It is finally here—the day we have all been waiting for—the official implementation date for ICD-10. Actually there still are approximately 30 days to go, but we are clearly in the final stretch and, at this point, the mission should be to ascertain that the “t’s” have been crossed and the “i’s” dotted for the most critical items.
Three key areas should be examined to ensure they have been adequately addressed in preparation for the big launch date of October 1, 2015: Readiness, impact analyses and monitoring/feedback mechanisms.
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At this late date everyone and everything within the organization should be ready for the go-live date. But rather than make that an assumption, it is important that true assessments be performed to ensure that this is indeed the case.
Internal Staff. If your organization does its own coding and billing then you must assess the current proficiency and skill levels for any individuals who will be impacted by the new code set. Has your staff received detailed training to prepare them to assign all of the necessary ICD-10-CM codes with accuracy and efficiency?
If not, where are your gaps and what are you doing to quickly fill those gaps? What type of assessment have they taken to show their proficiency? If you have not tangibly measured their proficiency you should do that as soon as possible so you know their areas of strengths and opportunities for improvement.
What type of ongoing support is available for your staff? Any new skill requires practice, and ongoing feedback and support, so it is important that you ensure that this support is available to your staff either through internal or external mechanisms.
If you find that there are staff members that need additional training prior to the implementation, do not delay getting this accomplished. There are a variety of training options available to address ICD-10 preparedness; avail yourself of these options so that you are as prepared as possible.
Payors. Most payors began testing with individual providers and clearinghouses in early 2015. If you did not participate in this electronic testing, how do you know that you will be able to successfully submit claims on the go live date? In addition to claim submissions, it is important to know how your payors are actually going to process the claims differently. Besides the obvious fact of new diagnosis codes, is more specificity required? Will the payors accept unspecified codes? Are there specific medical conditions that you are being paid for today that will be denied in an ICD-10 world?
Medicare has published a list of proposed “future” Local Coverage Determinations (LCDs) converted to ICD-10 that is available on the Local Coverage Index. To view the information, select either “LCDs by Contractor” or “LCDs by State,” and check the box for “Future LCDs/Future contract number LCDs.” LCDs that have been converted to ICD-10 will be listed with an October 1, 2015, effective date.
With commercial payors, it is important that you have open dialogue with your provider representatives to ensure that you have all of the information that is available to be able to anticipate potential problems and address them in advance.
Vendors. Early in the planning process, one of the first steps in any ICD implementation plan was to ensure that you conducted a vendor inventory to identify which of your external vendors, including any software providers, would be impacted by the implementation of ICD-10. External vendors include clearinghouses, billing companies, computer-assisted coding software. At this point all software upgrades and enhancements necessary for the transition should be in place and appropriately tested so that any potential problems are identified and appropriately mitigated.
Any computer systems that are utilized in the revenue cycle process—from scheduling to bill submission (e.g., practice management, electronic health record, software and hardware systems)—should be double checked to ensure that patient problem lists, alerts, system interfaces and reports are compatible with ICD-10-CM. It also is important to appropriately estimate system down time (if any) expected during the implementation.
If your organization outsources its billing, or even just the coding function, it is very important that you confirm that the specific staff performing your coding is ready to accurately assign ICD-10-CM codes. You should receive information on the content of the training that the staff received as well as the qualifications of the instructor. You should request validation of their proficiency for assigning ICD-10-CM codes specifically for radiology services.
Radiologists. While the goal is always to minimize how much the radiologists have to be involved in the coding and billing process, it is important to remember that ICD-10 does require an increased level of documentation for some key clinical areas, particularly those related to fractures, OB/pregnancy conditions, neoplasms and other specific types of injuries. At this point, all of your radiologists should have received education on documentation requirements and feedback on their specific documentation patterns to minimize the amount of queries due to insufficient documentation that will potentially be required when ICD-10 is implemented.
If you have not conducted radiologist educational sessions and/or provided individual feedback—this should occur right away. Unlike other initiatives, this is not something that can be successfully implemented without the radiologists’ support and buy-in. Accurate coding for radiology services can only come from accurate and detailed documentation in the dictated radiology report.
Referring providers/staff. Last, but not least, you need to ensure that you have accurately communicated the enhanced need for details to your referring providers. It is important to remember that ICD-10 does not require a change in how providers practice medicine or treat patients, but rather it demands more accurate documentation so that more detailed codes may be provided to the payors.
Do your referring providers really know in which circumstances they are not providing sufficient information today, much less for ICD-10? The problems that you have today will be amplified in ICD-10. If you have not communicated with your referring providers, make that a priority today since change takes time.
