How confident are you in having ICD-10 success?
You have done your upgrades, added Computer Assisted Coding (CAC), conducted internal and payer testing, conducted physician and coder training, communicated every step throughout your organization so everyone is aware of the activities and their part, but how do you know that means you are going to have success with ICD-10? Successful completion of each of these areas in and of themselves does not guarantee you will submit clean claims and get paid timely. I liken these activities to building an application, testing that application in the lab but never testing it in real life scenarios.
Like most enterprise efforts in healthcare, ICD-10 success is dependent on life cycle planning, operational strategy integration, as well as, testing and remediation. Benchmarks and results based on overall strategies rather than individual component success is a much truer indication of the likelihood of success, however, that still doesn’t guarantee success. In our client engagements, Adept works hard to drive process improvement and enhance performance excellence. While these process advancements are substantiated through life cycle testing, we have concluded that numerous uncertainties still remain.
Our ICD-10 Program was built to ensure not just achieving success with the critical success factors but also validating these concerns are addressed or have processes in place to address as they are uncovered once ICD-10 does finally arrive. As with anything, it’s best to plan for the unexpected. An ability to react and adjust is just as critical as proactive planning and improvements.
Remediation planning is a core part of the ICD-10 program we have built as it creates mechanisms to make adjustments to the overall ICD-10 life-cycle once you go live with ICD-10.
Here are some questions to ask yourself;
- Are you certain your CDI efforts deliver patient documentation as needed for the specificity of ICD-10 and is it aligned with ICD-10 approaches?
- Have you reviewed and adjusted your coding documentation requirements based on specificity requirements to code for ICD-10?
- What payer variations were not accounted for and how do you handle those?
- How do you approach CAC inconsistencies or manual coding inconsistencies?
- What is your strategy to improve denial management impacts that weren’t expected?
ICD-10 is really a comprehensive program, a series of initiatives that touch most major areas of healthcare. It is not just an IT or revenue cycle initiative. There are components critical to the life-cycle process which impact results for other downstream parts. At Adept, we have developed a lean process tool, called 100 Day Waves, which allow us to do fast-track assessments to determine where exactly a client is with the critical path components of ICD-10. It will tell you if you are achieving your expected results or if a particular area is not expected to produce and thus may result in issues or problems in your overall strategy for ICD-10. We recommend every organization do these type of assessment to ensure you are achieving success across the entirety of ICD-10. Some examples may be, how many remediation’s do you have from payer testing? How many quality ICD-10 codes are you generating, from each specialty area and are you meeting quality coding thresholds? What are your productivity standards for coding and how have you validated those?
Here are some particular considerations to keep in mind as you evaluate the probability of your ICD-10 success;
There are two primary parts to payer testing, functional and native coding. Functional testing is about ensuring you can submit a claim to your clearinghouse or directly to the payer and getting a claim back and it processing without issue. The second is where testing becomes critical.
- Functional – Determines provider and payer can submit electronic claims between each other (835/837 claims). Most providers submit x12 format claims to clearinghouse’s who generate the 837 claim format. Payer responds with 835 claims.
- Native coding validation – Provider submits high risk and high volume claims which are analyzed by payer so payer can provide feedback on code interpretation. A provider organization should take these and identify process variations and modify their processes to accommodate these variations.
Most organizations use GEMS for crosswalks which is a huge benefit, however, each payer and provider organization then customizes and interprets these differently. This is where native code testing helps to identify these variations. The challenge is that the provider needs to capture these variations and determine a means to communicate with the coders when coding claims for that payer. In some cases remediation’s can be done to the system as they may impact all payers but the bulk of these really are payer specific. This means some vehicle needs to be developed or identified which can alert and notify a coder before coding or at the very least alert and notify during CDI review depending on the nature of the variation.
There are 4 major approaches to addressing the ICD-10 coding challenge. Most organizations use a variation of these different approaches;
- Adopt technology and functionality within systems to define and select appropriate ICD-10 codes
- Adopt technology and functionality to allow physicians to select and code ICD-10 codes
- Train physicians to code during patient activities
- Train coders to natively code in ICD-10
Whether your organization is utilizing technologies to improve proficiencies in coding or heavy training and having physicians and coders bear that burden, the bottom line is the organization needs to have a strategy that is aligned with how HIM and coders plan to operate. Providing a sandbox (test system designed to allow the coders to get familiar with new systems and functionality will help. Dual or double coding sometimes helps mitigate this but it doesn’t allow for adjustments and tweaks as much as most are done in production capacity.
One key is to ensure your approaches to ICD-10 coding fit in real-time. In example; I have noticed many organizations doing heavy coder training for ICD-10 and then rely on them to get familiar through limited dual coding. If your organization uses Epic, this is somewhat self-defeating as the Epic tools are designed for the physician to select the code and the coders to validate the code. The focus needs to be on validating as many 1-1 coding scenarios to streamline validation for those and focusing training on more complex coding scenarios.
Computer Assisted Coding (CAC)
CAC systems are an impressive tool and can really be beneficial, especially with automating the 1-1 scenarios we mentioned above. However, many organizations don’t realize these systems are not out of the box solutions. They require significant planning and coordination. As with any system it carries the garbage in, garbage out philosophy. It is not as simple as send documents to the system and you’ll get quality codes and deliver to the productivity standards as defined by the vendor. Document types, formats, source system versus system of record (preliminary versus final) all require careful consideration as they impact the output. CDI alignment is a huge impact as well. These systems are not stand alone systems and should be considered in the life-cycle of coding just as ICD-10 is. Sure you may get 120 Radiology codes per hour but can your CDI reviewers handle that volume? Have the adjustments for payer variations been built into it? Fine tuning and other activities need to be planned as getting quality coding standards consistently doesn’t just happen. So yes, CAC is a great tool but needs to be planned carefully with continued maintenance to ensure overall success.
The bottom line is there are numerous touch points within ICD-10. Any one issues or area not addressed can have a daisy chain affect and impact the entire process and success of ICD-10. All of the testing available can’t account for real world challenges that weren’t identified or undervalued during planning. So ask yourself, before pushing off ICD-10 activities, are you really confident your organization is ready?
I recognize there are different approaches and priorities for any strategic initiative and welcome comments and suggestions to further educate and provide insight to all. Please comment here as well as in the discussions for this post. Thank you, I look forward to hearing your thoughts.
Adept Healthcare is a Healthcare Managerial & Solutions Consulting Group that specializes in Clinical, Revenue Cycle, and IT. We have knowledge & thought leaders who help our clients develop plans and strategies to integrate and improve. We support operational performance, leverage IT investments, improve patient care tools and governance standards and to achieve strategic goals through change management, program and PMO development, operational performance and performance excellence.