ICD-10 | EMR and HIPAA

Dual Coding for ICD-10 Prep: Worth the Work?

The following is a guest post by Karen M. Karban, Director of Coding Integrity at H.I.M. ON CALL.
Karen Karban
At the recent AHIMA ICD-10 and CAC Summit, virtually every speaker discussed the need to begin dual coding prior to the October 1, 2014 implementation of ICD-10. Dual coding is the clinical process of coding and billing of encounters in both ICD-9 and ICD-10. It is one of the top four steps in preparing for ICD-10.

However, with clinical coders already in short supply, dual coding places additional demands on budget, staffing and workflow. So before your organization hires more coders and spends more money to dual-code, it’s important to take a closer look at the supporting rationale.

For Practices and Groups: Probably Not

For physician practices and medical groups, dual coding is probably not worth the work. Most practices treat only a few specific diseases, so the number of new ICD-10 codes and impact on revenue is limited. Furthermore, super bills and EMR templates are used to automatically code office visits. While physician practices and medical groups must certainly update these tools for ICD-10—as well as train staffs and educate physicians on new documentation requirements—the actual dual coding of office visits is probably cost-prohibitive. Dual coding in hospitals, however, is a completely different story.

For Hospitals: Absolutely

In the hospital setting, dual coding generates solid, comparative data for forecasting and preparing prior to going live with ICD-10. It delivers three key benefits and is absolutely necessary, even up to one year prior to the October 1, 2014 deadline.

Benchmarks financial impact and DRG shifts. Hospitals identify revenue winners and losers under ICD-10.
Assesses actual coder productivity and CDI specialist workloads in ICD-10. Hospitals calculate staffing requirements for operational budgeting.
Identifies gaps in clinical documentation that must be reinforced prior to 2014. Hospitals target physician education, fine-tune CDI specialist activities and update medical staff queries to improve documentation ahead of the ICD-10 deadline.

Dual coding helps hospitals prepare for ICD-10 and mitigate their risk of denied claims under the new coding system. Dual coding is also the first step in end-to-end testing for ICD-10, which is another key task to start this year, according to speakers at the HIMSS 2013 ICD-10 Symposium.

Beyond 2014

I don’t expect dual coding to continue past October 2014. However, providers will need to maintain a few ICD-9 skilled coders and CDI specialists. RAC audits and other retrospective reviews carry multi-year look-back periods, a few payers may not transition to ICD-10, and quality analysis and reporting will encompass both systems.

Although dual coding is a new concept for many of us, it is fast becoming common practice for most of us.

Karen M. Karban is the Director of Coding Integrity at H.I.M. ON CALL where she leads all coding initiatives.She can be reached at: Karen.karban@himoncall.com. Prior to joining H.I.M. ON CALL in 2012, she served as Director of Operations, HIM Services at M*Modal; as Healthcare Consultant at Craneware, Inc.; and as Chief of Operations – Chargemaster Services at Healthcare Concepts. Ms. Karban’s experience includes Medical Staff quality assurance, state survey corrective action plans, coding compliance plans and operational workflow redesign of coding departments. She spearheaded the Ambulatory Coding Lunch and Learn™ and is a founding contributor to JustCoding.com™. Ms. Karban remains active as a member of AHIMA. She is a past program chair of CHIMA and AZHIMA. She holds multiple certifications through AHIMA including RHIT, ICD-10-CM/PCS Trainer and Coordinator, and Certified Coding Specialist.

Hilarious ICD-10 Holiday Parody Video

Written by: John Lynn

As most of you know, Nuesoft has a great video team that’s put together some great videos in the past. Most of you will remember the HL7 Interface Lady Gaga video from Nuesoft and for those who don’t know that video, go and watch it. Sometimes we take ourselves too seriously in healthcare and these are some great reminders to keep it lively.

In fact, Nuesoft’s last video was far too formal for me. So much so that I let them know in the comments of the video how disappointing it was to have a formal video when I was use to Nuesoft’s creative masterpieces. I’m happy to report that Nuesoft is back again with a great ICD-10 Holiday parody video. I was laughing through the whole thing and I think you’ll enjoy the video embedded below.

Yes, Healthcare IT Adoption Is Expensive AND Painful!

