Report from the AHIMA 2011 ICD-10 Summit

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AHIMA’s 2011 ICD-10 Summit convened more than 500 healthcare professionals to discuss the state of the ICD-10-CM/PCS transition in the US. Their discussions—in presentations, Q&As, and hallway conversations—offered a rich view into the progress that providers, payers, and vendors are making, the challenges they are encountering, and the insights they are gaining and generously sharing.

AHIMA President Bonnie Cassidy, MPA, RHIA, keyed in on this spirit of collaboration and shared learning in welcoming remarks that set the tone of the summit.

“The only way America’s healthcare system is going to realize the full advantages of ICD-10 is if we all work in universal recognition of one another, as unique and responsible professionals, each lending a valued voice to this process of change,” she said.

The summit, the third that AHIMA has hosted, took place April 11 and 12 in Baltimore, MD, attended by health information professionals, clinicians, payers, CIOs, government administrators, educators, consultants, and vendors.

Following are the key themes that emerged.

The Work Has Begun

It was clear from the first conversations that organizations have gotten started on their implementation plans and were making progress.

This was perhaps the most noticeable change from the previous year’s summit. More attendees were discussing specifics of their transition plans, asking more focused questions in the sessions, and sharing concrete examples of early steps such as system assessments.

It was also clear that those who had begun were more optimistic about the transition. The more engaged the participant, the farther they were from the fretting phase. Having a plan is an important tactical and emotional milestone.

The progress that attendees reported varied widely, but it was not limited to large provider systems or payers. Smaller facilities such as community hospitals also reported good progress and smart planning.

Example: Systems Inventory

Many presenters described their work in conducting systems inventories, an early step in identifying the databases, systems applications, and interfaces within the organization or enterprise that currently use ICD-9-CM codes.

Many described how deep this assessment took them into their organizations.

Banner Health, for example, operates 23 acute care facilities as well as laboratories, clinics, and even a health plan. As Banner’s ICD-10 team began conducting a systems analysis they were surprised by how deeply the ICD code set had worked its way into the enterprise’s operations.

“This was a surprise for everybody. As we got into this, we learned there are so many business areas that are impacted by ICD-10,” said Linda Martin, MA, PMP, Banner’s IT project management senior consultant. “This kept me up at night as we were uncovering more areas that were affected. It was just mind-boggling.”

One tool essential to the assessment was a spreadsheet listing all applications, interfaces, and report extracts across 14 business units. That accounting allowed the Banner team to analyze workflow and pinpoint the places where ICD-9 was being used.

“It seemed like we were going down rabbit holes all the time trying to find areas that will be impacted,” Martin said.

Other speakers echoed Martin’s experience.

“When looking for ICD-9 codes, you need to look in the strangest places,” noted Christine Armstrong, MBA, RHIA, a principal with Deloitte Consulting. “For example, CPOE data, credential data.”

George Alex of Johns Hopkins University and the Advisory Board Company, a consultancy, described his experiences working with clients this way: “Seemed every time we picked up a rock there were codes under it. [It’s] surprising the places you will find ICD-9 codes being used in an organization.”

Example: Version 5010 Testing

The upgrade to X12 version 5010 of the HIPAA transaction standards is a project separate from ICD-10 implementation. However, it is a related milestone because the new standards are necessary to support the upgraded code set.

For this reason, CMS is requiring that the 5010 upgrade be completed well in advance of the ICD-10 deadline. Covered entities must submit electronic claims using the new standards beginning January 1, 2012.

It’s been no secret across the industry that organizations are not tracking well with that deadline. However, within the ICD-10 summit the outlook was not as dim.

In the relatively small sample of the summit, there was a clear correlation between organizations that were progressing on ICD-10 and those that were on schedule with their 5010 upgrades. Many attendees who reported having their testing under way said they were close to done with the upgrade.

Growing Concern over Clinical Documentation

Attendees expressed more concern about documentation at this year’s summit, likely another sign that their planning has progressed. More organizations have reached a stage where they recognize that their current documentation will not fully support the new code set.

No one on either side of the podium was heard to say that their current documentation was sufficient to support ICD-10.

In fact, attendees were more likely to express their concern with training their clinicians than their coders. As many noted, without changes in clinical documentation, it won’t matter if ICD-10 is more specific because coders won’t have enough documentation to record the new codes.

“I’m not confident that the data will be there. There is a tremendous educational challenge in terms of physicians documenting practices and making sure they understand the level of specificity needed in the record,” said Ann Watt, MBA, RHIA, associate director in the department of quality measurement at the Joint Commission.

There were “a-ha” moments when attendees saw how EHR systems could help with the challenge by triggering documentation alerts for clinicians, reminding them that the new code set required additional specificity, such as the severity level of respiratory failure.

Alerting physicians at the point of documentation can clearly save the time and effort of querying after the fact. Many attendees left with notes to contact their software vendors to discuss the possibilities.

