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Have No Fear of ICD-10
By Christopher Burgess

Over the past year, there has been a great deal of discourse surrounding the mandatory transition from ICD-9 to ICD-10 to occur by October 2014. The Centers for Medicare & Medicaid Services (CMS) noted in 2008—and continues to detail—how ICD-9-CM does not provide the necessary level of detail on either patients’ medical conditions or procedures performed on hospitalized patients. The CMS notes ICD-9-CM is more than 30 years old, outdated, and utilizes obsolete terminology married to outdated codes producing inaccurate and limited data that are inconsistent with current medical practice (See CMS ICD-10 Overview).

That said, in late 2011, the CMS conducted a readiness survey in which 26% of providers indicated they are at risk of not meeting the compliance date, which at the time was October 2013. (Health and Human Services has since approved a new compliance date of October 2014.) In April 2012, the CMS requested formal comments on a proposal to delay the 2013 compliance date for the ICD-10 data code sets for a period of one year. (Note: The author filed a formal comment to the CMS with respect to the proposed delay. A copy of the submission is available here.)

Technologists’ Thoughts on the Transition
AHIMA has endorsed the ICD-10 transition and formally urged the CMS not to delay the transition but, if necessary, to make the delay brief. Similarly, HIMSS supports the transition. Indeed, HIMSS and AHIMA have jointly produced the informational document “ICD-10 Critical Pathway for Getting Started—2012 and Beyond.” HIMSS noted in February that its research showed approximately 90% of the 302 HIT executives participating in a HIMSS survey on the topic of readiness expected their entities to be ready for the ICD-10 implementation date, which was October 2013 at the time.

MDs’ Thoughts on the Transition
The American Medical Association (AMA) has not minced words with respect to its desire to see the transition tanked and a review conducted as to the efficacy of an ICD-9 to ICD-11 transition. On the other hand, the Association of American Physicians and Surgeons, which also is comprised of medical doctors, has stepped right over the ICD-10 transition discussion and reiterated its long-standing suggestion that the AMA’s CPT codes should be tanked.

The less-than-lukewarm attitude from the physician community toward ICD-10 is understandable because it requires doctors to learn a host of new codes and be more specific in their documentation. However, ICD-10 poses new opportunities to improve care, documentation, and billing accuracy.

There are gaps and challenges to implementing ICD-10 that require the use of drastically new technologies and approaches. Healthcare providers whose implementation includes the mastery of machine learning technologies and natural language processing are poised to bridge these gaps more effectively. This approach goes beyond what is currently being offered by the coding software companies.

Concerns With ICD-10 Implementation
• More medical coders needed: Will there be a need for doubling or even tripling the number of medical coders in order to address the increase of coding options (40,000+ for ICD-9 and 177,000+ for ICD-10). If your organization performs coding manually without a computer-assisted coding application to assist or if you are utilizing a manual or pseudoautomatic application that does not adhere to the CMS’ General Equivalence Mappings (GEMs) guide, you have some heavy lifting ahead. Investigate the advanced intelligent technological solutions that are available. These solutions prove the axiom “work smarter, not harder,” as the applications can process the EMRs directly to ICD-10 from its native state, plus utilize an ICD-9 to ICD-10 translation map. These solutions greatly reduce or obviate the need for an increase in the number of medical coders.

• Revenue: The bottom line will go south due to the expense and difficulty in implementing ICD-10. Organizations will need to increase their cash on hand from 30 days to 90 days to 180 days. Accounts receivables will double, and the human capital expense associated with the increased number of coders will be staggering. These concerns are very real. Absent mitigation, they could individually or collectively cause an entity to reduce services or shutter their doors, neither of which is a desirable outcome.

