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May 2015

Don't Sleep on ICD-10 Testing
By Ken Edwards
For The Record
Vol. 27 No. 5 P. 31

The value of ICD-10 testing is deeper than confirming that your software is up to date and your vendors are tuned in and ready to provide support throughout the transition. Testing is a time-sensitive training and learning opportunity for everyone involved in the process, from the health care organization to vendors and payers. However, it's perhaps most important for key frontline employees.

For back-office administrators and staff, testing is a chance to examine existing claims management processes with fresh eyes and an opportunity for deliberate, structured reflection among teams whose workday is likely fast-paced and nonstop.

Organization leaders should be confident that ICD-10 testing is worthwhile. The initiative directly supports a facility's ability to execute properly when the financial and operational impact of ICD-10 becomes real as opposed to imagined and subject to ongoing doomsday hyperbole. Yet the fact that the stakes are lower before go-live should not lead organizations to lose sight of the testing's urgency or true goals. The objectives are to figure out what isn't working, perfect new processes to preempt those errors moving forward, and ferret out imperfections that create bottlenecks or otherwise limit efficiency.

Defining, and Adding, Long-Term Value
Regardless of whether ICD-10 ends up being delayed yet again—which appears increasingly unlikely according to many industry experts—a culture of collaboration among staff, vendors, and payers will pay off for years to come. As public and commercial payers continue to accelerate their shift toward value-based and accountable care models, it will be necessary to test, analyze, and optimize new functionality and processes that support these still-developing platforms. In fact, that may be a hallmark of the shift toward value-based care: fundamental and potentially disruptive change that requires collaboration and collaborative testing.

Framing ICD-10 in the context of other major health care shifts can help organizations transcend any past disagreement or debate. And reframing the value of ICD-10 testing creates something of a blank slate for those who opposed—or still oppose—moving to ICD-10. It frees them from concerns driven by ego or self-consciousness, making it easier for them to commit and participate in testing and training without feeling like they "gave in" or "switched sides."

Leveraging Clinical and Financial Arguments
ICD-10 will provide additional and more granular detail about chronic diseases, comorbid conditions, disease management best practices, and mental health care—just to name a few top-of-mind examples. In aggregate, this detail will become a rich source of insight for evidence-based medicine and possibly accelerate the research process since historical data (both coding and clinical documentation) will be more comprehensive and specific. The data will underpin newfound abilities to manage population health by enabling informed, accurate segmentation of patients within existing disease registries or among previously indistinguishable subsets of patient populations.

Other examples in this vein may include the following:

• Physician Quality Reporting System (PQRS): In many cases, the details needed to support PQRS reporting also are needed to support ICD-10 coding. Are you reporting on smoking status and cessation for PQRS? You'll also need to record smoking status to avoid ending up with an unspecified code under ICD-10. Or take reporting on Measure 117: Diabetes: Eye Exam. For any diabetic patient who becomes pregnant, it's necessary to record the trimester in which the eye exam takes place. Similarly, ICD-10 requires the trimester for nearly every type of encounter with every pregnant patient to be recorded.

• Population Health Management: Fee for service isn't going away, but as fee for value rises, identifying and addressing gaps in care, along with other aspects of population health management, are more likely to impact an organization's overall clinical and financial performance.

Fee for value requires clinical integration and comprehensive longitudinal records of care. The quality of those records starts with the granularity and quality of the documentation—the same foundation required for accurate ICD-10 coding. Whether an organization strives to meet specific quality measures for a state incentive program or takes on new risk-bearing contracts with payers, documentation plays a significant role in successfully navigating fee-for-value models. Among other things, it determines how wisely an organization expends case manager hours and other care intervention resources.

State It Plainly — Sometimes It's Necessary
Claims rejections and denials are frustrating for everyone. They create backlogs, delay revenue, and drive up costs by forcing rework and appeals. If the backlog becomes unmanageable, the inability to meet timely filing requirements results in either lost revenue or long hours and extra stress for back-office staff.

ICD-10 testing is an organizational and industry imperative. Leaders must do whatever it takes within reason—don't lock the doors until testing is complete—to not only make it happen but also make it worthwhile rather than a pro forma exercise. That means being a relentless advocate for its value and a nimble articulator of its benefits. In some cases, it means going to the mat for the resources necessary to jump-start testing with vendors and payers—and in all cases it means ensuring results are thoroughly analyzed and insights are diligently acted upon. It means refusing to let your commitment waver and to let anyone's lack of commitment derail the overall initiative.

The responsibility doesn't fall to one individual. It's on all of us.

— Ken Edwards is vice president of operations at ZirMed, specializing in operations management and leadership.