Written by: Mandi Bishop

<Mandi’s Rant>

Few topics infuriate me as much as the notion that national standards-based implementation and adoption of healthcare IT should be cheap and easy. Haven’t we all heard the adage, “You can only have things done two of three ways: fast, cheap, or well”? Considering that the “thing” we’re trying to do is revolutionize the healthcare industry, the effects of which may be felt in each and every one of our lives at some point, don’t you want to include “well” as the bare minimum of what is required? After all, this is YOUR electronic health record, YOUR data, YOUR treatment plan and effectiveness measurements. So, what’s the other way we want this “thing” done: fast or cheap?

We’re talking about an industry that takes an average of 17 YEARS to put significant medical discoveries into routine patient care practice. (Numerous sources confirm this: The Healthcare Singularity and the Age of Semantic Medicine Translating Research into Public Health Action, etc.)

17 years is an entire generation of doctors. Doogie Howser could have been born, graduated med school, and begun to practice medicince by the time any insights from his birth were applied to practice. Suffice it to say, “fast” is not a way that healthcare is used to doing a “thing”.

Let’s contrast that with the information technology industry’s acceptance of iterative development releases and planned obsolescence for enterprise AND consumer assets. The big boys (Oracle, IBM, etc.) generally cease support of older products between 7-10 years after their introduction. Your company’s AS/400 server hardware may be 15 years old, but the O/S is the latest release, and all the data on the legacy server is preserved with the latest in backup packages over a wire-speed network connection. How long have you had your laptop? How frequently have you updated your Facebook app this year?

If someone tried to sell you a 17 year-old 480DX PC with a 9600 baud modem, 5″ floppy disk, 64MB RAM, running Windows 3.11 using the argument that, although much newer, faster, cheaper, more effective technology is available it is not yet PROVEN, would you buy it?

So, healthcare – an industry which moves at the speed of 17 years of Doogie Howser medical student maturity, and technology – an industry reinvented with the introduction of the iPhone in June of 2007, are at a crossroads for how to accomplish this “thing”: developing, implementing, and widely adopting national standards-based healthcare IT within mandated timelines that fall well within the next 10 years.

It must be done “fast”, relative to the usual pace of healthcare change.

And it must be done “well”, because it is OUR health at stake.

Suffice it to say, it will not be “cheap”. And my momma always told me that nothing worth doing is easy.

We have to stop whining about how costly and hard it is to turn this ship, and start working with the ONC on how to make healthcare IT better, faster, and ultimately more meaningful to all stakeholders involved in its use.

</Mandi’s Rant>

Keeping Up with Healthcare Regulations

Written by: John Lynn

I know that meaningful use and the EHR incentive regulatory process has been an eye opening experience for many of us that weren’t as familiar with how the government put regulations in place. However, most hospitals are quite familiar with this process since they have been having to deal with it for a very long time.

Even with all this background and expertise, I’ve heard more and more organizations telling me that “they just can’t keep up with all of the healthcare regulations.”

Think about all of the regulations in just healthcare IT. It’s overwhelming and the healthcare IT regulations pale in comparison to many of the other regulations that hospitals must know about and follow. Plus, we’re just getting started with the fun of 5010 and ICD-10 is right around the corner.

With all of these regulations I was intrigued by a new offering from HCPro I saw during the AHIMA convention in Chicago this year. While HCPro has long been a publisher of healthcare content, they have a new product they are just launching called HCPro Comply. I think the best way to describe HCPro is a portal into every healthcare regulation imaginable. Certainly you could find all these regulations in other locations for free, but there was something beautiful about having them all available in one easily searchable place.

Plus, HCPro Comply does a lot of things to add value to the regulations they make available. For example, they chunk out sections of the regulations that really matter. I remember my shock when I heard that the Meaningful Use regulation was 692 pages. Then, as I looked at the regulation, I realized that there were really only a small number of pages in the middle that really mattered since the beginning was a bunch of overview. From what I understand, HCPro uses its clinical regulation experts to help you identify and bring out those sections of the regulation that matter most.

