When the Department of Health and Human Services (HHS) delayed the implementation date for nationwide ICD-10 adoption from October 1, 2013, to October 1, 2014, many healthcare organizations put their ICD-10 projects on the backburner. For some, the policy change cre-ated complacency, with expectations of more delays. In response, the Health Information and Management Systems Society (HIMSS) sent a letter to HHS and the Centers for Medicare and Medicaid Services on February 11 expressing “strong support” to maintain the current date in order “to realize the significant advantages of healthcare transformation.”

As a provider of regulatory compliance solutions for healthcare providers and payers, Edifecs supports HIMSS’s recommendation to uphold the 2014 date and therefore resolve ICD-10 issues now. Among the multiple time-sensitive mandates that healthcare providers are juggling, ICD-10 is the only one “that poses the threat of decreasing revenue in ways that are very tangi-ble for many of us,” said Deepak Sadagopan, general manager of clinical solutions. By helping more than 250 healthcare clients improve their operational efficiencies, Edifecs has gained an understanding of how efficiencies can help meet compliance and, just as important, mitigate financial and operational risks. To highlight healthcare organizations’ challenges and how their best practices address those risks, HIMSS Media convened an Executive ICD-10 Round-table Meeting on February 4 in Austin, Texas. The roundtable meeting, sponsored by Edifecs, brought together executives representing large and midsize healthcare provider organizations and payers, many of which are at different stages in their ICD-10 implementation.

Working with service and technology providers to meet complianceMany roundtable attendees conducted readiness assessments as a first step. Through its as-sessment, an academic healthcare system in Kentucky identified 70 IT systems that would be impacted by ICD-10. The healthcare system sent out surveys to all its IT vendors to determine when their systems would be upgraded and when they could be scheduled for an upgrade. Since the delay, however, executive management requested that the timetable be revised in order to spread out the cost of upgrading the IT systems. “We’ve been working individually with every single vendor,” the project manager said. Sadagopan emphasized the importance of healthcare organizations engaging with their vendors. By working closely with vendors, healthcare organizations can ensure that they are committed and have the technical capabilities to help them achieve compliance.

A Texas not-for-profit healthcare system purchased a tool from its electronic medical record (EMR) vendor that identifies where ICD-10 is being used. The subsequent analysis enabled the information systems (IS) director to notify the impacted business areas, including labs and radiology, and track them to ensure that necessary changes are made to their IT systems. Operating on the belief that not all IT vendors will be ready by the October 2014 deadline, the healthcare system is also deploying Edifecs’ code management tool for mapping and mapping exportation. While the healthcare system will be using ICD-10 ahead of the deadline, it will use the tool to map back down to ICD-9 for trading partners that aren’t ready and then send files using ICD-10 when those partners have made the transition.

An Ohio academic medical center is also leveraging tools from its EMR vendors, as well as in-stalling computer-assisted coding (CAC), conducting a Request for Proposal to select educational tools for training and expanding its clinical documentation improvement (CDI) program in preparation for the transition. Just as important, it is leveraging data analytics. “Robust data ana-lytics will help us pinpoint areas that will help us with everything from clinical documentation to revenue risk,” said the senior director for health information management (HIM).

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ICD-10 is the only mandate that poses the threat of decreasing revenue in ways

that are very tangible for many of us.

Deepak Sadagopan General Manager

of Clinical Solutions Edifecs

“ “

Best practices for ICD-10 transition

Edifecs has helped more than 250 healthcare organizations improve their operational efficiencies while comply-ing with federal mandates by provid-ing turn-key solutions and services to meet their specific needs. By work-ing closely with its healthcare clients, Edifecs has developed a set of best practices that are applicable to health-care organizations regardless of where they are in the process – whether far along or just starting out – in their ICD-10 project.

• Takeadata-drivenapproachtode-termine prioritization. Healthcare providers should analyze the last 18 months of their utilization or claims data, particularly around ser-vice lines. Analysis will determine what these services will look like when coded in ICD-10 and expose which services will pose the great-est financial risk. Providers can then prioritize what areas they need to focus on during the transition.

Provider-payer collaboration: Testing, defining and measuring financial neutralityTo reduce revenue risk, healthcare providers need to test with payers, according to Sadagopan. ICD-10 and other federal mandates are disrupting the business process of providers submitting claims to payers, who process and reimburse providers. “It’s increasingly going to be the rule of the land for these entities to speak directly to one another,” he said. “Engage with your payers and identify your risks. It’s not in their interest to see you fail.” Indeed, executives from the larger healthcare provider organizations reported that payers have already reached out to them.

The Kentucky academic healthcare system collaborated with one of its payers to determine ICD-10’s impact on its diagnosis-related groups (DRGs). It took sample historical claims from one payer, ran them through its upgraded system and then compared the results to what its coders coded in ICD-10. “The impact did not favor us,” the project manager revealed. Testing, however, identified potential risk areas that need to be taken care of ahead of the compliance date. The healthcare system is investigating whether faulty documentation is the culprit. “If the specificity wasn’t there, then we’re not going to get the DRG impact,” she said. By exposing the need for improving documentation throughout the organization, the healthcare system is not only resolving a problem with ICD-10 coding it is also “bring[ing] to light to management where some of its opportunities are.”

A national managed healthcare company has already tested its systems and is now seeking healthcare providers that are ready and interested in testing. In March, the payer will work with a vendor to transfer three months’ worth of claims – some 1.3 million claims – to ICD-10 and run them through its system. The results will be compared to what the claims looked like in ICD-9. “Granted, it’s only crosswalk data, but it will hopefully give us a gauge of what might be potential problems, where our risk corridors are, so we can reach out to those providers,” said the director of operations support.

