Achieving and sustaining ICD-10 success

Nov. 24, 2015
By Susan Belley, M.Ed., RHIA, CPHQ , Manager, Clinical Content Development,
3M Consulting Services

On Oct. 1, the U.S. healthcare industry finally moved into ICD-10 production mode after years of preparation. With one month into the transition, performance and process improvement activities are the priority focus areas, as well as careful monitoring of key performance indicators. As we move into the post go-live phase of the ICD-10 transition, healthcare organizations should focus on five key areas to ensure ICD-10 compliance and success:

1. Physician documentation

ICD-10 compliance begins with physicians and other care providers who must incorporate the new ICD-10 terminology into their documentation. Without complete and accurate documentation that fully captures the specificity required for ICD-10 coding, compliance with the new code sets will be impossible.

As Example 1 illustrates, physicians will need ongoing education and feedback to help them make documenting in ICD-10 second nature. It will take effort on the part of providers as well as their organizations. The support and engagement of medical staff leadership during this period is critical.

Example 1: ICD-10 demands greater documentation specificity

A patient involved in a car accident arrived in the local hospital’s emergency department, having sustained a neck injury and complaining of not being able to move or feel her legs. After physical exam and workup, the physician recorded the diagnoses of “cervical spine fracture with cord compression.” The patient was then transferred via helicopter to a larger facility for surgical intervention.

Subsequently, upon review of the patient’s medical record, the coder also noted that it included a detailed report from the radiologist, which indicated fractures of C1, C2, C6, and C7 vertebrae. The radiologist had further documented that the fracture of C2 was a Dens fracture with minimal dorsal displacement, and the presence of an epidural hematoma at C6-C7.

Thanks to documentation specificity provided by the radiologist, the coder was allowed to assign one of the new, specific ICD-10 codes for fractures – in this case, a code for a posterior displaced type II Dens fracture.

Based on the physician’s documentation, the coder also assigned a code for an unspecified injury at C6. However, the radiologist’s report indicated the presence of an epidural hematoma at C6-C7. If this information had been incorporated in the physician’s diagnosis, it would have allowed for the assignment of a specific ICD-10 code that would have described the epidural hematoma with incomplete compression of the cord. The result would have been complete, accurate, and compliant ICD-10 coding, as well as documentation that fully explained the severity of this patient’s injuries.

In the short term, an ICD-10 hotline that physicians can call for assistance may help during the transition, but over the long-term, a clinical documentation improvement (CDI) program will promote consistent education and establish a feedback loop. 

Organizations with existing CDI programs will need to infuse their programs with new vigor to assist providers. Those without a CDI program may need to consider implementing one to ensure documentation accuracy and completeness over time.

2. Validate coding accuracy

Success with ICD-10 requires ongoing coding validation and lots of it! ICD-10 is brand new to coding professionals – especially ICD-10 procedure coding. The ICD-10 Procedure Coding System (ICD-10-PCS) requires coding professionals to radically change their way of thinking when applying procedure codes as compared to ICD-9 (see Example 2).

Example 2: Coding procedures in ICD-9 vs. ICD-10

In order to code a carotid endarterectomy in ICD-9, the coder would look up this procedure in the ICD-9 procedure index. The ICD-9 code listed for a carotid endarterectomy is 38.12 Endarterectomy of other vessels of head and neck.

In ICD-10, the coder must first identify the body system on which the procedure is performed – in this case, upper arteries. Next, the coder must select one of 31 root operations that best describes the procedure. In this case, extirpation. Then the specific body part must be identified – either the left or right common carotid artery. The coder then reviews the operative report to determine the approach. Was the site of the procedure accessed via an open incision or percutaneously? The coder must understand all aspects of the surgical procedure in order to assign the correct I-10 code. The result is more complete and accurate information about the procedure performed on the patient, but the process is very different from looking up a code in an ICD-9 index.

Every organization needs a coding audit plan – be it an internal process, or through an external resource, or a combination of both. Don’t wait for denials before auditing coding accuracy. Daily audits should start immediately so errors are detected early on and resolved. Focused as well as random auditing will identify coders who are struggling and pinpoint areas for additional coder education, as well as opportunities for documentation improvement. Coding professionals should continuously review “the sources of truth” when it comes to compliant ICD-10 coding, such as the ICD-10-CM/PCS Official Guidelines for Coding and Reporting as well as the AHA Coding Clinic for ICD-10-CM and ICD-10-PCS.