The other part of HCPro Comply that I found quite interesting was their “Ask An Expert” feature. While many hospitals likely have someone (or multiple people) in their organization that understand regulatory changes very well, there are always situations where it’s beneficial to get outside advice and analysis about a particularly challenging regulatory change. I’m quite familiar with meaningful use, but I’m often emailing a number of other experts to either make sure my interpretation is correct or to ask about nuances I haven’t quite figured out.

One thing that I think HCPro Comply should consider adding is allowing the experts from the various hospitals share their expertise with their colleagues. I can easily see a community of healthcare regulatory compliance experts interacting on their platform to discuss the latest regulatory changes. I’m sure that HCPro has many experts on their staff, but a network of the top hospital compliance experts would be an even more powerful offering.

Now that Obama won the Presidential campaign, ACA, HITECH and other healthcare reform are here to stay. I can see portals like HCPro Comply being a great asset in the ever changing healthcare regulatory environment.

ICD-10 Benefits to Patients

Written by: John Lynn

In March I asked why we haven’t seen stories of all the benefits of ICD-10 to patients. Considering many other countries around the world have been using ICD-10 for years and years, I wondered why we hadn’t heard more stories of the benefits of ICD-10 to patients.

In the following video I asked Doris Gemmell, BSc, MBA, CHIM, Director of Coding Services at Accentus Inc. this same question and she provided a simple but thoughtful example of how ICD-10 could benefit the patient.

I’m also a big fan of Doris because she blogs about ICD-10 on her blog. I always love when smart people share their knowledge on a blog.

Clinical Documentation Upgrade Critical Before ICD-10 Conversion

Written by: Katherine Rourke

For most providers organizations, the news that ICD-10 implementation is likely to be delayed is, at minimum, a big relief. But don’t let that lull you into a false sense of relief, suggests Priya Patel of tech consulting firm Perficient. Even if the ICD-10 rollout is delayed — as many hope — until October 2013, it’s still going to happen.

So what can organizations due to reduce that weak feeling in the knees associated with ICD-10? Well, generally speaking, Patel notes, your organization is already overdue for doing an ICD-10 impact assessment to figure out how to move ahead.

While the whole assessment is important, perhaps the most important element of the ICD-10 preparation process is clinical documentation assessment, Patel says. In fact, “if you choose not to assess your clinical documentation, you will certainly lose!” Patel asserts. Lose what? Well, clinical and business effectiveness, sure, but also a great deal of money.

Right now, few doctors document efficiently enough to support coders, who are forced to do their work based on their assumptions and often, make mistakes and end up doing things over again. As things move to ICD-10, these problems are only likely to get worse, as consistency in coding will become even more important.

Unfortunately, that’s not going to happen on its own. In fact, According to Patel, a recent study of 3,000-odd medical records across the country found that only 37 percent of physician documentation in existence would meet standards set by ICD-10. Most organizations, in other words, will find that the documentation they have on hand is nowhere near as specific as it should be to support ICD-10 coding.

To figure out just how much your physicians need to improve before you transition to ICD-10, it’s critical to assess what clinical documentation gaps your organization faces, Patel says.

Anyone who reads Patel’s article and doesn’t see it as a red-hot wakeup call (deadline move-up or not) they’re crazy. It’s hard to argue that it will take a lot of time and physician training of doctors, coders and hospital staff. If your clinicians don’t drill down to codes that have the clinical impact for them, and medical coders get much more training on documentation, anatomy and physiology and disases processes, things could get ugly, Patel notes.

ICD-10 Benefits – Where are they?

Written by: John Lynn

One of the interesting topics of discussion at HIMSS was around the delay of ICD-10. However, I have yet to find an answer to what I think is probably the most important question around ICD-10. I posted the question and some other thoughts related to the question on the EHR Guy’s passionate post about ICD-10. Here’s my question and comments:

“What are the true benefits to using ICD-10?”

I’ve read story after story about ICD-10 (including this post) and so far I’ve only seen people giving general lip service to the basic idea that more specifically quantified data will somehow have a benefit to the healthcare system. Darren in the comment above says, “The fact that ICD-10 helps so many electronic and quality initiatives right now, or as pointed out above, are, in fact, required to achieve them”

What are the electronic and quality initiatives to which he speaks? What are the true benefits that we’ll get if we go to ICD-10? I haven’t seen enough of these examples.

