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May 2013

Dual Coding: An ICD-10 Jump-Starter
By Elizabeth S. Roop
For The Record
Vol. 25 No. 8 P. 14

By adopting this tactic, health care organizations can accelerate the transition process.

There has been a palpable shift in the conversation surrounding the transition to ICD-10. No longer is it focused on whether the Centers for Medicare & Medicaid Services (CMS) will extend the deadline yet again (it won’t). Instead, it centers on just how soon organizations should start coding in ICD-10 to minimize operational and financial impacts once the October 1, 2014, deadline hits.

For early adopters, the opportunity to code in a dual ICD-9/ICD-10 environment can generate benefits that outweigh negatives such as productivity declines and revenue cycle slowdowns.

“There is a cost factor [to dual coding]. You have to have the ability to capture the ICD-10 codes in your system, and doing it earlier in the process means incurring those costs earlier,” says Chris Armstrong, a principal with Deloitte Consulting. “But there are also risks [to not dual coding]. If you haven’t had the practice, if you don’t do the claims testing, you face some pretty big risks on October 1, 2014.”

Mitigating the Impact
Coding in a dual environment allows organizations to test clinical documentation to identify weak areas “so you don’t have to start with a ‘big bang’ situation,” Armstrong says. “There is also the advantage of having a larger set of data that enables you to test ICD-10 claims data in your system.”

Dual coding also enables financial modeling. For example, coding a subset of claims in ICD-10 sets the stage for closer collaboration with payers through claims testing to determine how certain diagnosis-related groups (DRGs) might be weighted differently, how the new codes will affect reimbursement levels, and what edits may be required. This yields insights into the impact on net revenue or where additional or more comprehensive documentation will be required.

“It’s been pretty illuminating for both sectors to see what these cases really look like when they’re coded in ICD-10 from a DRG perspective,” Armstrong says. “Another form of financial modeling is when organizations cross-map data and performance to [create] early scenarios for a better idea of what the net revenue impact will be for [certain] claims when they build in assumptions. Those doing early adoption will have better outcomes they can look at before and after.”

More accurate predictions of the impact on productivity, staffing, and documentation improvement needs and training requirements are another bonus for organizations that opt to code in a dual environment in advance of the transition deadline.

Productivity under ICD-10 is expected to decline by anywhere from 30% to 60% and, based on Canada’s experiences with the transition, never fully recover. As such, knowing in advance how hard the hit will be helps organizations make informed decisions on how best to mitigate the damage.

“Plus, if you have coders doing dual coding, you have that education, that familiarity, so when you get to October 1 and have to flip that switch, it’s not as big of a deal as far as the learning curve. It has already happened,” says Karen M. Karban, RHIT, CCS, director of coding integrity for HIM ON CALL, which provides HIM and coding services to hospitals.

Dual coding also helps evaluate vendor readiness and support. Karban notes that while most encoder systems can code in both ICD-9 and ICD-10, the mechanics and processes for doing so may need refinement to ensure the transition goes as smoothly as possible. “That is the first thing hospitals need to do: define what they hope to accomplish with dual coding, such as abstracting, data capture, and time studies, and what vendors can do to support those,” she says, adding that the final impact “very likely depends on how well tuned the data systems are and what bells and whistles can be put in.”

Vendor readiness also extends to payers. Not all payers are expected to be ready to accept ICD-10 codes by the deadline. Organizations that have established a dual coding environment “can adapt to changing timelines and readiness situations within their trading partner environment,” says Deepak Sadagonpan, general manager of provider segments and clinical solutions for Edifecs. “Dual coding also allows a provider to be ready for ICD-10 earlier and creates an opportunity for greater rigor in the testing and validation before the deadline arrives. Their coders will get hands-on experience by applying their ICD-10 training in a production environment well in advance of the deadline, which means the transition will be a lot smoother.”

Two organizations that are making the leap to dual coding are Vanderbilt University Medical Center in Nashville, Tennessee, and the University of Utah Hospitals and Clinics. In both cases, the goal is to get coders up to speed and ensure the proper systems and processes are in place to lessen the blow on revenues and productivity.

