Hospital Information Systems
Countdown to ICD-10: Are you ready?
By Katie Carolan, February 2011
You should be assertive, if not aggressive, in pursuing vendors for ICD-10 plans.
The warning signs are blaring. The universe of articles, Webinars, conferences and consultants is expanding. Yes, ICD-10 is here to stay. And if the experience of the international community is any indicator, healthcare providers should be bracing themselves for a monumental event, requiring herculean effort.
To get started, CIOs should take a look at where ICD-10 has been used for the past five to 10 years and absorb the international lessons learned:
1. It will take longer than you think.
2. It will cost more than you budget.
3. You will miss some important areas to upgrade.
Lastly and perhaps most importantly, providers should have started the process long ago.
Y2K vs. ICD-10: 13 years and 124,000 codes
Many have touted the ICD-9 to ICD-10 conversion as similar to Y2K. Considerable preparation, testing, working with vendors and go-live anxiety was the order of the day for Y2K. Yet, it was much ado about nothing. The transition to ICD-10 will be a much different experience. Y2K involved primarily systems technology, while ICD-10 goes beyond technology to involve workflow changes, policy and procedure changes, screen and report format changes, data conversion, education, training and more. Specific areas of concern include:
• 16,000 codes converted to 154,000 codes and vice-versa.
• It's a nationwide, single-day, big-bang approach.
• Most of the change will occur in health-information management (HIM) and information technology (IT).
• Physician documentation must be more specific and granular.
• Wide breadth of systems will be impacted, primary and downstream.
• All system interfaces must be tested and potentially updated.
• Mapping and crosswalks will be used as a short-term bridge.
On Oct. 1, 2013, nearly 16,000 1CD-9 codes must convert to more than 154,000 ICD-10 codes (or vice-versa) in a multitude of systems. Furthermore, ICD-9 coded diagnosis and procedure information must be converted to ICD-10 for any type of clinical decision support, reporting or longitudinal studies.
For HIM departments, the transition will be a huge change. CIOs must work very closely with HIM and align their teams accordingly. The integration of ICD-10 codes into the revenue cycle is another important area for careful analysis.
Failure to successfully convert will result in failed claims and halted cash flow. All Medicare billing for discharges on or after Oct. 1, 2013 will be ICD-10 based. Sept. 30, 2013 discharges are ICD-9 based. Think about the billing, revenue-claims adjudication and accounts-receivable issues involved with a single-day, big-bang go-live event — and one easily understands the enormity of the task at hand.
ICD- 10 ASSESSMENT:
INVENTORY OF SYSTEMS*
Claim Submission Systems
Compliance Checking Systems
National and Local Coverage
Disease Management Registries/
State Reporting Systems
Patient Assessment Data
Aggregate Data Reporting
Managed Care Reporting
Case Mix Systems
Medical Necessity Edits
Test Ordering Systems
Clinical Reminder Systems
Medical Necessity Software
Disease Management Systems
Decision Support Systems
Internal Home Grown:
Systems and Customizations
*Suggested systems for evaluation. Exact list of systems varies by organization.
Last, and certainly not least, ICD-10 will require the involvement of physicians. Physician documentation must become more specific and granular to accommodate ICD-10 coding. Failure to train physicians on documentation and terminology specificity requirements now will result in great frustration down the road. Under ICD-10, inaccurate and incomplete physician documentation will not suffice, and coders will be forced to relentlessly query physicians for additional information.
From a systems perspective, there are three major problems associated with the conversion from ICD-9 to ICD-10. Number one is the breadth of systems requiring upgrade or replacement. Number two is the issue of interfaces. Number three is the issue of mapping I-9 to I-10 and I-10 to I-9 and building a crosswalk between them.
CIOs must assess all technology now
Essentially, every system in the institution needs to be part of the ICD-10 assessment and should be evaluated now. There is evidence to suggest that many organizations have systems in place that CIOs are not responsible for, and in fact may not know about. These, primarily clinical, systems often capture, share and/or store codes; and, further, they send this information to billing and EHR systems. The assessment and potential replacement or upgrade of these downstream systems is an enormous undertaking and is in addition to the work needed on the institutions' primary applications (see Table). Finally, interfaces between and among systems must also be updated to accommodate ICD-10.
Many vendors are sitting back, waiting for hospitals to come to them and tell them what is needed. Do not assume your vendors will be ready and that your current version of software will comply. Organizations should be assertive, if not aggressive, in pursuing vendors' ICD-10 plans. Questions to ask include:
• Which version of the software will be ICD-10 ready?
• What is the timeline for general availability of this version?
• What will be the cost to upgrade current systems, if any?
• What are the ongoing costs (upgrades and support) for the new version?
If upgrade or new support costs are substantial enough, 2011 may be an ideal time to consider changing systems. Benefits of new applications include software designed with ICD-10 in mind and ongoing support for the ICD-10 version. Furthermore, vendors should provide working systems well ahead of the 2013 deadline. Having a full test environment available with vendor support on hand is best practice. Finally, organizations will need dual processing capabilities for quite some time; ICD-9 processing and ICD-10 processing will have to coexist.
And CIOs should not forget the need for hardware upgrades (such as servers, workstations and clinical monitors). With good planning, costs can be spread over three to four years, minimizing the financial impact of new capital investments.
Interfaces: The Achilles heel of ICD-10
System interfaces could be the Achilles heel in an otherwise successful ICD-10 conversion. Testing all interfaces in both directions is a critical step in the process. Interface issues are fraught with finger-pointing possibilities, so a test environment is crucial to dealing with interfaces before go-live. Continued support at go-live is recommended, as hidden problems will arise. It is a good practice to have a fallback plan in case of a go-live failure that requires considerable work to fix.
Understanding crosswalks and GEMS
The third issue is the creation of institution-specific crosswalks between ICD-9 codes and ICD-10 codes in both directions. Crosswalks are a one-to-one mapping that is application and institution specific. There is a free available mapping scheme called general equivalence mappings (GEMS) that organizations can use as a starting point where appropriate.
GEMS are a mapping to "probable" matching codes. These GEMS were created by the CDC and CMS as a general-purpose translation tool to ensure national data consistency post-transition. Since there are many more ICD-10 codes, there will be numerous instances of one-to-many mapping. For example, angioplasty has one ICD-9 code, but 85 ICD-10 codes.
GEMS are available for a limited time (three years) and should be viewed as a short-term starting point for system crosswalks. GEMS are "diamonds" in the rough that need to be cut and polished to meet the needs of each individual organization.
Finally, IT and HIM should be the leaders of the crosswalk-building team. In fact, these two departments must work closely together on the ICD-10 transition for the next three to four years, as mentioned above.
Checking your list … twice
The three issues explored in this article — systems assessment, interfaces and crosswalks — are high-visibility components of the transition; however, they are not meant to represent all the issues to be reckoned with. Education, communication and collaboration are the keys to a successful ICD-10 transition. While it's not yet the time to panic, it is certainly time to aggressively move forward. Let the games begin!
Katie Carolan is vice president of operations, Health Record
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