Be ready for declines in coder productivity. Establish a contingency plan for addressing productivity issues in the short and long term. Some organizations have temporarily adjusted staff schedules. Others have supplemented their coding staff via outsourced resources to help their staff through the learning curve. Finally, look for ways to support coding and CDI professionals and keep morale up during the transition.

3. Provide ongoing education and feedback

Keep the lines of communication open across your organization in the weeks and months following ICD-10 implementation. In addition to physicians, coding and CDI professionals will need ongoing education and feedback as they adjust to the changes. As coders begin coding the whole spectrum of real-world medical records in ICD-10, they will encounter unfamiliar situations where advice is needed. Even experienced coders may come to different conclusions when coding complex cases. Create a process for resolving these differences, and once resolved, establish standard guidelines for your institution to help coders address these complex coding scenarios in the future.

When coding guidelines are updated, inform coders, CDI professionals, and physicians as quickly as possible. Creative ways to disseminate need-to-know information can be employed such as a daily huddle with staff, email alerts, one-on-one physician consultations, or posting to a VPN or SharePoint site.

4. Remediate

Beginning in mid to late October, hospitals and health systems will start to see claims come back, particularly from Medicare. Monitor denied claims closely to identify coding errors and potential documentation gaps, and then take appropriate corrective action. A careful review will help determine where more education is needed – with coders, CDI specialists, and with physicians.

5. Monitor KPIs

Organizations should closely monitor key performance indicators (KPIs) post go-live. The following metrics need to be evaluated daily and shared across the revenue cycle (finance, billing, patient registration, HIM, and CDI teams) along with the medical staff office/CMO, those responsible for quality and public reporting, and with your organization’s top leadership:

  • Days not final billed (DNFB)
  • A/R days
  • Financial impact on MS-DRGs and APR DRGs
  • Coder productivity metrics
  • Coding quality
  • Denials

Monitor case mix and review high-volume diagnosis-related groups (DRGs). Look for the root cause of any change, as it may be a sign of something gone awry with ICD-10 code assignment. For example, DRG shifts, both positive and negative, should be investigated to determine the cause. Another indicator to watch is a decrease in patients’ Hierarchical Condition Categories (HCC) scores that could be related to something as simple as a physician not understanding the new etiology and manifestation combinations for diabetes mellitus and resultant target organ disease.

Close attention should also be paid to publicly reported quality and outcomes data, especially since ICD-10 codes for hospital-acquired conditions (HACs) and patient safety indicators (PSIs) have increased in specificity with new documentation requirements. Work closely with your quality and public reporting teams to make sure they understand the ICD-10 codes and the corresponding documentation that drives this data.

Proactive and frequent data monitoring will ensure your ICD-10 transition is on track and any problem areas are addressed immediately.

Through complete and accurate capture of the patient’s experience in both documentation and coding, ICD-10 will promote more accurate reimbursement, and allow for a more precise assessment of quality and better disease management. Given a change of this magnitude, there will be challenges, but with careful planning and the right resources, healthcare organizations can achieve and sustain ICD-10 success in the weeks and months ahead.

CMS releases ICD-10 claim denial numbers

By Chad Michael Van Alstin, Features Editor

Just over 10 percent of claims filed since the implementation of ICD-10 on Oct. 1 have been denied, the Centers for Medicare & Medicaid Services reported on Oct. 29.

Of the 10 percent, 2 percent were reportedly rejected as a result of incomplete or invalid information, with 0.09 percent being denied due to the use of invalid ICD-10 codes.

The metric for claim denials is based on “end-to-end testing conducted in 2015,” CMS notes on its factsheet. According to what’s published, there have been an average of 4.6 million total claims submitted per day since Oct. 1.

This is the first metric on progress to be released by CMS since the ICD-10 launch, though more accurate numbers are expected to be released before the end of the year, after more claims are processed.

“CMS has been carefully monitoring the transition and is pleased to report that claims are processing normally,” the organization states on its website.

Also worth noting, 0.11 percent of claims were reportedly rejected due to improper ICD-9 coding. In an effort to ease the transition process, CMS has previously stated they would not deny claims coded in the correct ICD-10 family.


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