Vanderbilt University Medical Center
Vanderbilt won’t go live in a dual coding environment until January 2014. However, planning has been under way since late 2011 when an early-adoption committee was assembled with representatives from HIM, finance, informatics, administration, and managed care contracting.

“We wanted to make sure our coders were proficient in ICD-10 before the go-live date and to ensure the documentation was ready and the specificity needed was there,” says Jennifer Causey, MSHA, MBA, RHIA, administrative director of Vanderbilt’s ICD-10 transition. “We also wanted to make sure our systems were ready. We didn’t want to do a big bang. Right now, we have 72 applications with ICD-9 codes, so we can’t just flip the switch on October 1.”

In addition to integrated testing and phase-in of ICD-10, Vanderbilt is conducting a reimbursement analysis to identify high-impact areas in the hopes that it will provide a framework for provider education. The health system also is currently implementing 360 Encompass from 3M, which enables it to track documentation gaps, a previously labor-intensive process.

“In the past, all of our query information was stored in e-mails and hard to analyze. … We are looking forward to having tools that will allow us to say we lack ICD-10 specificity in documentation,” says Theresa Zuckowsky, CBCP, MMHC, Vanderbilt’s IT program director for ICD-10. “This will drive education down to the physician level.”

Coders will phase in ICD-10, beginning with cardiology. Coding will be done in ICD-10 where appropriate and then mapped back to ICD-9 prior to the compliance date. Mappings deemed to be high risk will be extracted and audited or natively coded to mitigate risk.

Vanderbilt also is in the process of implementing computer-assisted coding (CAC), which Causey says should help limit the expected drop in productivity. However, the health system has budgeted for additional coders if necessary to deal with any backlog. In addition, it is working closely with its various system vendors to ensure everyone is ICD-10 compliant prior to the transition date.

“We have a solid plan, and we’re progressing. We have really good relationships with our vendors, and that is paying off now,” Zuckowsky says, noting that success also rests on how well the transition team communicates with every staff member affected by the transition. “We’ve tried to create an environment where people want to communicate with us because ICD codes are everywhere. … We can’t be everywhere, so we have to rely on people feeling comfortable to help us and look under every rock to find every code.”

For example, the emergency department white-board system contained ICD codes. By working with the clinical leadership to review processes and systems, it was possible to eliminate the codes from that particular system.

“You’ve got informatics and then you’ve got the business side, so this has been a really good opportunity to cross-pollinate the two. Show informatics how change impacts business, and business gets to see what it takes from an informatics perspective to get the job done,” Causey says. “We’re using the ICD-10 transition to improve processes. Even if it’s delayed again, we’re getting value from the work that’s being done now.”

University of Utah Hospitals and Clinics
University of Utah Hospitals was inspired to launch dual coding because of numerous key influences, particularly the need to differentiate between coding skill and system issues. This was particularly crucial because the academic health system is also undertaking an enterprisewide Epic conversion.

“We needed to make sure that we could separate out issues related to coding and coding skills from the issues around new systems that we have coming on just before the implementation, and the potential for all the remediation and all things coming together at the implementation date. We didn’t want to overlap technical and coder skills,” says Connie Tohara, RHIT, director of health information. “We’ve got to do all these things with physicians so we’re not competing on October 1 for their attention.”

By implementing dual coding well in advance of the mandated transition date, the organization hopes to get a better read on ICD-10’s impact on cash flow and reimbursement levels. Having data coded in both ICD-9 and ICD-10 enables true apples-to-apples comparisons.

The data warehouse pushed to start dual coding to enable remediation of data and to ensure the structures and data mapping were complete so reports could be built and ready for use on the go-live date. “My concern was productivity,” says Michelle Knuckles, RHIT, manager of inpatient coding and clinical documentation improvement. “Education is imperative, so we are fully up to speed with ICD-10 to maintain an acceptable level of productivity and to produce accurate codes. One issue that we have to deal with is the lack of documentation to support full codes in ICD-10, so we’re working on how to manage that. It is easier to walk through one coding pathway to get to both codes than it is to code in ICD-9 and then again in ICD-10.”

