ICD-10 Implementation: High Level Overview for

Organizational Leaders, Part I

Juliet A. Santos, MSN, CCRN, FNP-BC

Sr. Director, HIMSS Business Centered Systems & Medical Banking Project

Learning Objectives

I. Identify ICD-10 impact to organizations.

II. Identify organizational and implementation strategies.

III. List vendor readiness questions to ensure efficient project planning.

IV. Discuss specific tactics to prepare and train your team for ICD-10 transformation.

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What is ICD-10-CM/PCS? • International Classification of Diseases, 10th Revision

• CM: Clinical Modification of World Health Organization’s ICD-10

• PCS: Procedure Coding System

• CM & PCS: level of detail needed in the United States

• Provides code titles and language that complement accepted clinical practice in the United States

• ICD-10 is much more detailed than ICD-9

• ICD-10: 69,000 diagnosis codes

• ICD-9: 13,000 diagnosis codes 3

What is ICD-10-CM/PCS?

• ICD-10-PCS consists of about 73,000 procedure codes

• ICD-10 has the potential to reveal more about the quality of care so that data can be sued in a more meaningful way to better understand complications, better design clinically robust algorithms, and better track outcomes of care.

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You Must Really Understand ICD-10 • ICD-9 and ICD-10 are derived from the WHO’s ICD

(International Classification of Diseases & Related Health Problems)

• ICD is the international standard diagnostic classification for all general epidemiological and health assessment purposes

• Used on for all health records, vital records and death certificates provides basis for the compilation of national mortality and morbidity statistics by WHO Member States 5

Why Replace ICD-9? • Lacks sufficient specificity and detail

• Running out of capacity –limited structural design cannot accommodate advances in medicine and medical technology and growing need for quality data

• Obsolete and no longer reflects current knowledge of disease processes, contemporary medical terminology or the modern practice of medicine

• Limited data to compare costs, outcomes of different medical technologies

• Cannot support US transition to an interoperable data exchange

• Unable to share same global data regarding morbidity and mortality—critical for public health reporting

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Value of ICD-10 • Greater coding accuracy and specificity

• Higher quality information for measuring healthcare service, quality, safety, and efficiency

• Improved efficiencies and lower costs

• Reduced coding errors---eventually!

• Greater achievement of the benefits of an EHR

• Recognition of advances in medicine and technology

• Alignment with coding systems world wide

• Improved ability to track and respond to international public health threats

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Processes Impacted

• MS-DRG conversion

• Convergence of other payment methodologies dependent on diagnosis/procedure codes

• National and local coverage determinations

• System logic and edits (ex. medical necessity)

• Provider profiling

• Quality measurement and quality initiatives

• Claims editing

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Process Impacted

• Claims data analysis

• Utilization management

• Disease management

• Aggregate data reporting

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Systems Impacted • Modified field lengths to accommodate expanded data

element length

• Modified logic to accommodate new code sets

• Systems accommodate the transmission of ICD-9 to ICD-10 simultaneously

• Data reporting elements

• Payment/revenue cycle systems changes

• Coding software systems

• End-coder software systems

• Physician/provider technology (ex. handheld devices, etc.)

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Operational Impacts

• Clinical documentation training

• Plan early for ICD-10 training for impacted staff—launch training later in the process closer to implementation

• Decreased coding and payment productivity post Go-live

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Financial Impacts • Decreased revenue initially

• Altered revenue payment due to mapping from ICD-9 to ICD-10 for DRG and payment classification

• Increased payment error rate post Go-live

• Resources (staff, budget, time) requirements to modify software systems

• Identified and unknown risks with modifying applications

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Prepare for Implementation

• Begin discussion of ICD-10 now to facilitate early awareness and education –take advantage of lead time!

• Perform detailed impact analysis—include systems inventory and current use of ICD-9

• Create a task force with all key departments represented to facilitate change and information dissemination

• Assess impact and training needs for physicians, nurses, clinicians, and ancillary departments

• Gather departmental information to assess implementation risks

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FAQ

• What can organizations do now to prepare for implementation of ICD-10-CM/PCS?

– Answer: Identify stakeholders

– Assess impact

– Formulate strategies and identify goals

– Develop education and training plans for employees at all levels

– Develop information systems and technology systems change implementation plan

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Impact on Systems • Upgraded software to accommodate expanded field

lengths and code changes

• Modified systems field lengths to accommodate expanded data element length

• Modified system logic

• Systems must accommodate transmission of ICD-9 to ICD-10 simultaneously

• Update super bills/encounter forms and databases

• Retain access to historical coded data in ICD-9 format

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Impact on Information Systems

• Review of storage and reporting practices for longitudinal data

• Payment/revenue cycle systems

changes

• Coding software systems

• End-coder software systems

• Physician technology (ex. handheld devices, etc.)