Presenters offered a number of tips for approaching clinician training, many related to providing direct examples and stressing the value more specific data will have to quality improvement.

In addition, organizations should budget plenty of time for documentation improvement efforts, advised Donna Smith, RHIA, a senior consultant at 3M Health Information Systems. Focus on the top 10 problem codes at the facility, she recommended, and begin to tweak physician queries so they reflect the questions coding professionals will ask on October 1, 2013, when the first services will be reported in ICD-10-CM/PCS.

“Think about how long it has taken you to get physicians to document the acuity of a heart condition,” she said. “ICD-10 has hundreds of those specific codes.”

ICD-10 does offer a code for “unspecified,” but Smith and other presenters warned against relying on it.

“Yes, there is an ‘unspecified’ code in ICD-10, and you can code it all you want,” Smith said. “But in two to three years when you review your severity and risk scores you will be in bad shape, because you won’t have the specificity in your codes that you need to justify higher levels and better reimbursement.”

Going beyond the Mandate

It’s not enough to implement ICD-10, many presenters urged, organizations need to leverage it. This is the opportune time to seek efficiencies and improvements. The organization’s shared goal should be to perform better using ICD-10 than it did using ICD-9.

Attendees discussed the potential to streamline old processes, rework coding workflows, leverage their use of secondary data, and generally clean house.

The window to do so, however, won’t be open forever.

“As the time horizon nears [on the implementation deadline], the opportunity for strategic initiatives decreases,” said Kimberly Telford, MBA, the director of strategy, revenue cycle organization, with Intermountain Healthcare.

An organization’s ability to assess and improve its processes will cede to the rush of simply getting its systems prepared in time, she said.

Example: Process Improvement

One example of leveraging the upgrade for improved performance comes in the review of policies and procedures related to assessing ICD-10’s impact on the organization.

Payers shared that they are using the upgrade to root out old and outdated business rules, taking a hard look at policies and procedures and reviewing the purpose of each. That kind of streamlining benefits payers and providers alike.

Providers described similar efforts. Christine Armstrong of Deloitte Consulting described her work with a nonprofit academic medical center that identified ICD-9 data in more than 2,600 reports, all of which required remediation.

In reviewing the reports, the organization was able to weed out unnecessary pieces. “They thought, ‘Do I need all of these reports?’” Armstrong related. The remediation process allowed for strategic development in trending reports and garners benefits from the more granular data set, she said.

As organizations begin reviewing their business rules against ICD-10, they may find the job is harder than they expected because their rules are scattered across departments and, worse yet, some have not been written down.

“You know how there is only one person who knows what they are doing, and they only tell their cousin who comes in at midnight?” said Sydney Ross-Davis, MD, from Blue Cross Blue Shield of Illinois. “It is something vital to your organization, but no one but that person knows it—it is a secret. Many of those [secrets] are business rules. And you have to find the impact of ICD-10 on those business rules.”

Even business rules that are not “secret” may be hidden, Ross-Davis noted. They may be coded in software, for example, not written down on paper.

The ICD-10 review offers organizations an opportunity to remedy these situations and improve the management of their business rules, she said, such as housing rules in a central database and reviewing them regularly.

Queuing up Coder Training

Coding professionals, meanwhile, can start preparing to work with the more specific documentation. It’s too soon to begin in-depth training on the code sets, but presenters advised that this is the year to begin introducing ICD-10 concepts and brushing up on supporting knowledge.

Reviews of the code structure and conventions can begin this year, and this is a good time to assess the extent of the anatomy and physiology refreshers staff may require, said Patricia Hildebrand, MSN, RN, CCS-P, CPHQ, of Hildebrand Healthcare Consulting.

In addition, this is an important year to create training plans. This is especially true in large enterprises that may include both inpatient and outpatient coding and distributed staff with a wide range of skill levels and learning styles.

Budgets Are Taking Shape, and They Are Big

It was evident from presentations and hallway conversations that the scope of the ICD-10 transition was clearer this year than ever before. With more work under their belts, attendees had a better view of just how far-reaching the ICD impact is within their organizations.

That was reflected in the budgets that were discussed.

Dave Biel, MS, a principal at Deloitte Consulting, offered some of his company’s insights into a sample of the company’s clients. Their budgets for the transition average $25 to $30 million for three years, Biel said, which includes money for post-implementation tasks in 2014 such as auditing. The budgets range from $17 million to $100 million, depending on the size and complexity of the organization, Biel said.

Intermountain Healthcare currently is estimating its costs at $20 million, expecting that 40 percent will be capital costs and 60 percent operational expenses.

Costs may be arriving sooner than expected, too. Leading provider organizations participating in a Georgetown University survey in April 2010 were not expecting significant ICD-10 expenses until 2012. Today more organizations are more likely to expect significant expenses this year.

