The transition from ICD-9-CM to ICD-10-CM/PCS is beginning to take shape as many providers scramble to prepare for the Oct. 1, 2013 compliance date. While some are just beginning their transition, others are thinking ahead to how they will manage the various challenges that ICD-10 will bring in 2013 and beyond. Of particular concern is an anticipated loss of coder productivity.
It is a fact that productivity decreases (at least in the short term) when workers are in training or learning a new skill. As we begin to learn more about ICD-10-CM/PCS, it is becoming clear that what we should be asking ourselves is not whether we think there will be a loss of coder productivity, but more specifically how much of a loss will there be, and for how long will it last? In our opinion a loss of productivity is inevitable, especially for inpatient coders, as they must learn two new code sets: ICD-10-CM for diagnosis coding and ICD-10-PCS for procedure reporting.
The anticipated loss of coder productivity stems from the changes that ICD-10-CM/PCS will bring, such as:
- An increase in the volume of codes available for assignment, as this figure will rise from approximately 17,500 ICD-9-CM codes to 141,449 ICD-10-CM/PCS codes for 2011;
- An increase in the number of characters comprising a valid code;
- An increase in the specificity of approximately 20 percent of diagnosis codes and 99 percent of procedure codes;
- An increase in the number of physician queries;
- An addition of alphabetical characters to what was once only a system of numerical codes;
- A complete overhaul of the procedure reporting system; and
- Changes to coding guidelines.
The increase in the volume of codes available for assignment coupled with the enhanced clinical nature and specificity of these codes will require a more intense review of documentation, leading to more dialogue between coders and providers. As a result, it could take twice as long to code and finalize billing of an inpatient record using ICD-10-CM/PCS as compared to ICD-9-CM. But as with all new things, there will be a learning curve with ICD-10, and this one is predicted to last approximately six months (this is based on Canada’s and Australia’s experiences in transitioning to ICD-10). This is not to say that on April 1, 2014 our productivity losses attributed to ICD-10 magically will be reversed, as many expect a long-term loss of inpatient coding productivity ranging anywhere from of 10 to 30 percent.
Unfortunately, lost coder productivity will not be the only impact on cash flow resulting from ICD-10. Payers are expected to take longer to pay claims, and the payment error rate is expected to rise to as high as 10 percent as a result of an increase in coding, billing and payment errors. Given ICD-10’s predicted impact on operating costs and cash flow, it becomes apparent that we must give consideration to mitigating (to whatever degree possible) a loss of productivity that could jeopardize operations.
Luckily, solutions are available, but they will require greater efficiency in preparation, implementation and management of ICD-10. We suggest employing the following strategies:
Preparation for ICD-10 (now through mid-2014):
Implement a concurrent clinical documentation improvement program immediately.
- A concurrent clinical documentation improvement program will ensure that documentation in the record at the time of discharge is clear, consistent and specific enough for coding purposes.
- If you already have a concurrent clinical documentation improvement program, ensure that you are getting the most from it by contracting for an assessment and/or follow-up visits.
- Provide coders with a proper introduction to ICD-10-CM/PCS, utilizing awareness training.
- Evaluate your coders’ baseline skills and provide additional developmental training in medical terminology, anatomy and physiology, pharmacology, and pathophysiology.
- Ensure that coders have an adequate degree of role-specific training, which consists of basic, intermediate and advanced ICD-10-CM coding training. The American Health Information Management Association (AHIMA) recommends 40 hours of role-specific training for coders. We suggest additional training, particularly in ICD-10-PCS for procedure coding.
- Devote resources toward providing awareness and developmental and role-specific training; this will improve productivity and accuracy and ultimately preserve or enhance cash flow and revenue.
- From an operational standpoint, mitigate coder productivity loss by:
- Eliminating interruptions;
- Eliminating abstracting of rarely used information;
- Hiring training an abstractor for registry data collection;
- Adding incentives for performance or introducing a career ladder program;
- Implementing a remote coding program;
- Ensuring adequate in-service and coding training based on annual audit results and changes to code sets, guidelines and payment methodologies;
- Ensuring that the content and format of the record promote timely access to, and ease of, viewing scanned images and forms. Improve the design, color, text size and organization if necessary;
- Ensuring adequate interfaces between groupers, encoders and abstracting systems;
- Resolving connectivity issues; and
- Considering automated tools such as computer-assisted coding (CAC) software applications or encoder software.
Implementation of ICD-10 (mid-2014 through Oct. 1, 2014):
First, don’t rely too heavily on contract coding services.The price of these services is expected to rise, and you still will need to monitor their productivity and accuracy, adding to the cost. Also:
- Consider hiring new graduates for outpatient coding positions in 2013 and transitioning current outpatient coders to inpatient coder positions. There has never been a better time to transition from an outpatient coding career to inpatient. Ramping up your coding team will provide a permanent solution to productivity concerns and will cost less than long-term (or permanent) dependence on a contract coding.
- Have coders specialize in specific types of inpatient procedure coding.
For example, assign one coder all thoracic procedures, and another all abdominal procedures. This decreases the learning curve and can improve accuracy as well.
Management of ICD-10 (Oct. 1, 2014 and beyond):
Manage ICD-10 by prioritizing clarification opportunities.
- Query any time there is a more specific code available in ICD-10-CM is not beneficial, or even necessarily compliant. Some detail in ICD-10-CM is informational only and will not improve your data reporting significantly.
- If clinical indicators, risk factors and impact on care are not documented, querying to assign a more specific code will not meet query guidance provided in AHIMA’s "Managing an Effective Query Process" (Journal of AHIMA 79, No.10, October 2008): 83-88..
- Weigh the cost of obtaining a higher level of specificity against the outcome.
- Avoid inundating physicians with clarifications/queries that are not truly adding value to your data or your bottom line.
Re-evaluate the diagnoses and procedures your inpatient coders currently are assigning.
- If codes are assigned for internal purposes only, determine the benefit verses the cost of doing so with ICD-10.
While a loss of coder productivity with the transition to ICD-10-CM/PCS is inevitable, the sooner you begin to accept and prepare for this new reality, the better off you will be come 2013 and beyond. Take advantage of the time remaining to prepare coders for the transition to ICD-10 adequately by providing them with the necessary awareness and developmental and role-specific training necessary to improve productivity and accuracy with ICD-10.
About the Author
Angela Carmichael, MBA, RHIA, CCS, CCS-P, joined J.A. Thomas & Associates in 2008. She is a HIM Product Development Specialist specializing in clinical documentation improvement, coding education & reimbursement methodologies. Angela earned a Bachelor of Science degree, in Health Services Administration from Barry University and a MBA from Nova Southeastern University. She is a Registered Health Information Administrator and also has achieved the designations of Certified Coding Specialist, and Certified Coding Specialist-Physician and AHIMA Approved ICD-10-CM/PCS Instructor.