Claims and Coding
The switch from ICD-9 to ICD-10
How to reduce claims and coding errors
As the healthcare industry undergoes conversion from about 17,000 ICD-9 codes to more than 155,000 ICD-10 codes on Oct. 1, 2013, we asked our panel of experts the following question:As we continue transitioning to ICD-10, what are the best ways to reduce claims and coding errors?
Increased specificity makes accurate documentation critical
Garri Garrison, director, consulting services,
3M Health Information Systems
ICD-10 brings a dramatic increase in the number of codes, from about 17,000 today to more than 140,000, which allows for a much greater level of specificity in coded patient data. This increased code specificity makes accurate clinical documentation critical to achieving accurate coding and billing.
Physicians are already challenged to meet documentation requirements under ICD-9, so focusing on clinical documentation improvement (CDI) early in the ICD-10 transition process is important for success. Not only is it essential because of the time needed to educate physicians in ICD-10's complexity, but also because of the potential impact on revenue from incomplete or inaccurate documentation.
Establishing a CDI program with concurrent documentation review helps verify that a patient's complete clinical status is accurately captured in the medical record, which leads to more precise coding and billing. Software tools and services are available to help educate physicians, and to assist coders and documentation specialists in querying physicians for more information. Implementing these tools now helps physicians understand how to document for ICD-10 well in advance of the 2013 deadline.
To help coders become efficient in ICD-10 coding, many hospitals are relying on computer-assisted coding (CAC) technology. CAC can speed documentation review and help coders quickly identify missing or incomplete information in the patient record. Implementing CAC now can help offset productivity losses with ICD-10.
ICD-10 could turn revenue cycle management upside down
The SSI Group
The best ways to protect the revenue cycle and ensure proper payments start in patient access. Correct coding, medical necessity and all the other aspects of capturing information on the front end will be profoundly expanded once the industry transitions to ICD-10. Collection of co-pays, deductibles and patient payments will be greatly complicated; therefore, providers will need to ensure their systems have the capacity to analyze expected procedures to the payer contracts in order that informed decisions can be made prior to the rendering of care.
Secondly, claims-processing systems will be of vital importance to ensure proper ICD-10 codes have been captured and to ensure all applicable codes are included in the electronic claims transactions. Further, these systems should have the capacity to calculate expected reimbursement to empower the providers with the tools to accurately forecast revenue. In addition, systems should include functionality to track utilization of the ICD-10 codes to ensure proper documentation is available to substantiate billed procedures.
Lastly, the electronic remittance and contract management systems will play a vital role in determining whether proper payments to the providers have been made.
So to sum up, patient access benefit verification and utilization systems, documentation, contract management, claims management, remittance processing and analytical systems are the keys to protecting the revenue cycle.
There are two reasons mistakes happen
director of services, product management,
The TriZetto Group
Claims and coding errors occur for two general but distinct reasons: 1) information about the claim is missing or inconsistent; or 2) the indicated diagnosis and procedural codes are inappropriate for the type and level of care.
In the first case, there are systematic and largely automated ways of confirming that a claim record is compliant with standards established for required data present (i.e., date of birth is present) and that the data is consistent (i.e., the zip codes match the state references). The second case presents a larger challenge and is likely to be a significant source of errors as a health plan transitions its systems to ICD-10.
There are three key steps to mitigate a substantial increase in claims and coding errors from inappropriate or incorrect ICD-10 codes:
Step 1: Collaborate and communicate. Payers and providers should invest now in training and certification programs for medical coding staff, nurse resources, CMOs and other healthcare professionals who will assign or evaluate ICD diagnosis and procedure codes.
Step 2: Determine your codes. As soon as possible, both payers and providers should begin evaluating the relationships between the ICD-9 codes in use today and the medically equivalent ICD-10 codes to be adopted.
Step 3: Test early and often to validate that both the payers' and providers' ICD-10 code usage is consistent with clinical accuracy and medical policy regarding benefits and treatment coverage.