Clinical documentation improvement and physician education also are key. How do physicians get up to speed on the documentation needs for ICD-10 when they already have so little time to devote to learning? “We don’t want them to be coders, but the documentation they give us makes all the difference in the world,” Tohara says. “Part of the dual coding process is getting our people coding early enough so that they can be talking to the physicians.”

To help with the process, the health system leaned on 3M for its 360 Encompass, CAC, and clinical documentation improvement systems. “We are counting on the CAC productivity enhancement to allow us to stay on top of ICD-10. It’s the only way to manage a year’s worth of dual coding without adding a bunch of staff,” Knuckles says. “If we can’t enhance productivity, we’re in trouble. We’ve been worried about that since the beginning because we can’t lose half our productivity.”

The technology alleviated another challenge to dual coding: where to actually store the codes. Under the implementation plan, the new Epic system won’t be ready to accept ICD-10 codes until May 2014, which leaves little time for data collection and testing, much less training and documentation improvement activities. “It was tough for us to know that although we saw the value of dual coding, we were maybe not going to have anywhere to put it,” Tohara says.
The health system also brought in a data analyst to ensure that the reports needed to fully analyze the impact of the ICD-10 transition are properly created and available in a timely manner. “With data becoming as important as it is, it just all fits together. There are a lot of reasons why we wanted to go in this direction and dual coding is just a piece of it,” Tohara says.

— Elizabeth S. Roop is a Tampa, Florida-based freelance writer specializing in health care and HIT.


Are You Ready for Dual Coding?
At some point, every health care organization will need to code in both ICD-9 and ICD-10 for claims testing. How early they begin that process and how much they benefit depends on their individual organizational readiness.

Andy Sager, product marketing manager for the 3M Coding & Reimbursement System, notes that one of the first evaluation points is whether an organization’s upstream and downstream systems are ready to support ICD-10. “Start with an evaluation of your HIM applications,” he says. “Are they ICD-10 ready? Have your vendors communicated release timelines? Vendor readiness will influence when dual coding can be initiated.”

That evaluation also should extend to workflow analysis, which will determine whether double coding (coding first in ICD-9 and then recoding in ICD-10) or dual coding is the best approach. This determination relies heavily on the application that calls for the codes and the level of ICD-10 training for coders. “Determining when and how to implement a dual coding approach depends on many factors,” Sager says. “Coder education, vendor readiness, physician documentation, and the overall ICD-10 rollout plans of your facility should all be considered when making the decision to dual code.”

Deepak Sadagopan, general manager of provider segments and clinical solutions for Edifecs, says not every scenario should be dual coded, a process that can be labor intensive and cost prohibitive. Instead, hospitals should identify the scenarios and variables for dual coding based on the following criteria:

• level of complexity in transitioning from ICD-9 to ICD-10;

• level of financial risk or reimbursement impact; and

• level of complexity in the ICD-10 codes.

To evaluate readiness, Sadagopan suggests first conducting a documentation audit to determine whether sufficient specificity exists to support ICD-10. Then evaluate impacted systems to ensure they can handle the new code set. Finally, “Ensure an optimal resource mix by using computer-assisted coding to automate the simpler scenarios and leveraging coders well trained in ICD-10 to manage more complex scenarios.”

To determine which diagnosis-related groups (DRGs) are most appropriate to target in a dual coding environment, Karen M. Karban, RHIT, CCS, HIM ON CALL coding integrity director, recommends several approaches. One is a baseline review of 100 records to determine where the documentation is in terms of readiness. Alternatively, identify the top 25 DRGs and drill down on the complexity of cases to create a DRG review list.

Whatever you do, she warns, “Don’t put it off. Every hospital is unique. … It’s really on a case-by-case basis and all over the board, so I really hesitate to put forth an ‘expert’ opinion on how best to do it … but ‘don’t wait’ is a really good theme.”