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June 14, 2004

The Migration to ICD-10-CM
Preparing for the Inevitable
By Sam Nagel
Vol. 16 No. 12 p. 30

The long-anticipated upgrade from ICD-9-CM to ICD-10-CM is still at least two years away. However, if your goal is a smooth transition and quick realization of benefits, there is no time to waste when it comes to getting the planning process underway.

The main impetus behind ICD-10 was to address the serious weaknesses of ICD-9, including its poor organization and inability to expand with the changing face of healthcare. The new system, which was originally developed by the World Health Organization and clinically modified by the National Center for Health Statistics, addresses those issues by accommodating medical advances through enhanced expandability and increased capability for specificity. ICD-10 also allows for global reporting and comparison.

While no exact implementation date has been set, most healthcare professionals concur that it could come as soon as 2006. And based on experiences in other countries, a complete transition could take as long as two years for most facilities, with training and implementation expected to be the two biggest hurdles (beyond information technology requirements) to a smooth transition—hurdles that can be overcome with early planning.

The need for change
The 24-year-old ICD-9 classification system is used to measure the quality, safety, and efficiency of healthcare services, as well as to conduct research, epidemiological studies, and clinical trials. It is also designed to improve clinical, financial, and administrative outcome performances. To accomplish those goals in today’s healthcare environment, however, the system needs to expand the distinctions for ambulatory and managed care encounters, as well as to include emerging diseases and more recent medical knowledge; develop consistent and current use of standard terminology; and capture procedures being performed with new technology.

With so many limitations, it’s easy to understand why HIM professionals involved in the discussions surrounding the proposed transition to ICD-10 feel the current system has outlived its usefulness. In testimony before the National Committee on Vital and Health Statistics (NCVHS) panel examining ICD-10 in October 2003, Michael Lundberg, vice chairman of the National Association of Health Data Organizations, stated that members had already begun to identify flaws in the system in the 1990s, including the following:

• The system is outdated and inconsistent with current healthcare practice, cannot be adequately updated, and cannot keep pace with the changes in healthcare.
• The lack of space does not accommodate newly identified diseases or healthcare encounters for reasons other than treatment of disease or injury, such as preventive medicine.
• The codes lack sufficient clinical detail to describe the severity or complexity of diagnoses and, as a result, lead to inconsistent code assignment.
• The system severely limits the ability to distinguish between events that happened in the hospital and those that occurred prior to admission.
• Frequent manual review of health records is required to meet the information needs of researchers and fulfill other data mining functions.

The solution, according to Lundberg and others, is the new ICD-10 classification system, which captures greater specificity, clinical detail, and new technological procedures. The improvements in the new system will ultimately result in improved ability of providers, payors, and government agencies to measure the quality, safety, and efficiency of healthcare services, as well as reduce the need for manual review of health records to perform research and data mining. ICD-10 will also serve to enhance public health decision making and improve the ability to forecast healthcare needs.

Another key benefit to ICD-10 is that the improved structure accommodates the entire healthcare continuum, which means codes are appropriate for home health, skilled nursing facilities, acute care facilities, etc. The updated terminology and additional clinical information within ICD-10 have also been tailored to the latest accepted pathways and current clinical practice. Other advantages include the following:

• improvements in content and format, such as the addition of information relevant to ambulatory and managed care encounters; expanded injury codes; the creation of combination diagnosis/symptom codes; the addition of a sixth character; incorporation of common fourth- and fifth-digit subclassifications; laterality; and greater specificity in code assignment;
• the new structure allows for further expansion than was possible with ICD-9;
• compliance with the Health Insurance Portability and Accountability Act and improved trending abilities, as well as fraud and abuse detection;
• improved ability to negotiate contracts between providers and payors; and
• improved patient safety and a reduction in medical review of claims.

Obstacles to overcome
In spite of the many improvements it offers over ICD-9 and the endorsements of several key healthcare industry organizations, the transition to ICD-10 won’t come without a downside. Migration will require the installation of new code sets, remapping interfaces, and re-creating all reports used by providers and payors in the clinical, financial, reimbursement, and quality analysis process—modifications that will affect virtually every provider and payor system and require extensive education, outreach, and training.