We could also look at this same question another way. The rest of the world has been using ICD-10 for a lot longer than us. What have been the benefits that the rest of the world has seen from their use of ICD-10 that we haven’t seen in the US since we’re still on ICD-9?

I’m not trying to say that there aren’t benefits. I’m just saying if there are, then why aren’t we hearing more stories with concrete examples of the benefits? If there are, I’d love to see them and make them more widely known.

The EHR Guy offered this reply:

What you are asking for is reasonable and fair.

I will post, in a future blog, examples of why migrating to ICD-10 has beneficial clinical quality outcomes other than the intended reimbursement aspect of it which has been the main purpose of implementing it here in the United States.

But in essence a deep specificity would eliminate the erroneous coding accompanied by bulk documentation to justify the claim to be reimbursed.

Achieving semantic interoperability with erroneous coding is impossible. I’ve been in aggregation projects where abstracting information from HL7 messages was futile because no one in the healthcare organization seemed to understand what was contained in them.

This will be a very lively topic for months to come. I look forward to your participation in the discussions.

I look forward to the EHR Guy offering some more concrete examples in future blog posts. Although, I think this question deserves much more attention. I’ll admit to not being an expert on ICD-10. I know enough to be dangerous. So, I’d love to hear some of the real life benefits that ICD-10 has provided other countries and/or the benefits the US will get from ICD-10 implementation.

If we don’t have more stories and example of these benefits, then instead the stories related to the cost and inconvenience of ICD-10 (which are easy to find) will dominate the conversation. If that’s the case, then we can be sure that ICD-10 will be delayed.

Top Five ICD-10 Pitfalls – “Top 10″ Health IT List Series

Written by: John Lynn

Today is going to be the last day looking at other people’s “Top Health IT Lists” since tomorrow I think I’ll create my own Top 10 Health IT 2011 List and then for the New Years I’ll see about doing a Top 10 Health IT in 2012 list. However, today let’s look at something that will likely make the Top 10 2012 Health IT issues: ICD-10. Government Health IT recently wrote an article what they call the Top 5 ICD-10 Pitfalls.

1. Reporting: I’m sure that many think that ICD-10 is just going to happen and be fine. They’ll assume that their reports are just going to work with ICD-10 since they worked with ICD-9. Don’t be so sure. Test the reports so you know one way or another. Diving a little deeper beforehand is a lot better than learning about the problems after.

2. Overlooking impacted areas: Much like an EHR implementation, don’t forget the other people that are affected by ICD-10. Involve everyone in the process so that they can share their concerns so they can be addressed. Plus, by having them involved you’ll get much better buy in from the staff.

3. Teaching old dogs new tricks: ICD-10 is a different beast and will require significant training even if you have an expert ICD-9 coder with years of experience. Don’t underestimate the cost to train your coders on ICD-10.

4. Preparing for impact on productivity: The article mentions Canada’s loss of productivity during their implementation of ICD-10. Do we think we’re going to be any different? Remember also that productivity loss can come in a lot of different places (which is kind of a repeat of number 2 above).

5. Communicating with IT vendors: It’s one thing to trust that your EHR and other health IT vendors are prepared to deal with ICD-10. It’s another to blindly follow whatever you’re being told. Remember at the end of the day it’s your organization that will suffer if your health IT vendor is not ready. I like to use the phrase, trust but verify.

Be sure to read the rest of my Health IT Top 10 as they’re posted.

Top Health Industry Issues of 2011 – “Top 10″ Health IT List Series

Written by: John Lynn

Next up in our evaluation of the various end of 2011 Health IT lists series is one that takes a bit of a look back at 2011. In this list, PwC lists what they consider the Top Health Industry Issues of 2011. The list starts with an interesting comment about the health IT spending in 2011:

More than $88.6 billion was spent by providers in 2010 on developing and implementing electronic health records (EHRs), health information exchanges (HIEs) and other initiatives. This surge is a sign of technology’s critical place in health system improvement.

$88.6 billion is a lot of health IT spending and larger than most numbers I’ve seen. Although, most numbers I’ve seen are only the EMR and EHR market and doesn’t include HIE spending and other healthcare IT initiatives. It’s quite clear that the health IT spending is up, and up Big!

