processes and departments — admissions, eligibility checking, medical necessity, contracting, care delivery, ancillary services, billing, claims, super bills, encounter forms

and quality reporting. Payor processes will be affected extensively, including medical policy, contracts and claims adjudication. All stakeholders must prepare to transmit transactions using the new 5010 format.

The health IT systems that support the care stakeholders and processes will be affected — wherever there is a diagnosis or procedure code entered, processed or transacted (visible or invisible), changes must be made.

Because of the magnitude of the difference in the number of codes in the sets, many times there will be no “crosswalks” with a one-to-one match. Software mapping tools will provide an equivalency of one-to-one, one-to-many, many-to-one, etc. The government is providing General Equivalency Mappings to help in the development of these tools.

The Timeline for Change — Start Yesterday

What’s the timeline? The date for use of the new code set is any service date or discharge date on or after Oct.1, 2013. And contrary to the hope and belief of many healthcare organizations, CMS doesn’t appear to be backing off from that date. Because some encounters will still be in process for previous service dates, it is anticipated that both provider and payer systems will need to support both the ICD-9 and ICD-10 code sets for a period of time.

CMS is laying the foundation for the change by requiring an update of systems that support the electronic distribution of information (EDI) of

healthcare data. CMS is requiring an update of the 4010/4010A transactions to the new ANSI X.12 Version 5010, which among other things will support the ICD-10 codes. ANSI 5010 must be in use by Jan. 1, 2012.

See the 10 Steps for Providers to Get Ready for ICD-10 below for a high level checklist to assess your readiness.

10 Steps to Prepare for ICD-10

These 10 steps will help you get ready for the transition to the ICD-10 code sets. You may want to forward this to those in your organization who are working on this initiative.

1. Establish governance and responsibility: Identify a project manager. For larger groups and hospitals set up a multidisciplinary team and governance steering committee. Communicate the financial ramifications of not being ready to gain buy-in and funding from the executive team.

2. Launch your ICD-10 compliance initiative: Hold your kick-off meeting and communicate timelines and impacts of the change to all staff. Ensure coders, physicians and other billing staff understand the impact on reimbursement and days in accounts receivable for claims that are not properly coded or substantiated.

3. Conduct a readiness assessment: Assess the impact to policies and procedures, payor contracts, training needs, staff augmentation or outsourcing and determine software vendor readiness.

4. Create a project plan detailing essential components for success: Key components would include communications, training and a software roadmap.

5. Identify clinical documentation required for coding: Reinforce the requirements in your organization’s policies and procedures.

6. Schedule and implement updated IT solutions: Ensure your implementation schedule provides time to perform any system upgrades, test releases and install updates. Determine when and how long you need dual coding systems.

7. Train coders on new code sets: Review coder experience – the new code set will require increased familiarity with medical procedures, anatomy and pharmacology.

8. Train physicians on new documentation requirements: Educate physicians on areas that require increased clinical documentation.

9. Perform service line assessments and potential impact to cash flow: Review coding that supports your key service lines and most commonly assigned and highly reimbursed DRGs.

10. Use enterprise intelligence analytical tools and reporting to monitor compliance and financial performance: Check first-time submission claims success rate, reimbursement turnaround time, days in AR, source of claim edits, source of denials and staff compliance/productivity.

Start Now. While the date to comply may seem far in the future, don’t underestimate the amount and complexity of change that will be required. While many organizations are hoping for a reprieve from the Oct. 1, 2013 compliance date, CMS is holding firm at this time, saying there will be no delay.

If you need assistance in getting ready for ICD-10, McKesson Practice Consulting Solutions offers services such as readiness assessment, roadmap development and implementation. For more information, please email consultinginfo@mckesson.com or call 1-800-789-6409.

About the Author

Bess Ann Bredemeyer, BSN, RN, CHC, CPC, PCS Director of Compliance Consulting McKesson Practice Consulting Solutions

Responsible for McKesson’s consulting services related to physician practice coding and compliance, Bredemeyer has more than 27 years of experience in assisting physicians, office, and billing staff with their coding and compliance needs. Prior to joining McKesson, Bredemeyer was the compliance and privacy officer for a large academic health center and was an active practicing critical care nurse. She guest lectures at physician forums and residency programs, and has authored several articles relating to physician coding and compliance.

www.mckesson.com/practiceconsulting1.800.789.6409

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