JUNE 2007 FEATURE ARTICLES

Claims and Coding

Expanding the Code

The methodical switch from ICD-9-CM to ICD-10-CM will bring both challenges and rewards to healthcare.

By George Schwend

With the long-awaited—and for some, feared—conversion to ICD-10-CM and possibly ICD-10-PCS looming in the near future, U.S. healthcare organizations are finally beginning to seriously consider the ramifications of the transition. Unlike the IT-focused Y2K challenge, the move from ICD-9-CM to ICD-10-CM will significantly impact healthcare organizations across numerous departments and functional areas including financial, IT, health information management, coders and clinicians. Detailed organizational assessment, analysis and planning can provide the needed foundation for an efficient, relatively pain-free implementation.

Although naysayers have contributed to the delayed industry and governmental acceptance of the ICD-10- CM conversion, few can argue the increasing need for its speedy deployment. By continuing to use ICD-9-CM—a more than 30-year old coding system—we have limited our ability to accurately capture the current broad spectrum of healthcare conditions and procedures. Additionally, because few unassigned codes remain, new advances in medicine and medical technology often cannot be accommodated.

Although the U.S. has used ICD-10 coding for morbidity data since 1999, we are now the last industrial nation to embrace ICD-10 for disease reporting (ICD-10-CM). Our reluctance to quickly adopt ICD-10-CM has impacted our ability to ensure data compatibility nationally and internationally, thus, shackling our efforts to proactively track and respond to pandemic viruses and bioterrorism threats. SARS, West Nile virus, Mad Cow disease, and bird flu are just a few examples of worldwide health issues that would have benefited from a shared worldwide data classification system based on ICD-10.

Why ICD-10-CM?

ICD-10-CM implementation also supports our national healthcare goals to establish quantitative performance-management metrics, accelerate patient safety initiatives, leverage technology within clinical research, and expand public health programs. Furthermore, the increased specificity of data within ICD-10-CM allows greater capture of needed information for pay-for-performance programs, and enables improved actuarial premium setting, fraud detection, service reimbursement (e.g., fewer claims denials, reduced accounts receivable days) and enhanced cost analysis. The magnification of patient-related data offered through ICD-10-CM will contribute to reduced medical errors while improving research sampling, tracking and trending of patient outcomes and costs.

To realize these benefits, healthcare organizations must address the challenges in multiple areas quickly, effectively and proactively. Health information management will need to encourage and educate coders who might struggle with the new requirements of expanded knowledge of anatomy and medical terminology, understanding of operative reports, and greater levels of cooperation with medical staff.

For example, coders will have to classify data based on ICD-10-CM’s 120,000 alphanumeric diagnosis codes and 2,033 categories, in contrast to the 13,000 alphanumeric diagnosis codes and 855 code categories of ICD-9-CM. As expected, there may be an initial drop in productivity. However, many claim that the augmented code sets will assist coders by providing the ability to accurately capture a diagnosis with a specific code, thereby accelerating the coding process.

In addition to the further education needed for coders, clinicians themselves may need to be apprised of how ICD-10-CM will affect their role in identifying the correct diagnosis and procedural codes. Clinicians may have to add detailed descriptions to their reports, and may need to respond to clarification requests as the coders adjust to this expansion in code sets.

These temporary dips in productivity will negatively impact both the patient financial services (PFS) and the hospital finance departments. The PFS department depends on health information management to supply the data needed for monthly summaries, operation reports and accounts receivable. The hospital finance departments rely on the same information to develop reports used in contract negotiations, resource deployment and cost management.

Implementing the New Codes

From an information systems perspective, the IT staff must ensure that all of the system interfaces that pass the codes through to the UB92, departmental databases and decision support systems are able to adjust from the four character numeric procedure codes of ICD-9-CM to the seven character alphanumeric codes of ICD-10- CM. Furthermore, the IT staff will be responsible for the implementation itself, as well as managing associated IT staffing and storage needs.

Although healthcare organizations will still maintain their historical records in ICD-9-CM, they will need to address the challenge of accessing this data for future case mix analysis and comparative studies. Fortunately, technological developments are on the horizon that will help perform automated mappings from ICD-9-CM to the appropriate codes in ICD-10-CM, thereby assisting in the conversion process.

ICD-10-CM is considerably more granular than ICD- 9-CM; therefore, maps between the two will not always have a one-to-one correlation. Two approaches will facilitate the mapping process: 1) Sophisticated content for the mappings and terminology service software to allow other applications such as electronic medical records to deliver the maps; and, 2) In cases where the map will not be one-to- one, advanced rules can be created to allow computer software programs to automatically ask additional questions and look for more patient data to derive the best map.

In addition, Language Engine, a terminology service application, allows the representation of all necessary terminology, maps and rules. Language Engine facilitates the ability of other applications such as electronic medical records and billing software to quickly look up the most current maps and follow the rules.

Similar to Y2K, the upgrade to ICD-10-CM is unavoidable for healthcare organizations. Many maintain hope that payers will bear much of the cost, given that they will be one of the key beneficiaries of the enriched capture of services and reimbursement processes.

Healthcare IT vendors are just beginning to plan for the software changes needed to handle the transition, but hospitals can’t afford to rely solely on vendors to pave the way. They not only need to update their own IT infrastructure and software, but must also start educating and preparing disparate stakeholders such as clinicians, coders, administrators and others for the impending change. As with most significant organizational changes, the secret to successful implementation lies within these standard best practices:

Plan early. Reassess operations and attempt to address existing organizational weaknesses prior to rollout.
Create awareness. Communicate the value and impact of ICD-10-CM to the entire organization.
Construct an overall project strategy. Be sure to incorporate the IT staff as soon as possible.
Determine major stakeholders and identify their priorities. These priorities typically include clinician documentation, organizational education, payer readiness and IT issues regarding system interoperability.
Address implementation issues. Strive to minimize negative impacts through positive outlook, increased education/training, interdisciplinary team participation and effective program management. Potential issues include increased clinician documentation, temporary decrease in coder productivity and a correlated increase in accounts receivable days.
Embrace change. The company champions within the interdisciplinary team should embody the positive aspects of change and elicit respect throughout the organization.
Start your budget. Begin budgeting now and continue this dynamic process throughout the implementation process.
Establish timelines. Identify gating factors by organizing tasks in a linear manner within each department and then link those tasks according to dependencies across the organization.
360-degree communication. Organizational changes should be communicated clearly, consistently and continuously. In conjunction, feedback should be solicited and integrated into the enterprise deployment on an ongoing basis.

The conversion from ICD-9-CM to ICD-10-CM may be disruptive to the operational efficiency of any healthcare facility, but with early and proper upfront investment in planning, training and technology adoption, the transition can be as uneventful as Y2K turned out to be. However, healthcare organizations must undertake an enterprisewide approach, since the change to ICD-10 CM will affect clinical, administrative, IT and many other departments. Is it worth all this effort? Absolutely. The conversion to ICD- 10-CM will allow us to leapfrog in our abilities to provide better quality data, essential to the foundation of our continuously evolving 21st century healthcare system.

Health Management Technology

George Schwend
is president and CEO of Health Language Inc., Aurora, Colo.
Contact him at george.schwend@healthlanguage.com.