Successful ICD-10 transition requires planning and collaboration
ICD-10 is coming — and while it will surely offer advantages, it's going to big and expensive, and there are going to be problems. So here are some tips for helping your organization to get ready.
? Evaluate all your systems to ensure that you're prepared for the changes. Any place an ICD-9 code is displayed or utilized is a potential point for change. Billing systems are obvious — but there are places throughout your major HIS systems and your niche products that use the current ICD-9 coding nomenclature and rules.
? This is a group activity. There's no one person who will be able to do everything. We share responsibility as vendors and providers for ensuring that we understand the codes that document care and then charge appropriately. Your vendors want your help in making this as foolproof as possible.
? There are many great resources and practice tools available from CMS and others. Use those tools now, examine the mapping templates and ensure you're familiar with the new structure.
Anything you can do to get ahead of the curve is a good thing. Using appropriate automated tools that are available and mapped today to ICD-10 takes the mystery out of many of the changes. Knowing that your vendors are already prepared to support the structure, volume and code edits that you need them to handle will make the process seamless in the end and allow you time to build out the changes now.
Key to reducing errors is education
VP, strategic planning,
Education is the best way to reduce coding and billing errors as we transition to ICD-10. I'm certainly not the first to talk about the importance of education, which is admittedly a very broad and general term. The key will be breaking that broad focus on education into a few distinct, manageable goals.
Right now, practices should be assessing the new ICD-10 code sets. There are a number of resources that map out how ICD-9 will "translate" to ICD-10. Although these conversion maps are not 1:1, they still provide solid educational opportunities. Providers and coders alike can see what the new ICD-10 codes look like, how they are different from current ICD-9 codes and how coding and documentation will need to change come Oct. 1, 2013.
Once providers and coders understand the new codes, they then must educate themselves about their own practice's coding patterns. It will be essential to understand the top 10-20 diagnosis codes billed — or at least those diagnoses that account for the largest percentage of practice revenue. Drill down into the particulars of those codes; become familiar with what the conversion will entail for those specific codes. Failure to do this successfully will create serious risk for revenue-cycle disruption.
Additionally, practices should vigilantly monitor key office metrics. Develop benchmarks and then monitor each metric by provider and payer to ensure reimbursement does not dip as the nation switches over to ICD-10.
While these pieces of advice are not comprehensive by any means, they provide a starting point for practices to ensure that revenue cycles remain steady.
Control the accuracy of coding where it matters
While the specificity of ICD-10 codes promises to improve clinical accuracy, speed, payment cycles and streamline utilization management, realizing these benefits will require a deliberate effort to control the accuracy of coding where it matters: at the point of code entry.
Traditionally, the root cause of coding errors has been the interpretation made by administrative staff based on encounter documentation provided by the clinician. The clinician does not describe the diagnosis or the procedures in a consistent manner, leaving it up to the staff, with varying levels of experience, to determine the appropriate diagnosis code. The translation of diagnosis as described in the exam room to a code goes through at least three discrete steps and many users/systems, introducing errors along the way. This workflow process is complicated by the changed ICD-10 code sets.
One approach to eliminate the inaccuracies and inefficiency is to eliminate the need to translate and re-key these codes in the clinical workplace. To do so, physicians should consider the use of smart/simple data-intake technology on a mobile device in the exam room. Using mobile technology will ensure that the physician can actually enter the codes in the visit notes. Use of various contextual validation aids — such as medical necessity relationships between the problem statements, diagnosis and procedures — can simplify the selection of codes by physicians.
Correct coding begins with thorough documentation
senior healthcare business consultant,
Correct coding begins with thorough documentation, well before the transition to ICD-10. With the increased code granularity in ICD-10, it's imperative that providers begin documenting details from each patient encounter so that transactions can be coded accurately.
In addition, all healthcare organizations need to understand both the differences between and the relationships among the ICD-9 and ICD-10 code sets. In reviewing more than half a billion ICD-9 codes in healthcare claim transactions, we know that more than 30 percent have complex relationships in ICD-10; meaning it's not a one-to-one conversion. From a health plan perspective, accurate and thorough knowledge of the differences between ICD-9 and ICD-10 codes will enable the health plan to accurately update its policies to reflect ICD-10 and to remediate its systems.
