Consultancy Phoenix Health Systems recently surveyed clients and colleagues at other firms to assess challenges that hospitals with fewer than 400 beds are experiencing during the ICD-10 transition. Tom Grove, principal of consulting and compliance services at Phoenix, presents the findings:
The press has published many positive overviews about the ICD-10 transitions of the country’s largest and/or most advanced hospital systems since the October 1 go-live. This post focuses on smaller community hospitals and health systems, many of which were not as well prepared. Though it is too early to measure revenue cycle impacts, the challenges that some hospitals are having may equate to financial disruption by the end of the year.
In the last week, we have talked with several client hospitals and colleagues at other firms to better understand how the transition to ICD-10 has progressed during its first month. Our focus was smaller community hospitals and hospital systems (generally under 400 beds), which tend to be off the radar of the press. Our comments are anecdotal, but are likely to represent common issues that many in this market segment are experiencing.
Caution: After only one billing cycle for healthcare organizations, it is too early to gauge revenue cycle impacts. Meaningful assessment will not be possible until providers have gone through two to three billing cycles — i.e. in December or January. The most significant transitional issues seen in October include:
Inadequate documentation improvements among physicians appears to be an issue among smaller hospitals and for many, their greatest challenge.
Despite extensive educational offerings by most hospitals to their physicians, many physicians have taken little or no advantage of them. We know of one five-hospital system in which the physicians finally agreed last week to participate in intensive training (beyond one past introductory session) They began the specialty-based sessions, focused on tailoring their documentation of procedures and diagnoses to meet the specificity requirements of ICD-10, during the last week of October.
In another 2-hospital system, many of its physicians had only participated in one two-hour web-based session despite the availability of other modules. In speaking with several colleagues, the problem of inadequate documentation improvement by physicians, even when training has been made available, seems fairly common.
Some hospitals, typically under 300 beds, have offered very little training to their physicians, either because of opposition by hospital physician staff, physician training was not a high priority, or ICD-10 transition teams did not understand the importance of upgraded documentation. We have direct knowledge of at least five hospitals in this size range that had not provided full-scale training to their physicians as of Monday, October 21, and were looking for solutions. Some of their physicians reportedly were already becoming frustrated because they had begun to receive extra queries for more detail from coders. One of our client facilities has experienced a 4 fold increase in the number of coding queries since October 1. Other ICD-10 consultants have reported similar stories.
At least some of these hospitals are working to catch up, but finding an affordable training solution that is available immediately is a challenge. In addition to any formal programs they may adopt, we recommend that they begin examining their CDI and coding queries to identify patterns of insufficient documentation, in order to help guide educational efforts to the target areas. As always when dealing with physicians, specifics like “we had 72 queries for CHF in the last 90 days” are of great value in communicating the importance of this education.
Health Information Management: Before ICD-10, it was projected that coders would see a 50% decrease in productivity in the short term, and many facilities have seen that. Others are reporting decreases ranging down to 10%. Hospitals who took a strong approach to training, including ample dual coding, and who have robust CDI programs are seeing the smallest drops in productivity.
One hospital that we have worked with installed CAC (computer-assisted coding) in hopes of offsetting the expected decrease in productivity. Thus far it has not experienced this benefit, primarily because going live both with the new CAC system and ICD-10 on the same day (October 1) created operational challenges. These caused the overall coding rate to drop the full 50% predicted.
Registration: Not surprisingly, hospitals are receiving some patients who are presenting with ICD-9 coded diagnoses on orders for radiology or lab testing performed after October 1. These orders generally have originated from outside providers that were not yet coding in ICD-10. Usually, these patients have been registered and seen, and the hospital’s HIM has been re-coding the orders in ICD-10. In one hospital’s experience, inaccurately coded orders were coming primarily from a local skilled nursing facility, and a phone call to the right person eliminated the problem and the extra workload.
Offshore Coding: At least one author has described the situation in off shore coding shops as chaos. It seems that, in at least some cases, these organizations have oversold their capabilities and are relying on overtime to address the quantity of charts. The quality of that coding is suspect. We recommend that if a hospital is using an off shore shop for some of its coding, the hospital should “overcode” at least a portion of their charts at first to ensure that they are getting the quality needed.
Revenue cycle: As noted in my introduction, it’s still too early to measure impacts. Many hospitals are only now receiving their first 835s, (healthcare claim payment / advice) and won’t have 835s from all the major payers for a few weeks yet. Still, early reports are generally positive. We are seeing hospitals that have come through the first Medicare and some commercial 835s with no apparent issues. Some revenue cycle outsourcing firms are reporting the same across multiple clients.
It is not time to relax. In the next few weeks, hospitals must keep an eagle eye on remittance advices, to ensure that issues are identified and addressed quickly. And with documentation inadequacies becoming more apparent, hospitals should consider new support and training reinforcement tactics to keep any bottlenecks from starting at the bedside.
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