ICD-10: Post-Implementation Challenges

If there's an October surprise, it may be that the transition to ICD-10 went off without a hitch. For many organizations, however, the surprises will be less welcome and may take weeks or months to reveal themselves.

No matter how smoothly the switch to ICD-10 may have transpired, after 36 years of using ICD-9-CM as the backbone for payment data, reports, and diagnosis and inpatient procedure coding, healthcare there are bound to be a few problems, experts say.

"Depending on how prepared the organization or facility is, they could see different issues," says Melanie Endicott, senior director of HIM practice excellence at the American Health Information Management Association (AHIMA). "There are facilities out there that have been doing dual coding for a year or six months or longer. They've had lots of practice, and will be able to jump right in."

She cautions against overconfidence, however. "Some issues that weren't identified will come to light. That's why it's important to get onboard and get everything ready."

ICD-10: Five Things Payers Want Providers to Know

Lynne Thomas Gordon, CEO at AHIMA, agrees, and compares the adoption of the new coding system to having a baby. "As any parent would know, the real work begins after you have the baby. Similarly, we need to make sure the correct metrics are in place, see how we're doing with quality, and stay on top of productivity."

Here are a few post-implementation ICD-10 problems providers may encounter:

Incorrect Code Mapping
"The 'gotchas' will be [associated with] legacy systems people were attached to because they got the job done," says Thomas Selva, MD, chief medical information officer for University of Missouri Health Care. He recently oversaw his organization's ICD-10 implementation. For example, the EHR/EMR system may still be mapping to ICD-9-CM codes. "I can guarantee that will crop up." The trick will be to quickly identify whether this is happening and to be able to fix it promptly.

Another problem: Not all reports will generate the same data as before, and may need to be re-built. "It will take at least a year until people have enough data to compare apples to apples," says Gordon.

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In the meantime, there may be a period of confusion as organizations adjust metrics from one coding system to the other.

"The best thing you can do is watch all of your reports," says Rhonda Buckholtz, vice president of ICD-10 training and education at the American Academy of Professional Coders (AAPC). "If you usually generate $100,000 daily in revenue, and now it's suddenly $50,000, there's a problem."

She recommends creating new denial codes to track where the problems are, and to expand rejection codes to cover new scenarios.

If incorrect mapping is suspected, contact any vendors involved and alert the IT team; it may take some time and hard work to reconfigure the systems, but it's necessary. If this goes unfixed, it can throw off metrics, billing, and reimbursements.

Denials
Will a provider get paid for unspecified codes under ICD-10? This is the million dollar question, says Kerin Draak, director of ICD-10 implementation at Hospital Sisters Health System in Green Bay.

CMS has said it will not audit claims for specificity in the first year. But Draak anticipates a bump in denials around November for many organizations—even organizations where leadership painstakingly tried to cover all their bases with regards to both clinician and coder training.

And she's not alone. "[Physicians] must be careful when [they] code," says Alan L. Plummer, MD, vice president of the Physicians Foundation and professor of medicine at Emory University. "If they do that, they will have fewer denials… but by and large, denials will probably go up."

It should be noted that the grace period approved by Congress earlier this year may protect organizations from many errors committed by coders who are still coming up to speed.

Denials are the source of real fear for providers, and they are the reason why many organizations have stressed training up until this point, say Gordon and Endicott.

But the training is not over. Even in a perfect world where coders and clinicians have absorbed everything they needed to know prior to implementation, there will be updates to keep up with yearly.

In the meantime, get in touch with payers and try to find out why the denials occurred. If the payer is unresponsive or the situation seems particularly dire, try reaching out to either an organization that is focused on healthcare technology, such as AHIMA, or the CMS ICD-10 ombudsman for help, Endicott suggests.

Productivity Drop
For years, critics have opposed ICD-10 in part out of fears of lost productivity—and few deny that this is a valid concern. Many point to Canada's often-cited 67% drop in productivity when the country transitioned to ICD-10.

The lack of familiarity will come as a shock to many, says Selva. "If memorized codes were something someone was leaning on, this will cut their productivity… the biggest change will be when coders are reviewing physician notes."

There is a concern shared by many that the level of specificity—and the sheer volume of codes—will prevent clinicians and coders from memorizing codes. "It will become much more complicated. There is a lot of fear right now regarding specificity. No one wants to be interrupted [to look something up] over and over again."

There's no easy solution for this one. The general consensus is that some loss of productivity is inevitable. "I think they'll be slower," says Draak.

But Buckholtz is more optimistic. "What we've seen from the coder standpoint is that after being trained for 40 to 80 hours, they do go back to old level of productivity," she says. She points out that coders will no longer have to do dual coding, which should be a relief to many departments.

Time and practice will help clinicians and coders memorize codes they use frequently, and EHR/EMR systems that auto-populate codes will also help. Now, however, might be a good time for hospital leadership to evaluate staffing levels.

Emory's Plummer suggests pairing struggling physicians with practices coders to help them adjust to the new system. "If coders are available to work with them, that's the best thing—tell them, 'don't ask another physician, they probably don't know any more than you do.'"

Perhaps most importantly, very few experts believe patient care will be impacted by the move to ICD-10. "I can rest assured that at our facility, patient care is our chief concern. We'll do everything around that as our focus. Our quality won't go down," says Draak.

Most organizations have done their homework and have spent many resources training employees and preparing, and most of them can expect a fairly smooth transition, says Gordon. "I think people are ready."