The key for both providers and health plans is using tools that assist in analyzing and comprehending these differences. Codebooks are always helpful, but more advanced software tools can go beyond what codebooks provide. Comparing the medical concepts that apply in an ICD-9 code to the medical concepts that apply in an ICD-10 code set provides the capability to determine which specific codes in ICD-10 are appropriate.
Due to the vast increase in the volume of codes available in ICD-10, a successful and timely implementation will largely be dependent upon an entity's ability to prioritize and streamline its work.
Need to evaluate CAC systems
VP of technology,
A-Life Medical (now part of Ingenix)
It's no question that coding in the ICD-10 world will be nearly impossible without computer-assisted coding (CAC) — there aren't enough coders in the world to support and maintain a manual coding process for 155,000 codes. Providers need to closely evaluate CAC systems with an understanding that coding accuracy and consistency can vary widely based on the natural language processing (NLP) technology that powers it. In addition, because one of the biggest obstacles for health systems is consistency of coding across inpatient and outpatient settings, hospitals need to implement CAC systems that can support all venues of care — inpatient, outpatient and even professional — to save time, improve revenue integrity and ensure compliance.
Coders will still very much be part of the process, but their lives are going to change dramatically. The use of CAC solutions will elevate the role of the coder to a reviewer or auditor, increasing the overall productivity and accuracy of the coding process. Bringing coders into the process as early as possible, rather than waiting until ICD-10 is imminent, will ease the transition, promote proper training and reduced errors, and provide financial stability for organizations in the long run.
October 2013 may seem far off, but ICD-10 should be a major concern for every hospital CIO now. While every hospital has a number of IT projects currently underway, providers need to prioritize the projects that will ensure profitability and return on investment — and with ICD-10 driving every hospital's reimbursement and financial future, they can't afford to wait.
Key is remediation
As we move from the 17,000 ICD-9 diagnosis and procedure codes to the 155,000+ ICD-10 codes, every system that uses these codes will need to be remediated. Similar to the challenges that organizations faced when addressing Y2K, the longer ICD-10 codes will require, in many cases, significant database changes, data migrations and modifications to numerous interfaces that are used to move data between various internal and external systems.
To help reduce claim and coding errors and ensure a smooth migration to the new standard, payers should employ the following strategies when transitioning to ICD-10:
? Start by training key business users and technical staff so they understand the differences between ICD-9 and ICD-10. This will allow people to be more proactive and make better decisions and recommendations related to both system remediation and how the organization can best leverage the new codes.
? Put a staged remediation plan in place that will allow the organization to design, build, test and roll out smaller changes over time, rather than address the entire effort all at once. This will help to ensure a more orderly transition to ICD-10, and it will help to avoid business and resource collisions.
? Evaluate all of the interfaces that exist between internal and external systems, healthcare data exchanges and partner networks. People often forget these during remediation planning, and are surprised by them later.
With a little planning, payers can enjoy the significant benefits of ICD-10 and ensure a smooth transition to this important new standard.
Must have detailed contracting arrangements
chief solutions architect, healthcare and life sciences,
ICD-10 will have a significant impact across the payer and provider food chain, not only limited to direct impact points, such as revenue cycle management (RCM), but also business areas, such as medical policy management, benefit design and provider contracting.
The most important requirement for reduction and elimination of coding and claim processing errors is for payers and providers to have established detailed contracting arrangements for each single diagnosis-related grouping (DRG) corresponding to new ICD-10 codes. It is a task easier said than done and will require some prior research by both sides to figure out the impact.
