As healthcare organizations make final preparations for the transition to using ICD-10 codes, it’s important for them to anticipate potential risks and have mitigation plans in place before October 1 to stabilize operations as quickly as possible.
Here are five key areas to include in go-live preparation and post-live mitigation plans to ensure a stable future and create bandwidth for optimization in 2016.
Use a dashboard to monitor performance
Healthcare organizations should use leading key performance indicators (KPIs) to build a dashboard that compares performance before and after the migration to ICD-10. Performance should be measured frequently, on a weekly basis, if possible, to determine where to focus resources as KPIs fall outside of target ranges.
The following indicators will provide strong guidance on organizational performance with ICD-10:
- Average time to code a chart (track results in a variety of settings)
- Case mix index
- Gross accounts receivable (AR), days in discharged not final coded
- Gross AR days in discharged not final billed
- Net AR days
- Cash collections as a percentage of net patient services revenues (NPSR)
- Initial denials as a percentage of NPSR
- Initial denials by reason code (focusing on those possibly affected by ICD-10)
- Gross revenue per adjusted discharge
- Clean claim ratio
- Claims pending national coverage determination/local coverage determination edits
- Claims held by clearinghouse (dollar amount and total number)
- Percentage of accounts reviewed by clinical documentation improvement (CDI)
- CDI query rate
- Physician query rate response
- Physician agreement rate to queries
Ensure sufficient coder resource levels
Coding productivity is likely to fall as coders wait for final code assignments and become proficient in ICD-10. Without proper resources, a backlog of accounts could occur. The decline in productivity at go-live could be as much as 50 percent for inpatient coders, 35 percent for outpatient day surgery or observation coders, and 25 percent for outpatient diagnostic or hospital clinical coders.
While productivity will increase as coders gain experience, it is expected to remain below the current baseline by 15 percent to 20 percent. As a result:
- Don’t use ICD-10-CM/PCS code assignments for procedures performed on outpatient accounts. Only CPT codes are required on outpatient bills for these procedures. Organizations that make this change will require support from key stakeholders first to determine the impact on the reporting and trending of data.
- Increase coding resources to give coders more time to dual code before go-live and to support code assignment after go-live.
- Evaluate computer-assisted coding, specifically to determine a return on investment, to assess potential benefits for implementation.
Evaluate and enhance clinical documentation improvement programs
Medical providers often document in clinical terminology that does not support accurate code assignments. Real-time verbal queries will help providers learn which words to use to improve specificity of documentation in patients’ medical records, and thus support accurate and efficient finalization of code assignments.
Analysis and review, conducted for each medical specialty, will provide information needed to build tools for focused medical provider education and new query templates. Here are some tips to make sure you’re ready:
- Analyze accounts by Medicare Severity DRG frequency to determine where specificity is need to continue to drive accurate code assignment.
- Form a work team made up of CDI and coding team members to develop standard query templates to address known ICD-10 documentation requirements.
- Build a process to share documentation gaps identified by coders with the CDI team, to enhance efforts for medical provider education and concurrent query generation.
- Implement a CDI program in hospital outpatient treatment areas to round with physicians on cases and perform verbal queries to ensure specificity in documentation.
- Develop specialty-specific training modules for physicians to cover the most frequent documentation gaps.
- Create a focused plan for physician professional fee billing. For example, analyze the frequency of the most commonly selected diagnoses and codes, focusing especially on unspecified codes selected by medical providers in ICD-9. Then, identify the correct code or range of codes in ICD-10, and train staff on the documentation required to support selection of the right ICD-10 code. Or, review denials for medical necessity and identify areas for focused review or training.
- Align tools used by physicians for ease of use when selecting diagnoses and codes, so the most frequently selected ones are at the top of the list.
Build early warning triggers and response teams for challenged claims
Most likely, the number of claims pending for final bill processing will increase as the number of NCD/LCD edits rises with the migration to ICD-10. Denials from payers will increase because of a lack of medical specificity, if inexact codes are selected or if there are coding errors.
Pended clearinghouse claims may increase as payers determine how to apply revised rules to make decisions about how to pay claims. To better manage these changes:
- Conduct analysis by reason code for edits, denials and pended clearinghouse claims, monitoring by total gross dollars and number.
- Add resources to review and resolve edits, denials and pended claims.
- Review update schedules for billing and encoder systems to ensure synchronization with NCD/LCDs updates.
- Perform root cause analysis to collect information and develop an action plan for long-term resolution.
- Provide focused documentation education and leverage the analysis performed to select unspecified codes or diagnoses by frequency and medical provider.
Evaluate and improve the quality of code assignment
Code accuracy in ICD-10 is essential to ensure the accuracy of reimbursement, severity of illness and risk of mortality for patients. Quality indicators and abstraction of core measures by payers and other organizations also are affected by the accuracy of code assignments.
It is important to foster an ongoing, safe environment for coders to learn and thrive. Validating code accuracy and sharing the information with coders should continue after go-live. This will help coders continue to improve their accuracy. Toward that end:
Create a communication plan for coders that outlines the process for reviewing accuracy and sharing results.
Identify approaches for reviewing a sample of encounters to validate accuracy in ICD-10 code assignment.
Build feedback reports to track accuracy and provide summary information about erroneous codes and DRGs to share with coders.
Set up weekly study sessions with coders to review common errors or difficult cases.
Recognize coders who accurately handle difficult cases and let them share the case during study sessions.
Follow the plan
While the level of risk with the go-live of ICD-10 will vary by organization, providers must create and follow a plan that will anticipate and mitigate threats. Incorporating these five areas into planning will help organizations successfully make the transition with minimal short-term disruptions to productivity and accuracy, while providing a long-term plan to gain efficiencies.
Teresa Benavidez is a manager of Aspen Advisors, which is part of The Chartis Group, a management consulting firm dedicated to healthcare. She is experienced in revenue cycle management and has more than 30 years of health information management experience in a large integrated healthcare system.
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