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Other System Modifications

• Implementation of HIPAA X12 Version 5010

• Transaction piece that ICD-10 which serves as the foundation for ICD-10 implementation

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Conducting Organizational Strategy & Impact Assessment

• Identify the goals you are working to accomplish along with your action plans to achieve your stated goals

• Name an executive sponsor

• Develop and interdisciplinary steering committee for project oversight

• Assign a Project Manager

• Identify Implementation Strategy

• Define Project Team Roles & Responsibilities

• Determine Project Success Factor

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Organizational Strategy & Impact Assessment

• Develop the work breakdown structure

• Develop the project schedule

• Develop the implementation timeline

• Create an ICD-10 Code Set Impact Awareness Campaign

• Employ change management strategies

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More Organizational Strategy & Impact Assessment

• Begin production activities before the Go Live date

• Go Live—the date for complying with the ICD-10 deadline

• Complete testing and implementation activities in advance of Go Live date

• Adequate time taken in the planning can mitigate negative outcomes

• All systems modifications, testing activities, and coordination must be successfully completed on the same day

• Go Live event will be nothing like you’ve ever seen before

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Org. Strategy & Impact Assessment

• Even when executed extremely well, it will still require remediation and resolution of issues

• Ensure that the project time line is realistic and can accommodate last minute issues that will arise during the Go Live event

• Establish the project budget

• Create project team communications management plan

• Review organization-wide strategy with the team 21

Impact Assessment Strategy & Activities

• Initial activities include emailing surveys focused to each specific department or service area

• Conduct face to face meetings to go over assessment questions and collect findings

• Project team to communicate with senior management that software vendors must work with internal resources to complete modifications

• Ensure enough time for detailed systems assessment with vendor for mutual understanding of all system modifications required to comply with 5010/ICD-10

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• Include assessment questions in IS department’s strategy

• Use intranet web surveys for all staff

• Paper surveys distributed via interoffice mail, etc

• In-person or telephone survey conducted through interviews

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Impact Assessment Strategy & Activities

Conduct Impact Assessment

• Goal is to determine the risk areas for organization

• Review and assess current processes in comparison to best practice methodology and identify opportunities to expand service offerings

• Optimizing operations and improving level of offerings, IT needs, patient care

• Must identify software currently using or producing data related to ICD codes is critical

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Impact Assessment

• May receive varied responses regarding the level of effort to modify systems.

• Some systems will require minimal effort to accommodate the field of strength and logic alterations.

• Other legacy system will require extensive changes to comply with new standards.

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Assessment Surveys for Software Systems

• Be sure to conduct an assessment of every department.

• Assess current use and future use of ICD-9 and 4010.

• Required modification to accommodate 5010 and ICD-10

• Ability for systems to process both ICD-9 to ICD-10 code simultaneously

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Information Systems Strategy & Impact Assessment

• Organize project team & identify project tasks

• Create an awareness campaign

• Assess impact to systems and technologies

• Review vendor & third-party contracts

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Organize Project Team & Identify Project Tasks

• Identify project lead

• Assign the project team resources

• Orient and educate team leaders on ICD-10 including field lengths, logic, and hierarchical structure

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Create an Awareness Campaign

• Understand the structural difference between ICD-9 and ICD-10.

• Work closely with HIM professionals

• Don’t depend on coding knowledge alone to identify impacts to systems and technologies.

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Assess Impact to Systems and Technologies

• Conduct a comprehensive systems audit to identify all applications and technology that currently uses, interacts, or plans to use/interact with ICD-10-CM/PCS data.

• Systems identified by audit will require an impact analysis between current technology and future standards required for ICD-10.

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Assess Impact to Systems & Technology • Conduct an inventory of all applications and systems with the

organization that use, process or store ICD-9 code--- add these to the assessment findings.

• Develop assessment questions regarding the usage of ICD-10-CM/PCS codes and data elements.

• Determine software systems using ICD-9 codes and plan to use ICD-10 codes.

• Staff currently using ICD-9 codes and plan to use ICD-10

• Staff currently using data elements derived from ICD-9 codes and plan to use ICD-10

• Future plans for implementing & using new technology or modules within current technology 31

Conduct a Comprehensive Systems Assessment

• Start with third party applications as their work is required to complete assessment and required modifications is out of direct control of your organization

• Vendor readiness is critically

important

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Sample Vendor Questions • Does this application currently use ICD-9 codes?

• If no, is the application planning to use ICD-9 or ICD-10?

• What date will the system begin to use ICD-10 codes?

• How is the system currently using ICD-9 codes?

• What departments are using the data collected by or provided by this application?

• Identify other systems that link to this application to transmit ICD-9.