Budgets also reflect the increased understanding that the transition is more than an IT project. Organizations are budgeting an estimated 30–40 percent of their implementations expenses for IT needs on average, leaving the larger expenses in overall business costs.

ICD-10 Is One Priority among Many

Perhaps one of the most significant challenges facing organizations is that ICD-10 is just one priority among many. The convergence of regulatory requirements in the coming three years is unprecedented: HITECH and the meaningful use program, the HIPAA 5010 standard, the ICD-10 transition, healthcare reform, accountable care organizations, and intensified pay-for-performance initiatives.

The requirements are stretching resources, and attendees spoke of trouble just finding time to meet.

“Everyone has so much on their plates. We have conflicting projects in house, so it is actually one of the biggest challenges, just scheduling meetings for everyone,” said Linda Martin of Banner Health. “Everyone is double-booked.”

CMS, which mandated the upgrade, is not immune from the pressures. Karen Trudel, the acting director of OESS, shared a slide showing the concurrent government initiatives involving healthcare. It is clear that CMS also is facing significant and far-reaching changes.

Still, Trudel stressed that CMS will stick to stated deadlines. Referring to both 5010 and ICD-10, she said, “The deadlines are not changing. Let me repeat that—the deadlines aren’t changing.”

Attendees described having to do more with less and seeking ways to use resources as effectively as they can, such as doubling up work where possible.

Meaningful use, for example, calls for advanced physician documentation in order to report quality measures and create complete summaries of patient visits. This work on improved documentation can be made to dovetail with the ICD-10 transition.

Combine physician education on these topics and narrow the training to items that affect both ICD-10 and meaningful use, recommended Kathy Westhafer, RHIA, CHPS, and Peggy Lynahan, project and program managers at Christiana Care Health System.

Any work an organization does on meeting the meaningful use requirement of using coded data in a problem list has to work in tandem with the organization’s transition from the ICD-9 to ICD-10 code set, they noted.

Everyone Is Affected…

A year or more ago, some organizations may have misread the ICD-10 conversion as an IT project or a coding issue. Presentations and discussions at this year’s summit illustrated how clearly those organizations that have begun the work understand that ICD-10 touches people, departments, and functions throughout their enterprises.

“ICD-10 is a business-driven initiative. This is not an IT initiative,” said Dennis Winkler, director of technical program management at Blue Cross Blue Shield of Michigan.

“We thought this was an HIM problem and would contain mainly HIM issues. That was far from the truth. It is really a multidisciplinary effort,” shared George Alex of the Advisory Board Company.

“ICD-10 is an integral part of everything we will be doing for the next 15 years. It is never over,” said Karen Trudel of CMS.

That deep reach can reveal itself in unexpected places. For example, health systems that acquire physician practices will be responsible for bringing those practices into ICD-10 compliance in short order. The first deadline is January 1, 2012, when the version 5010 transaction standards take effect. Practices that are not ready will face claims rejections.

ICD’s many intersections also express themselves in the innovative ways that organizations are managing their planning. At Christiana Care Health System in Delaware, the vice president of quality and safety serves as the executive representative for ICD-10 implementation, a reflection of the organization’s view that ICD-10 is a quality initiative, not just a reimbursement issue.

Some of the connections are a source of concern. Attendees from provider organizations expressed worry that their state Medicaid systems will not be ready for ICD-10 by the deadline.

CMS will reach out to Medicaid state providers and get them engaged, Trudel told her audience. It will make sure the states are ready, and it will begin to track the states’ progress on its Web site, she said.

…And No One Can Go It Alone

Nearly every presentation, every conversation in a hallway touched on the theme of collaboration. Whether it was collaboration between departments within an organization, facilities within an enterprise, or across all stakeholders in the industry, the need to work together in achieving the transition was a binding theme of the summit.

“Collaborate, collaborate, collaborate—you cannot do this in a vacuum. It will take all of us in healthcare to successfully implement ICD-10,” said Kimberly Telford, MBA, the director of strategy, revenue cycle organization at Intermountain Healthcare.

“Providers, payers, and vendors are all in this together,” said Dennis Winkler of Blue Cross Blue Shield of Michigan. “It is important for us all to figure it out so that on October 1, 2013, we don’t go bump in the night.”

“It is a shame it takes an initiative like this to get those three parties together to talk about what is good for the industry,” he said. “But we have a great opportunity to use this as a spring board.”

AHIMA Resources for ICD-10 Planning and Preparation

AHIMA offers many resources for planning and preparing for the ICD-10-CM/PCS implementation:

  •  AHIMA’s ICD-10 Preparation and Planning Checklist identifies high-level tasks in four stages of the implementation, including the post-implementation year. Checklists for the top-10 tasks in phase 1 and phase 2 are also available.
  • AHIMA offers both foundational information on ICD-10-CM/PCS and advanced implementation and training resources on its Web site.


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