Aside from costs—which are expected to run between $6 billion and $14 billion to cover information system changes, training, lost productivity, and contract modifications—perhaps the greatest obstacle will be the adaptation of software and reimbursement methodologies. The full extent of that problem will likely not be known until additional data have been tested. However, because existing software has been developed based on ICD-9—as have the reimbursement methodologies—it’s a safe bet that there will be issues to address as the transition is undertaken.

There will also be resistance to change. For some, it will be a matter of finding the time and patience to learn a new system before they can realize the advantages. For others, however, the change may be too great. In fact, some predict the challenge of updating skills will be enough to drive some coders out of the profession rather than adapt to the new system. Of course, the need to update skills isn’t limited to coders. The medical staff must also be educated on the new system so it includes the proper level of specificity in its documentation.

ICD-10’s other challenges include the following:
• Without implementation of a standard clinical vocabulary, many of the benefits will be difficult to achieve.
• In the short term, code disconnects between ICD-9 and ICD-10 could result in medical knowledge “degrading” significantly for three to five years.
• Crosswalks have not been able to address all the compatibility issues.
• During the transition period, the time required for providers and coding experts to properly code claims could increase significantly, creating backlogs and payment delays.

Fortunately for professionals, healthcare implementation does not have to take place in the dark. Several countries have already gone through the migration process, allowing the United States to glean valuable information from their experiences.

For example, in Australia, ICD-10-AM was phased in over a two-year period and has been fully implemented since 1999. In that country, a central point coordinated education, implementation kits were distributed to every healthcare facility, and postimplementation workshops were conducted to clarify any coding issues.

In Canada, which implemented a fully electronic ICD-10-CA product, the conversion was also phased in over two years and is nearly complete. There, they implemented a three-phase plan that included the following:
• a self-learning package with 21 hours of continuing education;
• two-day workshops with hands-on experience; and
• a self-learning package with 10 case studies.

Canada found the average learning curve was four to six months, which corresponded to the findings of a U.S. field test undertaken in 2003 by the American Hospital Association and the American Health Information Management Association (AHIMA) for the purpose of assessing the functionality and utility of applying ICD-10 to actual medical records in a variety of settings and to assess the level of education and training required by professional credentialed coders to implement ICD-10. Key findings from the U.S. pilot included the following:
• The majority (83.6%) of participants supported the move to ICD-10.
• The guidelines developed were identified as clear and concise by 64.5% of participants.
• ICD-10 was considered an improvement by 76.3% of participants.
• Most participants (60%) needed no more than 16 hours of training.
• Face-to-face training was preferred by 76.6%, while Internet-based training came in second at 47.6%. Hands-on training was encouraged to reinforce lessons learned.
• A majority (58.6%) of participants felt the training curriculum should begin three months prior to implementation.

The pilot project also demonstrated that documentation quality will directly impact coding and data quality; that ICD-10 will be more applicable to the non-acute setting than its predecessor; that coder productivity may increase after the learning curve; and that, based on the average amount of time to code an inpatient record using ICD-10 and if coders are working at 75%, production under the new system can be expected to be 22.5 records per day.

Training is critical to success
Armed with the results of the U.S. field test and the lessons learned from Canada and Australia, U.S. facilities are strongly encouraged to begin the planning and preparation process now to ensure the smoothest possible migration from ICD-9 to ICD-10.

While adaptation has not been difficult in other countries, the level of effort—including developing an inventory of affected software products and complete vendor information, ascertaining vendor plans for transition, developing training programs and documents, and updating forms and records—requires ample time for preparation, training, implementation, and troubleshooting.

In fact, the preparation for migration to ICD-10 actually involves two distinct tracks: personnel training and implementation. Implementation can take more than two years based on the level of detail involved (see sidebar). Developing and conducting the training program is a two-year process that involves multiple departments, including coding, case management, human resources, clinical, and HIM.

