What Canada Can Teach the U.S. About ICD-10 Conversion

When the World Health Organization (WHO) realized decades ago that the ICD-9 descriptive codes for disease and care processes would soon be outdated by the rapid advances in medical knowledge, technology, and healthcare diagnosis and treatment, they began the work that would transform ICD-9 to be better able to meet the increasing demands of the industry.

When complete, ICD-10 promises to improve the recording of quality care management and has the possibility to substantially affect reimbursement, yet the impacts of moving America’s healthcare system to ICD-10 have been estimated to require efforts surpassing those of Y2K.

The contrasts between ICD-9 and ICD-10 are dramatic in the high level of coding granularity, complex format changes and required medical knowledge. A five-fold increase in the number of diagnostic codes, the realignment of injury codes to represent the site of injury rather than type of injury, completely new codes in high risk obstetrics, new post operative complication codes, and the replacement of “catch all” codes with new specificity requirements across the board represent only some of the changes. All of these codes however, contribute to the value potential afforded to all stakeholders, given well planned preparation.

Since the code was first endorsed by the WHO in 1990, a number of countries have implemented ICD-10 and it has already begun to show benefit in several ways. Canada is often praised for the approach that it took to move to ICD-10 CA, and therefore can provide important lessons to the U.S. to help ease its transition in three important areas: statistical analysis, coder productivity, and education and training.

The Statistical Impacts
Canada implemented ICD-10 in a staggered fashion across nine of the 10 provinces between the years of 2001 and 2004. As data was returned, comparison was undertaken of information classified by ICD-9 and ICD-10, beginning with volumes and length of stay within major diagnostic groups.

The large scale realignment of individual diagnostic and procedural codes demanded close analysis of the impacts to existing indicators of healthcare delivery. Using data reported in 2001 and 2002, the Canadian Institute for Health Information, an independent organization that works with the federal government, tabulated the input. Rigorous statistical analysis was conducted to evaluate the comparability of ICD-9 codes to ICD-10 codes as they pertained to the Canadian version of diagnostic groups, Case Mix Groups (CMGs), which are used in the patient classification system to group together patients with similar characteristics.

It should be noted that an “interim grouper” was used, incorporating ICD-9 grouping methodology adjusted for ICD-10 codes. Not surprisingly, the study, published in 2004 by the Canadian Institute for Health Information, reported difficulty in mapping the new codes, due to the new data structures, increased specificity and new concepts introduced in ICD-10 such as combined codes (previously two separate codes).

Also, as recommended by the WHO, new standards for coding of angina, chronic obstructive pulmonary disease (COPD), and pneumonia were taken into account, as were changes to length of stay for such diagnoses as the acute phase of a myocardial infarction. Given the necessary adjustments and “best fit” selections for new codes, it was nonetheless concluded overall in the first year of data returned, that 62 percent of the 478 CMGs experienced statistically significant changes in volume and/or length of stay.

Subsequent testing lowered this percentage to near 40 percent by 2003, as additional data from the other provinces became available and testing methodology was refined, but it was felt that sufficient proof was available to conclude that the introduction of ICD-10 resulted in a significant shift in case assignments to diagnostic groups. It was formally recommended that ICD 9-ICD 10 Crosswalk not be attempted. The leading practice is to naturally process the code within the systems.

Coder Productivity Loss
Given the increased detail required by the new codes, the initial impact on coders is significant. Reports to date, both retrospective and prospective, suggest that for a medium to large acute-care facility, an initial productivity decrease in the neighborhood of 50 percent is to be expected.

According to reports published by the American Health Information Management Association and the American Hospital Association, at one 605-bed hospital in Canada, a conversion to ICD-10 indicated that after one year, coders had recovered some of their pre-conversion productivity rates (see www.ahima.org/icd10 for the full report). For inpatient records, one month post conversion, coders were coding generally at rates just under 50 percent. One year later, they had returned to 81 percent of their former 4.6 charts hourly, and for day surgery and emergency records, 79 percent and 85 percent, respectively.

It should be noted in considering these results that Canadian equivalent to ICD 10 PCS expanded by only six-fold to 17,000 procedure codes, while the U.S. version will contain 120,000, making both the learning and the task itself that much more onerous. Yet, this example provides a rough benchmark for similar sized U.S. hospitals and what to anticipate.

More insidious than the bottom line coder productivity is the trickledown effect that will be experienced throughout the revenue cycle and even within clinical groups should the lost productivity not be compensated simultaneously. “Backfill” for coders during training and at least the initial period of productivity loss must be budgeted in order to avoid the inevitable cash flow impact to the organization that will result from significant coder slowdown. Additionally, during the initial post-conversion phase, it would be practical to anticipate a spike in billing inquiries and claims delayed.

Also impacted by productivity, reports used for managing aspects of the revenue cycle, resource use, and research will potentially be delayed by any significant coding slowdown, and should be factored into the productivity losses overall.

Education and Training
By all reports, it is strongly recommended that managers undertake a bottom line assessment of coders’ current education and skill levels. ICD-10 will require an expanded coder knowledge base, specifically in the areas of detailed knowledge of anatomy and medical terminology; comprehension of operative reports; comprehension, interpretation and application of standardized ICD-10-PCS definitions; and increased interaction and collaboration with medical staff.

Ideally, adequate advance training will highlight weaknesses and be met with additional focused education before the necessary knowledge is applied on the job. In Canada, coders underwent a mandatory two-day workshop six to 12 months in advance of the change, and several took advantage of options for additional resources, including self learning programs and hospital- sponsored practice time. Trainers and coders in leading roles underwent a more intensive six-month program online, combined with newly developed text materials. The training proved to reduce productivity loss.

Another training area is with physicians. Over the years, innumerable efforts to effect positive change on physician documentation in patient records have produced mediocre results at best. While physicians are not likely to anticipate any required training for ICD-10, it should be presented in a message strongly supported by senior management that not only documentation requirements are changing, but that also, physicians should expect an increase in coder requests for collaboration. This will be particularly evident with respect to coding procedures, and physician support is critical to the renewed efforts with which patient data is being collected.

As with coders, physician education will need to include information about the changes to the basic structure of the classification system, how this relates to what they document and where, and the expanded requirements for assigning a code.

Overall, the conversion to ICD-10 represents a major change to the organization. The greater and more planned the effort however, the less the disruption, and ultimately, the greater the gains. Careful and clear-eyed planning today will position your organization to not only reap the expected benefits, but to meet the regulatory, clinical, and reimbursement challenges of the years to come.

Bruce Hallowell is a managing director in the Revenue Cycle HIT Practice at PwC, Columbus, Ohio.