After completing the readiness assessments, the impact of the implementation should be analyzed, documented and agreed upon by the management team. The specific areas with significant impact by ICD-10 implementation may vary by organization. That said, it is relatively safe to say that the biggest areas of concern lie in the coding function and any area that is responsible for obtaining and/or maintaining clinical data that will be utilized in the coding process.
Coding. Arguably, the area that will have the greatest area of impact on October 1st will be the coding function. There will be decreases in productivity, but since no country has the myriad of payors that we have in the United States, we do not have any studies or comparisons that can be used to accurately determine what the decreases actually will be for those assigning only diagnosis codes.
Additionally the utilization of software services, such as computer-assisted coding, and whether or not the coder is assigning procedure and diagnosis codes will factor into the productivity numbers. It is generally accepted that the initial decrease in productivity for radiology coders will be 25%. As with any estimate, there will be those that have minimal productivity losses of 5% to 10% and others with numbers exceeding 25%. What is critical is that you accurately determine what your estimated decrease will be based on your current systems, staff,and other factors, and set the standard expectation for how long the decrease will be maintained, realistically when the a new “norm” will be reached and what your new standards will be for the staff.
Given that there will be decreases in productivity, preparations must be made to ensure that all of the work is performed in a timely manner. At this point, you already should have a plan in place that addresses overtime, outsourcing, temporary coding staff and/or new staff members to compensate for the additional time requirements.
Non-coding staff. Many areas outside of direct coding will be impacted by the implementation of ICD-10. These areas include registration/reception, preauthorization, accounts/receivable (A/R) follow-up and any other function that works with the patients and/or claims submission.
Similarly to the coding discussion above, there is no information available that can tell an organization exactly what the productivity impact will be given the myriad of software packages and payors that impact a given organization. This is why it is critical that you have completed your own impact analysis so that you have your plan in place to identify your potential areas of concern with specific response plans should the anticipated problems arise upon implementation.
For example, how will the pre-certification/pre-authorization process be different once ICD-10 is implemented? Have your top commercial payors indicated how any of their policies and procedures will be changing with ICD-10? Who within your organization is responsible for taking the lead in communicating with the payors if/when issues arise?
The management of payor rejections and denials is a major area of concern that you should be prepared for today. Every organization should have created the customized tools and materials necessary for filing appeals, monitoring reimbursement post-implementation and identifying and correcting problems in ICD-10-CM reporting.
When addressing post-implementation problems, it is important that a trend approach, opposed to a purely individual claim approach, be utilized so that we don’t get into a situation where we can’t see the forest for the trees. While we don’t know exactly what issues will arise, it’s critical that we quickly identify trends of concern that may impact reimbursement. Key staff in the A/R follow up department should be able to clearly articulate the post-implementation plan and understand their role in this critical component of the revenue cycle process.
Any time a process is evaluated, it is rare that opportunities for improvement are not identified during the review. The most productive approach is one that embraces these opportunities and uses them to improve process flows, which should result in improved employee and patient satisfaction.
Financial. At this point, the implementation money should have been spent, and it is now time to see what the true financial impact will be upon implementation. It is prudent to do one last check to ensure that you have the financial resources available should the worst case scenario occur where you do not receive the funds that are needed to handle your day-to-day operations.
Every organization should have expanded cash reserves and/or a line of credit to cover any delayed reimbursement due to the transition. The radiologists and the staff need to understand that there may not be year-end bonuses if there are delays in cash flow. While that is not a popular potentiality to publicize, it is better to give fair warning than to provide an unexpected surprise at the end of the year.
Auditing and Monitoring Mechanisms
Last but not least, it is important that every organization has auditing and monitoring mechanisms in place to ensure that things are going along as planned. There must be a streamlined way to provide feedback to the staff, radiologists and referring physicians about what is working and what needs to be improved upon. Dashboards and analytical tools can help organizations monitor productivity and minimize financial difficulty during the transition.
Even prior to the implementation, these tools can help organizations identify frequently used ICD-9 codes to anticipate how they will be paid under ICD-10, find opportunities to benefit from areas of ICD-10 that were not present in ICD-9, and measure staff productivity changes that may indicate need for additional training. This is an ideal way to test the tools to see how they will be used in a post-implementation world so that necessary modifications and adjustments can be made to the reporting functions.
The transition to ICD-10 is colossal, and no one person or entity has identified every potential problem or every potential solution to the problems they have identified during their preparation. Regardless, that does not mean that mitigation is not possible. Planning is essential, critical and the only way that organizations will not just survive, but successfully thrive in an ICD-10 world.