• Provide a brief description of the plan to accommodate ICD-10 code sets to this application.

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Sample Vendor Questions • Specify how the ICD-9 codes will be disabled in the

transactions once the ICD-10 code sets are all in full effect.

• List all vendor supported interfaces that will be affected by the ICD-10 and how each will be remediated.

• List all steps that this facility must perform to implement ICD-10 in this application.

• Specify the date that the application compatible ICD-10 will be available for testing.

• List all steps that the facility must perform to implement ICD-10.

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Sample Vendor Questions • Specify the earliest date that he current software version can

be upgraded to accommodate the ICD-10 code sets.

• Specify how long it will take to implement.

• Attach proposed project schedule for implementing the compatible version to support ICD-10.

• List facilities within this organization that are behind on the current application releases and how many upgrades will be required to bring each facility’s application current.

• Indicate resources that are available to assist with application upgrade (ex. third party contractors, consultants, etc.).

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Review Vendor & Third-party Contracts • Identify resources to review vendor and third-party contracts in

detail to determine if modifications are necessary to change systems or procedures required by regulations.

• Run this process concurrently, if needed, with assessment activities.

• Some vendors are not able to comply with 5010 transaction formatting so will need to be replaced with a new vendor –will require identification, review, negotiation, and acquisition of replacement technology.

• Allow as much time as possible for this process and modification activities.

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Health Information Management Strategy & Impact Assessment

• Develop a HIM project team

• Designate a team leader

• Organize the HIM project team

• Develop a HIM Project Plan

• Create a work breakdown structure

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Develop a HIM Project Team • HIM department a highly impacted area

• Data changes related to personal health information created with in daily business functions

• Team should have specific predefined objectives set by the steering committee for ICD-10 implementation

• Designate a team leader to work with the steering committee—will select team participants

• HIM Project Team might include: project lead, education/learning leadership, quality management reporting, coding supervisor/manager, patient financial services, documentation improvement manager, physician liaison, patient access services, HIM, IS testing coordinator

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Developing the HIMS Project Plan

• Team members

• Objective

• Work breakdown structure to reach objective—focus on deliverable for each task

• List who will be responsible for each task

• Timetable for meetings, milestones and deliverables

• Identification of project methodology and communication tools

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Assessment of Educational Requirements for Coders

• Appoint a coding assessment coordinator

• Develop survey questionnaire to assess educational needs in each department

• Initiate an education process for coders

• Examine staffing needs

• Evaluate the coding functions

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Initiating an Educational Process for Coding Professionals

• Focus on learning the structure, organization, challenges and unique features of ICD-10-CM/PCS

• This process will alleviate concerns and anxiety of the staff

• Practice ICD-10 coding exercises using ICD-10 resources during coding meetings

• Refer to various websites with ICD-10 coding

information

• Identify what skills are needed

• Identify classes, training plan, resources 41

Determine Staffing Needs

• May require additional staffing

• Consider hiring new coding graduates at some point during implementation phase to alleviate short term backlogs .

• May need to reallocate more experienced coders to educate and monitor quality.

• Usually takes 12-18 months (leaning more towards 18 months) for coder training.

• More experienced coders should be interacting with provider staff for documentation and follow up.

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Review Provider Documentation Tools

• Includes any health information documentation tools planned or currently used for physician documentation

• Begin a systematic review of clinical documentation templates for history and physical, progress notes, consults, commonly performed inpatient procedures, etc.

• Assess disease specific protocols that could provide an opportunity to enhance clinical detail.

• Increasing and improving specificity of clinical documentation early in process enhances the provider documentation to support the detail needed for ICD-10.

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Documentation Awareness

• Begin early

• Use physician newsletters or company web pages to focus on one service disease category at a time.

• Begin with the highest volume service types.

• Highlight specifics available once ICD-10 is implemented.

• Example: educate on range for epilepsy—intractable or non-intractable, focal or generalized, idiopathic or special epileptic syndromes related to alcohol, drugs, stress, etc. 44

Documentation Awareness

• ICD-10 includes encounter and external

injury cause details within the code

selection

• Include more accuracy in terminology

• Ex: acute or chronic when documenting active conditions instead of using “history of”

• Currently already required to document everything that ICD-10 requires

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Go Live • A well thought out Go Live event anticipates issues

and is able to respond quickly to fix problems with the right resources.

• Go Live should be a well coordinated event that involves senior management, information systems, ancillary departments, and HIM staff.

• Must ensure gap analysis and assessment activities are complete

• Go Live preparation must include system and process updates, testing, and validation activities.

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Questions?

Contact information:

Juliet A. Santos, MSN, CCRN, FNP-BC

HIMSS Senior Director, Business Centered

Systems & Medical Banking Project

jasantos@himss.org

Cell phone: 312.909.9602

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