Payers are already working on analyzing their historical claims to figure out the high-value payout categories. It is absolutely essential for payers to use some kind of a modeling tool that leverages the historical claims data to predict the impact on payouts with ICD-10. Some of the models available in the market are sophisticated enough to allow multiple types of slicing and dicing of data against a variety of DRG-ICD combinations to throw out invalid combinations, establish primary and secondary code dependencies, and allow end users to create trial scenarios to test out their baseline assumptions. The actuarial staff can also use these modeling tools to establish new benefit design guidelines for the ICD-10 world. Providers must also use similar kinds of modeling tools to establish the proper reimbursement rates for each new code.
Once both sides are done with proper models, based on their high-value payouts (in the case of payers) and areas of specialty (in case of the providers), it will behoove both parties to establish new contracts lest there be any confusion regarding the amounts being paid out. The establishing of these new contracts will go a long way towards future reduction of coding and processing errors.
Mobile solutions are important
CEO and founder,
Today's healthcare organizations are increasingly turning to the use of mobile solutions in their transition to ICD-10, particularly those built on coding expertise. Healthcare organizations can use mobile devices to help reduce claims and coding errors by implementing frequent charge sets for services rendered throughout healthcare facilities in a way that empowers care providers to capture and deliver valid ICD-10 charges from their mobile device of choice. The same content and coding knowledge leveraged for frequent charge sets can also be utilized to create ICD-10 charges from dictations captured during the patient encounter in a mobile environment. From these mobile solutions, healthcare organizations can more easily transition to ICD-10 by submitting complete and valid charge claims that originate from the point of care. All of this is accomplished without the need for physicians to be trained on the intricate details and magnitude of newly created charge codes that will be forthcoming with ICD-10.
Whole practice must embrace the challenge
The transition to ICD-10-CM is not just a problem for software vendors. I recommend that you:
? Designate an internal staff member, a physician, a small committee or a temporary outside consultant to rally staff and spearhead ICD-10 until it is up and running.
? Schedule training for everyone, including an average of 16 hours for certified coders; the AAPC, AHIMA and ACMCS Web sites are the best sources of online education.
? Locate every piece of paperwork — internal and external — that includes ICD-9 codes and prepare to say goodbye to the "super bill" and other "cheat sheets" and "encounter sheets," which lack the specificity for more granular ICD-10. Maintain old records containing ICD-9 codes for historical purposes and to resolve old claims.
? Streamline all work processes; consider implementing an EHR.
? Schedule downtime for updating hardware and software.
? Analyze your payer mix, factoring the percentage of delinquent payers and set aside in escrow.
Important to identify early opportunities to optimize systems
AVP and partner,
Cognizant Business Consulting
The conversion to ICD-10-CM is more than a simple update; it will bring fundamental structural changes spanning the entire healthcare delivery system. Throughout this transition, the best ways to reduce claims and coding errors will be through early and comprehensive transition planning; effective code mapping and conversion strategies informed by sophisticated analytics designed to achieve financial, benefit and clinical neutrality and equivalence; thorough end-to-end testing; and training.
How effectively and completely payers and providers perform these critical functions will determine to what extent cost benefits outweigh cost liabilities — and how quickly. It will be important to identify early opportunities to optimize systems and processes to minimize claims and coding errors, and to derive real business value from the new codes. Organizations that plan, analyze, test and train effectively will be best positioned to go beyond mere neutralization strategies and adopt a speed-to-value approach that will improve productivity through better claim auto-adjudication and first-pass rates; increase claim payment and provider reimbursement accuracy; reduce miscoded, improper or rejected claims; automate authorizations and referrals for a significantly larger set of procedures; assess risk, profile patient status and manage length of stay through more informed utilization management; and improve revenue cycle performance through enhanced outcomes management and proactively monitoring key indicators.
Viewing the transition as just another IT project will be a lost opportunity to achieve competitive advantage, reveal process improvements and drive value.
Best approach will start with an impact assessment
founder and president,
Culbert Healthcare Solutions
The best approach will start with an impact assessment before planning, implementation and optimization efforts occur. The assessment should include an inventory of all related clinical and business functions and the IT applications that support them.