• Training staff: There will be an expense to train medical staff; the key clearly is to reduce cost while maximizing training outcome. One solution is to process for ICD-9 and demonstrate ICD-10 contemporaneously. This allows medical staff to be coached on the verbiage to use with ICD-10 while smoothly processing ICD-9. In the end, the medical staff will achieve dexterity in crafting medical encounter verbiage for ICD-10 as currently enjoyed within the ICD-9 rubric.

• Cash on hand/accounts receivable: The discussion on the need to increase cash on hand and watch accounts receivable be doubled is largely centered on the erroneous expectation that transition is going to result in less accuracy. If accuracy diminishes, it will result in challenged claims and reduced payments. Advanced intelligent solutions increase accuracy and revenue due to reduced underbilling. Accuracy also reduces accounts receivable (see coding accuracy below). As noted, beginning contemporaneous processing now provides users a minimum of a one-year head start on transition, and seeing does evolve into believing.

• Vendor readiness: EMR/EHR vendors aren’t ready; they have an automated lookup system that is cumbersome. As noted previously, 90% of HIT departments believed they were well positioned to achieve technological readiness by October 2013. Now, with an October 2014 deadline, the transition should be achievable.

Applications exist that marry to any EMR and process in both ICD-9 for today and ICD-10 for tomorrow. Clearly, not all healthcare providers have the luxury of an IT department to address preparedness; therefore, ease of use will be a significant differentiator.

A quick online search reveals a large number of vendors with ICD-9 to ICD-10 transition capabilities, including the major EMR/EHR providers. True, some of these are less intuitive than others or involve more manual steps, but this doesn’t negate the fact that vendors have been thinking about the transition for the past three to four years. Most traditional vendors are there to help but not solve the deep problems associated with ICD-10 coding. A different approach and a fresh perspective are needed.

Automatic coding technologies are available today and can be proven to assist with ICD-10 transition. Not all vendors are ready, but those who rely on new technologies are better prepared to get you there.

• Coding accuracy: Coders will make mistakes. As mentioned above, the CMS has provided the GEMs to assist coders with transitioning their understanding from ICD-9 to the appropriate ICD-10 codes. To that end, vendors, coding experts, and solution providers have created mapping tools, some manual, some semiautomatic. These are evolutionary solutions. Revolutionary solutions use natural language processing, pattern matching, or rule-based system technologies. These solutions read the EMR and automatically generate the requisite codes, which the coder then reviews and validates. The revolutionary technologies also include a machine learning component that ensures the consistency of medical coding results.

Additionally, an audit tool is a hospital administrator’s best friend. Fortunately, coding audit tools can be acquired and implemented quickly thanks to new technologies and cloud-based computing.

Existing technological solutions have evolved and indeed revolutionary solutions exist and are available to assist every entity, be they a small single physician practice or the largest research hospital in the country. The utilization and advancement of the ICD coding systems since 1893 has facilitated the continual advancement of healthcare transformations. According to HIMSS, “ICD-10 is the very basic foundation for other healthcare transformation efforts, including meaningful use.” AHIMA has gone on the record noting, “Without ICD-10 data, there will be serious gaps in our ability to extract important patient health information that will give physicians and the healthcare industry measures for quality of care, provide important public health surveillance, support modern-day research and move to a payment system based on quality and outcomes.”

There is no reason to fear the ICD-10 transition; it does require good planning on your part and selecting a leading technology partner to cross the chasm. The transition to ICD-10 is achievable today if you break away from the traditional coding software and think about taking a new course with solution providers offering new technologies such as natural language processing and machine learning systems. Advances in healthcare will be provided tremendous lift with adoption. Advances such as individualized medicine (both predictive and preventive), accessing and interpolating global health data, improving and evolving clinical decision-support tools, and optimized billing and revenue capture are all enabled by ICD-10.

— Christopher Burgess is chief operating officer and chief security officer at Atigeo, a technology company delivering, via its xPatterns, big data cloud software solutions that provide intelligent analytic solutions in a variety of industries, including healthcare. Atigeo will be at booth 855 at AHIMA.