The first step in developing a comprehensive, effective training program is to measure coders’ baseline knowledge of anatomy, physiology, medication, and medical terminology and to enhance and/or update as needed to prepare for ICD-10’s higher level of detail. This process can take up to one year and is critical for laying a solid foundation for the upgraded system. Ensuring that coders’ baseline knowledge is at the appropriate level will ultimately shorten the learning curve and reduce the level of degradation of medical knowledge while lessening anticipated backlogs and speeding the realization of benefits from the new system.

One year prior to implementation, it’s time to begin the documentation training process, with a focus on reinforcing best practices through enhanced communications. This involves working with multiple departments and focusing on the unique ways each will be impacted by the transition. For example:
• Coders: Reviewing and improving the query process
• Case Management: One-on-one documentation training with physicians and training on the process of obtaining complete documentation prior to patient discharge
• Human Resources: HEDIS (Health Plan Employer Data and Information Set) requirements
• Primary Care Physicians: Reinforcing documentation “best practices” and drilling on specifics
• Radiology: Training on the inclusion of specific anatomic locations and identification of right and left within all interpretations
• Cardiology: Training on the inclusion of specific anatomic locations and severity (acute vs. chronic) within all interpretations
• HIM: Training on performing concurrent analysis, discussing documentation needs with ancillary departments, and reviewing documentation forms to identify deficits

Four to six months prior to implementation, the training focus should become more in-depth for coders, as well as case management and utilization review departments. Higher-level training should also be instituted for the business office, registration, administration, information systems/services, human resources, and planning.

Three months prior to implementation, ICD-10 case studies should be shared with coders and case managers to help put a “face” on their training. Further, all impacted employees should be educated on the new ICD-10 guidelines and in-depth discussions should be held to review any new policies and procedures that result from the implementation.

One month prior to implementation, it’s time to measure coders’ current understanding of ICD-10 and customize learning schedules to fill any knowledge deficits while still providing standard training. This is also the time to formalize new policies and procedures for coders, the business office, case management, patient intake, etc. Communication will ensure everyone is not only well versed in the new system but also comfortable in its use and confident in their skills and understanding of the new system.

Go it alone or seek outside help?
As with any major migration, consideration should be given to whether a facility can go it alone or if outsourcing all or part of the process is a worthwhile investment.

In some cases, an outsourcing partner may have a distinct advantage in several areas, in particular with education of internal and medical staffs. Often, an outside resource can conduct necessary educational sessions without the distraction of internal politics. Also, an outside resource can often take an objective “snapshot” of implementation problems and suggest solutions for areas that are deficient.

Other roles an outsourcing agency can play include the following:
• cleaning up old accounts while new claims are handled by the internal coding staff;
• taking some of the pressure off the internal coding staff so they can slow down and place an initial emphasis on achieving a high level of quality when utilizing the new system;
• monitoring and trending coding quality under ICD-10;
• providing coverage while the coding staff is training on the new system; and
• filling interim gaps in coverage due to turnover.

Facilities should base the outsourcing decision on factors that encompass both cost and internal resources. Look at current staffing levels and volume, as well as anticipated levels for October 2006 and October 2007. Understand what challenges the facility will face during the training and implementation process.

In some instances, outsourcing will be a contingency plan. If that is the case, start developing relationships now as agencies are likely to be in high demand during the implementation year, and loyal customers will get preference.

The time is now
Regardless of how highly anticipated it is, the transition to ICD-10 will not be without challenges. That is why information, education, and advance planning are critical to success.

Detailed ICD-10 information is available from a variety of sources, including the AHIMA (www.ahima.org), the NCVHS (www.ncvhs.gov ), the Centers for Medicare & Medicaid Services (www.cms.hhs.gov), and the National Center for Health Statistics (www.cdc.gov/nchs). Several books have also been published on the subject.

The key is educating yourself and your facility on ICD-10. By doing so, you’ll see there is no reason to fear the new coding system. Also, by starting the planning process now, issues can be identified and resolved early on, making the final transition as stress-free and successful as possible.

— Sam Nagel is group vice president, HIM/medical records and special services for Kforce Inc., a full-service professional staffing firm providing flexible and permanent staffing solutions in more than 40 North American markets, as well as through online services.

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