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ICD-10 is Coming: 10 Steps for Full Implementation

Deborah Grider, senior manager with Blue and Company, offers 10 steps to prepare for full implementation of ICD-10.

1. Keep executive stakeholders, steering committee and subcommittee up-to-date. The organization's steering committee should develop an ICD-10 implementation subcommittee to manage and report on the progress of ICD-10 implementation. The subcommittee should meet as frequently as the steering committee — which could be monthly or bi-monthly depending on the size of your organization.

"The subcommittee brings the issues related to ICD-10 to the forefront and discusses what is working and what the challenges are," says Ms. Grider. "The steering committee approves actions going forward and provides guidance. When people leave the meetings, they shouldn't be confused about what needs to happen going forward."

The subcommittee should work on these aspects of the program:

•    Budget
•    Impact assessment
•    GAP Analysis
•    Building the Project and Action Plans
•    Building and Education and Training Plan

"There is a big push right now for coder assessments on the anatomy, physiology and pharmacology associated with the code changes," says Ms. Grider. "I've worked with hospitals that say they are 90 percent sure their systems are ready for ICD-10, but after the impact assessment we are only finding them 60 percent sure. We need to look at all the systems and process that must be pulled together and know whether they can integrate or if we need to update them for ICD-10."

2. Continue to meet regularly with ICD-10 subcommittee. The subcommittee should meet regularly to identify where the organization is at and construct a reasonable timeline for ICD-10 implementation. The timeline should include:

•    Impact assessment
•    GAP analysis
•    Report on the current state of the organization
•    Ongoing update of the budget
•    Project plan development

"Once the preparation work is complete, a project plan should be developed to identify every action item," says Ms. Grider. "This plan should consider how implementation will start, how many days it will take and who is responsible for each step. Progress must be discussed at every meeting so people know where the organization is compared with where they started."

3. Complete the impact assessment.
The next step is to complete the impact assessment, which identifies all areas and departments that are affected by the ICD-10 transition. Healthcare organizations are at various places with current coding efficiencies, and the more efficient they are with ICD-9, the easier their transition to ICD-10 will be.

"We are looking at how organizations use ICD-9 codes currently, what reports they generate that are tied to coding and reimbursement as well as workflow so we can assist with implementation and assist with improving information as we go along," says Ms. Grider. "Some organizations just survey department heads, but my team suggests interviewing each department head in person with questions about their workflow. Most of the people you are talking to know coding ties into the success of their department but don't deal with it on a day-to-day basis."

By sitting down with the department head, you can spend 30 to 40 minutes figuring out how the department works, what reports they are using their most utilized diagnosis codes and what software they use. In some cases, if you just send a survey people will send it back incomplete, so by meeting in person you can gather all the information you need in a timely manner.

The discussion should include information such as:

•    Where the department has deficiencies
•    What their workflow looks like
•    Whether they are all paper, all electronic or a combination of both
•    What software programs they are currently using and what additional tools they need

4. Conduct a GAP/Solutions analysis.
The GAP/solutions analysis should identify who the ICD-10 transition impacts, the current state of the organization and where you want it to be in the future. The two most common challenges from healthcare organizations include: whether documentation is sufficient for the transition and how to integrate systems that will accept ICD-10 codes.

"Clinical documentation that was good for ICD-9 is not sufficient for ICD-10 because the codes have been expanded for detail," says Ms. Grider. "Look at the documentation now and see what they are missing for ICD-10. After the analysis, you might find that physicians need to provide additional information in their orders for the clinic to treat patients and code their claims."

There are programs being developed to assist physicians during the documentation process to query physicians for more information, including pop-up reminders. These programs may make it easier for physicians to document for ICD-10, and are more efficient than coders emailing physicians after the fact asking for more information.

The second challenge is integrating systems to support ICD-10, and those that won't integrate will have to update their systems. "We have to test their systems and decide how to integrate or upgrade," says Ms. Grider. "Know how long it will take and prepare payors to test with you. Figure out what kinds of algorithms they are building into their systems to drill down to more specific codes."

In some cases, electronic health records already have algorithms built in, while others are purchasing computer assisted programming. "There is a lot the information technology department has to do to get ready for ICD-10," she says.

5. Build your communication plan and update the schedule periodically.
It will be important for the ICD-10 subcommittee to communicate regularly with all stakeholders, including the board of directors, CEOs and the medical director, and the entire organization. These updates can happen at the regularly scheduled meeting, but if you need more immediate action have a communication process in place to keep everyone updated.