Their list of top Health issues isn’t that surprising, except possibly one of them:

Meaningful Use – This has to be topic number one for health IT in 2011. It’s had a trans formative effect on healthcare IT and EMR and EHR as we know them. Pretty much every EHR vendor I’ve talked to basically had to take an entire software development life cycle to meet the meaningful use and certified EHR requirements. This is the dramatic effect of meaningful use on EHR development.

PwC actually focuses on how meaningful use will encourage patient participation in their healthcare or “shared medical decision-making.” To be honest, I’m not sure meaningful use has done much to help this goal, yet(?). Possibly meaningful use stage 2 and meaningful use stage 3 will help to further these goals. MU stage 1 has done little to encourage this. Regardless of the impact of meaningful use, shared medical decision-making is going forward fast and furious.

HIPAA 5010 and ICD-10 – The interesting issue for 5010 and ICD-10 is that they’ve basically been overwhelmed by meaningful use and EHR incentive money. Either of these changes alone would have been a reasonable challenge for a normal year. However, clinical organizations are battling through 5010, ICD-10 and meaningful use all at the same time. Are there any other IT projects going on that don’t involved these three things? I’d say probably very few.

Electronic medical device reporting (eMDR) – I found this point quite interesting. There’s been a lot of movement in 2011 in regards to what constitutes a medical device and who should take care of tracking and collecting the adverse events that occur on these devices. I don’t think we’ve come to a final conclusion on what will be considered a medical device and how we’re going to deal with reporting adverse events, but finally getting electronic reporting of adverse events is a good step in the right direction.

Be sure to read the rest of my Health IT Top 10 as they’re posted.

Crazy and Funny ICD-10 Codes

Written by: John Lynn

The Wall Street Journal put out an interesting article about the switch from ICD-9 coding to ICD-10. The title mocks the ICD-10 codes, Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way”, and the subtitle is funny as well, “New Medical-Billing System Provides Precision; Nine Codes for Macaw Mishaps”

I must admit that I’m not very well steeped in the history of ICD-9 and ICD-10. Nor am I that familiar with the process that was used for creating the voluminous ICD-10 coding system. I’m more of a practical person and so I’ve been more interested in EHR’s ICD-10 preparedness and the timeline for ICD-10 implementation. Seems like we won’t have much choice.

I guess I should have known that going from 18,000 codes (which doctors can’t even stay up with as is) to 140,000 codes would offer some crazy and hilarious codes. Here’s some examples from the article linked above:

There are codes for injuries in opera houses, art galleries, squash courts and nine locations in and around a mobile home, from the bathroom to the bedroom.

And the appropriate follow up question from a family physician, “Really? Bathroom versus bedroom? What difference does it make?”

Some other interesting codes mentioned in the article:
R46.1 is “bizarre personal appearance”
R46.0 is “very low level of personal hygiene”
W22.02XA, “walked into lamppost, initial encounter
W22.02XD, “walked into lamppost, subsequent encounter”
V91.07XA, “burn due to water-skis on fire”

There are codes for injuries received while sewing, ironing, playing a brass instrument, crocheting, doing handcrafts, or knitting—but not while shopping. There are codes for injuries from birds such as: a duck, macaw, parrot, goose, turkey or chicken. I’d hate for my doctor to choose the “bitten by turtle” versus “struck by turtle” code. My insurance company might not reimburse the second.

Do people know of any other off the wall ICD-10 codes?

While this has me a little concerned to see ICD-10 in action, hopefully it will give all of you a good laugh going into the weekend. I can’t say I saw a code for any sort of Friday inefficiency, but there probably should be.

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Dual Coding for ICD-10 Prep: Worth the Work?

Hilarious ICD-10 Holiday Parody Video

Keeping Up with Healthcare Regulations

ICD-10 Benefits to Patients

Clinical Documentation Upgrade Critical Before ICD-10 Conversion

ICD-10 Benefits – Where are they?

Top Five ICD-10 Pitfalls – “Top 10″ Health IT List Series

Top Health Industry Issues of 2011 – “Top 10″ Health IT List Series

Crazy and Funny ICD-10 Codes

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