Panel Recap: Operationalizing ICD-10: It’s October 1, 2015… Now What?

Phil CartagenaA discussion on this topic was held on Wednesday at HIMSS15 by ICD-10 Task Force members Jon Melling, Betty Gomez, and myself. Its purpose was to emphasize the point that the effort to make the transition a reality needs to extend to activities beyond October 1, 2015.  Preparation and an eye toward efficiencies now will make living in an ICD-10 world much more manageable for organizations.

For at least 3-6 months prior to October, organizations should focus on laying the groundwork by asking the right questions, like:

  • What is your current understanding of your pending and denied claims status?
  • Do you have the right reports to understand your claims status—by payer, physician and diagnosis/procedure?
  • How will the transition from ICD-9 to ICD-10 coding affect your internal and external reporting for things such as disease management, HEDIS and pay-for-performance?
  • Do you have a process for monitoring performance? 

More than asking the right questions, you need to determine the necessity of the following actions:

  • Reduce pending claims, denials, or other processing backlogs.
  • Evaluate your process for monitoring performance.
  • Identify key metrics to measure/monitor for at least 90 days before/after October 1.
  • Organize reporting channels and identify decision-makers.
  • Develop benchmarks for success, of concern and for all-hands-on-deck!

Based on the organizational efficiencies gained and other metrics collected prior to the transition, organizations should spend at least 3-6 months after October 1, 2015 considering potential operational, clinical and financial impacts and implement mitigation strategies.

If your organization does not currently have a handle on key operational metrics, it is imperative that – prior to the ICD-10 deadline – you:

  • Ensure the quality and completeness of clinical documentation of patient encounters.
  • Recognize key operational metrics that require ongoing monitoring, like:
    • Daily time allocation to non-coding activities
    • Cases coded by coder/hour
    • Cases coded by specialty/hour
    • Coding accuracy rate

While clinical reporting will require staff to be proficient at selecting the most specific and appropriate ICD-10 codes, the following clinical realities should be considered:

  • Increased detail in patient documentation offers the opportunity of more in-depth understanding of a patient’s overall medical condition.
  • Factors that may not have been identified in prior, less detailed documentation may now be identifiable and documentable.
  • Requests for prior authorizations will benefit from the additional details as well.
  • Quality and safety reporting should not materially change after systems are updated with information from CMS, NCQA, AHRQ and other quality and/or safety standards organizations.

Lastly, it is important for organizations to consider key financial metrics that allow you to “keep the lights on,” like:

  • 80/20 payer analysis
  • A/R days by payer
  • Cash flow
  • Denial statistics including: numbers & percentages for various time periods overall and by coder with reason codes

Here are some questions from the audience and the responses given:

  • For prior authorizations, if a patient gets an authorization in July for a procedure after October 1, what should happen? The authorization SHOULD be coded using ICD-10 given the procedure will take place after October 1.  Payers should be able to accept that as such. It doesn’t hurt to make this a scenario that is tested, or at least confirmed, with your payers as implementations may vary and you want to be aware of potential variations.
  • What do you do if you cannot get payers to test with you? You can attempt to be a squeaky wheel to try and get your key scenarios tested. If you use a clearinghouse, work with them to get those key scenarios tested.  Failing either of those, you are entitled to the results of testing so that you can ensure your systems produce the expected output and so that you can learn from those results. 
  • Is there a way to leverage/benefit from RACs audits? There is valuable information learned during those audits and your organization should make an effort to capture and maintain the knowledge in the event of turnover.  The adjudication of under and overpayments in those audits provide information on the level of documentation that supports certain claims and this can reinforce the message to clinicians regarding the need for more complete documentation.

F. Phil Cartagena Jr. is a terminologist and leads an ICD-10 effort for the Enterprise Clinical Informatics & Infrastructure Services group at Partners Healthcare System, Inc. (PHS) to provide the PHS community with web services. Phil has over 20 years of experience in program management, business process redesign and technology implementations. Phil has a BA in computer science from Harvard University, an MBA from Columbia Business School and certifications from PMI, HL7 and HIMSS. He is also an adjunct Professor at Boston University and is a member of the HIMSS CPHIMS Technical Committee.