"Stakeholders have to be informed if they are on budget and on their timeline, and know what barriers they still face," says Ms. Grider. "For example, if there is an upgrade on an electronic medical record that is more than $30,000, you might not have time to wait until the monthly meeting to approach that issue. It might be necessary to send out a group email so people are able to see the information quickly."

The subcommittee may also need to send emails with immediate barriers that need fixing and consider ways to become more efficient. Put together a monthly email blast between meetings to keep people up to date. "Establish how you want to communicate on the front end," says Ms. Grider. "There is a lot of unknowns and confusion around this transition."

6. Complete and update the budget.
Make sure you review the budget routinely to account for unexpected costs outlining the project versus expenditures. Ms. Grider arranges the budget into different categories:

•    Clinical documentation for improvement
•    Educating physicians on documentation
•    Coder recruitment

"We are looking at lower productivity at least throughout the first year after implementation," says Ms. Grider. "Some countries realized a 50 percent drop in productivity in the first six months, and their challenges were less than ours. We have to prepare for that so we are looking for coder recruitment and productivity."

Figure out how many coders you will need to bring on in the short and long term to keep productivity. Also consider current coders' salaries and whether those need to be increased so they'll stay with your organization throughout the transition. Finally, think about how much training you will provide coders on ICD-10.

"I estimate training will go through 2016 because there will be some coders who will need retraining because they didn't understand the first time, and there will always be new coders coming into the system," says Ms. Grider. "When you build a budget for ICD-10, identify assumptions such as how many physicians you have now and how many coders you anticipate needing. Make sure human resources people are involved so they can determine compensation increases and how many hours you need."

7. Develop a training plan for coders and others.
Coders will need extensive training in ICD-10, but so will other members of the department. Many staff members will need some sort of training in these topics, which will take an extra time commitment from them as well.

"A lot of the training for coders can be conducted via internet or online learning," says Ms. Grider. "Some will go to seminars to achieve it. A lot of groups are doing the coder assessment to see what their coders need to get up to speed. Some places have a 'trainer-to-trainer' model and others will bring trainers in or go to courses so everyone is educated at the same time."

Inpatient coders will require approximately 60 hours of coding training, while outpatient coders will need 16 to 20 hours. You will also need to train physicians in how to document for ICD-10 and nurses so they understand patient access codes.

"They need new information to code and how to use the templates and forms built into the EHR to gather more detailed information," says Ms. Griter. "They need to be trained on what information they need to gather and why. You have to look at the entire organization. For the billing and revenue cycle team, they have minimal or no coding training; it's beneficial to get them some training so they can look at a denial for a diagnosis to and determine why instead of writing it off."

8. Develop the action plan.
Subcommittee members will develop the action plan, which is overseen by the steering committee. For example, if you are developing electronic templates for physician orders, you will have a team of a few department heads on the subcommittee to make sure they are developing those tools.

"Certain people are responsible for that team and they must work together to make sure each action item is executed," says Ms. Grider. "Otherwise, they need to have an answer as to why it couldn't be executed. The action plan is the most important piece of phase two of implementation because you are making sure things occur on a specific timeline."

If the organization is relatively small, things can be done quickly. However, there are some things that require waiting several months before completion.

9. Develop a work breakdown structure.
The work breakdown structure will identify who is responsible for which steps of the action plan. Take the action plan and list what needs to be done. Assign each point to a specific person.
"Know what needs to be accomplished and what the timeline is for each item," says Ms. Grider. "Drill down details to the minute. For example, an action plan that is 30 pages long and involves three departments, within each department there are things you need to accomplish. If you break it down into small pieces by department and make a certain person responsible for each action item, it's more manageable."

10. Execute the action plan.
After you've finished planning and developing the work breakdown, it's time toe execute the plan. "There are a lot of organizations out there that have started this process—some have built their steering committees and others are just beginning to think about ICD-10 — and other organizations that are waiting to see if it is delayed again," says Ms. Grider. "The more arguments that represented against moving to ICD-10, the more skeptical people will be."

Regardless of whether the next deadline is enforced, ICD-10 will become the standard at some point in the future and organizations could be problematic if they aren't prepared.

"It will be devastating if we go live in 2014 and 5 percent of the providers in the country aren't ready," says Ms. Grider. "If they aren't ready for ICD-10, their reimbursements are going to stop. It's better to be ready and if they delay it again, at least you are ready."

More Articles on ICD-10:

3 Tips for Designing an ICD-10 Financial Risk Assessment Proposal

5 Things Hospital CFOs Should Know About Accounting for ICD-10 Related Costs

5 Steps to Prepare for ICD-10

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