After the impact assessment, organizations must undertake separate functional and vendor readiness assessments. With the exception of those using home-grown IT solutions, most groups will need to rely on IT vendors for ICD-10 updates. Do not underestimate the time and effort vendor coordination and testing will entail; it may well be the most challenging aspect of the transition. Develop a testing schedule with payers and/or vendors for each type of EDI transaction before the Oct. 1, 2013 compliance date to ensure that they all process smoothly.
When it comes to billing compliance and coding errors, however, physician documentation and coding training will be key. The training itself should be performed in the months leading up to go-live, but at implementation organizations should plan to conduct real-time monitoring of clinical documentation, coding productivity, claim edits, claim denials and more.
Tracking performance metrics throughout implementation will be central to identifying and curtailing claims problems, coding errors and a number of other potential issues. Metrics also provide an opportunity to go beyond mere implementation. They should act as a catalyst driving the additional training, workflow redesign and system modifications that can help optimize claims and coding performance going forward.
Education, training and support are keys to avoiding coding errors
Steve Sabino, president,
DST Health Solutions
Although payers face challenges in transitioning to ICD-10, they can overcome them through education, training and support, scenario-based thinking and investment in newly available technologies.
Providers must learn how to select from among an escalating number of increasingly granular diagnoses to receive accurate, timely reimbursement. Because ICD-9 offers three codes for angioplasty and ICD-10 offers 1,098, cardiologists, for example, must focus on their most frequently used codes. But each physician, no matter what his or her specialty, must work from an expanded set of clinical notes to isolate the most appropriate diagnoses and express clinical intent.
By reviewing potential scenarios, payers can ensure they won't pay $16,000 for a service they previously paid only $10,000 for under ICD-9.
GEMs are already guiding payers on appropriate provider reimbursement. As an alternative, payers can invest in technologies that identify dominant ICD-9 codes based on claims analysis, as well as those at greatest risk for improper interpretation within ICD-10.
Payers should use this time of transition to evaluate how the structures and processes of ICD-9 compare with the purpose, design and anticipated results of ICD-10.
Create an acceptance test that defines the expected outcome
Healthcare Productivity Automation
In software, test-driven development (TDD) is among the most reliable rapid development methodologies.
This strategy is easily adapted to help in the transition to ICD-10 and can help to significantly reduce coding errors. While many ICD-9 /ICD-10 codes map cleanly, the combination of ambiguous mappings and reimbursement types is more likely to result in errors. For these scenarios, create an acceptance test that defines your expected reimbursement outcome. In order to pass this test it will take a combination of finding the correct mapping and working with internal and external stakeholders to have results that can be compared to the test.
What's noticeably different about this approach is that it makes the time-consuming planning and analysis project phase more outcome-centric. A project team has the least amount of experience at the very beginning of a conversion project and yet ironically this is precisely when they are expected to plot out a successful road map. A TDD approach focuses the project team solely on the intended outcome and quickly immerses them in the more complex implementation component of the project. It further limits the scope to bare minimum requirements needed to achieve success, circumventing debilitating analysis-paralysis that often occurs during significant large-scale change.
Education will remove barriers to ICD-10 success
director of revenue cycle, coding and compliance,
The need for ICD-10 training is urgent, but providers may not be up to speed. Seventy-one percent of providers have formed an ICD-10 task force, although only half have invested in staff training, according to a survey of U.S. hospitals by J. A. Thomas & Associates. Three-quarters of respondents point to physician buy-in and training as the most significant challenge, with slightly more than 70 percent citing a need for in-house and external ICD-10 program training. Providers can ease ICD-10 education by following these steps:
? Identify the unique learning needs of stakeholders. Conduct focus groups, surveys and meetings to discern healthcare professionals' needs, priorities and reservations.
? Make education and training an ongoing process and daily event.
? Monitor coding accuracy and productivity. Develop tracking mechanisms to identify professionals' coding speed, efficiency and accuracy. Develop training experiences to fill productivity gaps.
? Engage in open communication with payers. Evaluate payer readiness.
? Estimate the impact of ICD-10. Conduct an evaluation of your case mix and top MS-DRG payments and then map to ICD-10.
? Identify workflow improvements.