The payer’s analysis identified where the risks were and what DRGs were at risk for its high-volume and high-dollar providers. To achieve financial balance, the payer developed use cases for risk categories that need to be examined. “We all want to win,” she said. “No one should be a winner or a loser.” While she acknowledged that some service lines will be paying more and others less, financial balance is the goal. Her organization doesn’t want every claim to pend, be rejected or have to be run through the system again; rather, her organization wants to pay claims correctly, she said.

Measuring the impact of ICD-10 on key performance indicatorsICD-10 has the potential to drive greater accuracy and therefore quality of financial and clin-ical data. While many executives agreed that coder productivity will take the biggest hit, how healthcare organizations address this issue will determine whether they have transformed this challenge into an opportunity or greater risk. The Ohio academic medical center budgeted for super users in its project plan. The Texas healthcare system identified qualified coders to do dual coding but expects to hire and train people on ICD-10, as well as train its current coders. That said, “some of them aren’t going to be able to do 10,” the IS director pointed out. Given the current coder shortage, however, hiring additional coders will be is difficult at best.

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• Don’t operate in silos. With proj-ects of great scope, departments, such as revenue cycle and clinical documentation, often work inde-pendently of one another, only concentrating on how the project impacts their processes. Healthcare organizations must build capabili-ties to bring departments and their processes together. Each depart-ment or area needs to understand the impact of what they are doing to other departments. For example, healthcare organizations should know the implications of clinical documentation and coding im-provements to its revenue cycle.

• Don’t forget your systems. Whilemany people perceive ICD-10 as a codingproblem,it’salsoatechnicalchallenge.Providers’ITsystemsgen-erate many reports that are depen-dent on code sets. Some of those reports gather data that will be used to determine institutional rankings, such as measures of patient popu-lations for particular diseases. Thetransition to ICD-10 codes may alter the data and therefore nega-tively impact institutional rankings. It’s critical for providers to ensurethat their systems, configurations and templates are upgraded. Theymust engage with their vendors to seek their commitment and ensure that they have the capability to help them comply with ICD-10.

Robust data analytics will help us pinpoint

areas that will help us with everything from

clinical documentation to revenue risk.

Ohio Academic Medical Center Senior Director of HIM

“ “

A dental benefits carrier modeled retraining its ICD-9 coders to determine the impact on its coders. While the first three to four months revealed 65 percent proficiency, continued practice and increased volume drove up the proficiency level. “We ended up resetting expectation of productivity, and we tried to offset it with hopefully the gains you’re getting in accuracy [of coding],” said the vice president of the office of compliance.

Healthcare providers are looking to tools such as CAC to offset productivity decreases. The Ohio academic medical center devised a formula that showed that CAC could boost expected decreases by 20 percent to 30 percent. Its research project with the American Health Informa-tion Management Association demonstrated 17 percent to 19 percent coder productivity with CAC, although the senior director for HIM admitted that the project was an isolated case.

Executives have had to make the case to leadership that implementing CAC does not replace coders. The Ohio academic medical center leveraged CAC to relieve the burden on coders and increase its coding accuracy. It embedded CAC in its CDI program, which helps deliver more front-end education to its clinicians. The senior director for HIM stressed the importance of clear and specific documentation and the need for physicians to use their EMRs. “That’s really our vision,” she said. “It’s really getting it as close to patient care so that the physician has meaningful information at that point.”

As healthcare providers work through multiple issues in implementing ICD-10, Sadagopan reminded attendees of the overall goal of adopting the more granular code sets. Rather than approach ICD-10 as a coding exercise or a technical requirement, healthcare providers need to see it as another important move toward healthcare transformation, as HIMSS pointed out. “Ulti-mately, all of these changes are taking place because we truly believe as a nation that it puts us on the right path to improve patient care,” Sadagopan said. “That’s what we’re all here for.”

About EdifecsAn industry leader since 1996, Edifecs provides healthcare software solutions that improve operational performance by streamlining the exchange of information between health plans, hospitals and other healthcare organizations, while enabling compliance with current man-dates such as HIPAA, Operating Rules and ICD-10. Today, more than 250 healthcare custom-ers use Edifecs technology to unify transactions from any information channel source and input mechanism, while automating manual business processes such as enrollment, claims and payments management.

Edifecs is currently recognized as one of the 100 Fastest Growing Private Companies in the state of Washington, 100 Best Places to Work for in the state of Washington, an Inc. 5000 fastest-growing private company and one of the 500 Fastest Growing Companies in North America by Deloitte. Edifecs is headquartered in Bellevue, WA. For more information, please visit www.edifecs.com.

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• Collaborate, collaborate, collab-orate. ICD-10 provides a great opportunity for payers and pro-viders to collaborate. By engaging and working closely with payers, healthcare providers can identify and therefore be able to eliminate risks more easily. By relying on and sharing data, both providers and payers can work transparently, which builds trust and drives fur-ther collaboration.

• Test, test, test. Healthcare pro-viders must define the scope of testing with their payers. Providers and payers need to ensure that claims can go through the systems and adjudicate cleanly. Especially in these early stages, many pro-viders and payers will be mapping or migrating their systems. Legacy systems, however, may not be able to migrate before October 1, 2014. Therefore, it’s critical that payersand providers collaboratively test their systems in advance of the deadline.

Engage with your payers and identify your risks. It’s not in their interest

to see you fail.

Deepak Sadagopan

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