ICD-10 Implementation Industry Concern

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  • December 30, 2009
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Vice President, Strategic Development
American Academy of Professional Coders
Recently, I traveled to Washington and was given the privilege to attend and participate representing the AAPC in listening session with various industry leaders in December in the country including AHIP, AHA, AMA, Blue Cross Blue Shield, CMS, and many other organizations regarding the problems and challenges the industry faces when implementing ICD-10. Every organization present during the session was asked to identify key challenges when facing the enormous task of ICD-10 implementation.  The most concerning area is that most organizations including health plans, hospitals, physicians and medical practices and many others assume that HHS will push back the implementation date and most have not begun to start the process of discovery and understanding of ICD-10 with their organization.  In fact the consensus from the industry that most were ignoring the ICD-10 mandate for now. One of the most significant areas of concern was business process changes which will impact every organization and ICD-10 training.  Getting ready for ICD-10 is the most significant change that our industry will experience in decades.
During my stay in Washington, I also testified in front of the National Committee for Health Care Vital Statistics (NCHVS) on behalf of the AAPC in reference to the Impact of ICD-10 on the medical practice, outpatient hospital facilities, health plans and others.  During this meeting the NCHVS heard from various organizations involved in ICD-10 and Implementation.  One thing we all agreed on was that if healthcare organizations, providers and health plans did not begin the implementation process now, the impact will be devastating in 2013.
Five specific areas relative to the transition from ICD-9-CM to ICD-10-CM/PCS include:

  1. What business process changes are going to necessitate training across all sectors of the health care industry?
  2. What parts of the work force must be trained in health plans, health care provider organizations, and others?
  3. How will the training be delivered?
  4. What methods can be used for training hundreds and thousands of individuals?
  5. Can training programs be deployed effectively via the web to maximize reach and reduce costs?

Business Process Changes that will Necessitate Training

One of the largest problems in any medical practice is documentation of procedures or services rendered.  Physicians and other providers struggle to document the services performed in detail to satisfy medico-legal issues as well as for health plans to support the services reported on a claim.  Because of the expansion and specificity of ICD-10-CM, a provider’s documentation must be evaluated to ensure that an ICD-10-CM diagnosis code can be reported after implementation of the new code set.  Many providers will need to undergo training on how to document a more complete assessment to support the ICD-10-CM code to support medical necessity for the service provided.
Another area of concern to the providers is the use of the “superbill”.  With the expansion of codes in ICD-10-CM, many practitioners will no longer be able to use the superbill to record procedures and services, regardless of what many in the industry claim.  For example with Diabetes Mellitus there are five categories in ICD-10-CM, which are E08-E13. Within this category there are 203 codes.  In order for the provider to include all the diabetes codes on the superbill, it is most likely the superbill will be more than the one or two page document that is currently used.  Just including the unspecified codes in any diagnostic category would defeat the purpose of migration to ICD-10-CM and many health plans may not accept the unspecified code(s).
The Blue Cross Blue Shield Association started with a model superbill created by the American Academy of Family Practitioner’s practice management journal, Family Practice Management (FPM) early in 2009. The back of the superbill showed 164 ICD-9-CM diagnosis codes identified with those most commonly used by family physicians. About half of the 164 ICD-9 codes on the superbill were general codes such as “unspecified” or “not otherwise specified.” These general codes exist so that all information encountered in a medical record can be assigned a code. While they lack the specificity necessary to infer diagnosis details, they are often used on superbills due to space limitations. Continuing their use in ICD-10 will only further prevent realization of the code set’s increased granularity.
In many practices the superbill will be a thing of the past, and other mechanisms or electronic tools for capturing procedures and services will need to be developed which will precipitate the need for training on how to use these tools.
For health plans, hospitals, and providers, medical coverage policy determinations must be updated to include the ICD-10-CM/PCS code set(s) which will require medical coverage policy revisions by all health plans. This will require all who work with medical policies including the health plans, hospitals, and providers to be trained on the change to the medical policies with ICD-10-CM/PCS code sets.
From the information technology perspective, information systems will need to be upgrades and mapping from ICD-9-CM to ICD-10 must occur.  One of the problem areas that has not yet been addressed is will all health plans use the GEMs mapping files or will they map using a different methodology?  If not all health plans use the same criteria, then this could cause much confusion in the industry whereas not all ICD-9-CM codes map 1:1 to ICD-10-CM codes.  In addition, once systems are upgraded whether in the health plan, hospital, or medical practice, every staff person or department that utilizes the system whether a practice management system, encoder, and/or claims processing system will need training.
Learning the new code set(s), ICD-10-CM/PCS will be a tremendous undertaking in all aspects of the healthcare industry.  ICD-10-CM codes are not only used to support medical necessity in both inpatient and outpatient settings, used for reimbursement in the hospital setting, but are used to track mortality and morbidity. For example, a pharmacist who works in the pharmacy filling prescriptions will need a minimal understanding of ICD-10-CM coding in order to receive reimbursement for covered drugs they dispense.  Pharmacy will need a level of training based on how extensive he/she uses the ICD-10-CM codes. The level of understanding and expertise depends on the role the person plays in the health care industry.  Coders and providers will need more training on the new code sets, than the administrative staff, or someone who works in customer service in the health plan.  Even with well trained providers, coders, health plan staff, and others, it is anticipated that during the “learning curve phase” after implementation there will be a 15-20% decrease in productivity and potentially delay or denial in claims resulting from cash flow problems for providers, hospitals, and others.
What Parts of the Workforce must be Trained

All health care organizations that use diagnosis codes for data collection, and/or reimbursement, must ensure that all staff that use the code set(s) must be trained on ICD-10-CM/PCS.  The level of training and time necessary for training will depend on the role the person plays in the organization.
There are two types of ICD-10 training; implementation and code set training.  Implementation training is a step-by-step approach on how the organization will migrate to ICD-10-CM/PCS. A few of the implementation steps include organizing the implementation effort, creating awareness, implementing ICD-10 in each business area, information technology considerations as well as post implementation compliance.  Code set training is actually learning how to code with ICD-10-CM/PCS, understanding official guidelines, format and structure of the new code set(s), and the ability to translate clinical documentation into ICD-10 codes.
Within the health plan, training on ICD-10-CM/PCS will depend on the business area the staff person works in. The transition to ICD-10-CM/PCS will impact almost every business area of a health plan that works with coded diagnostic and procedural data. Those health plan business areas potentially affected include Actuarial and Underwriting, Claims Operations, Customer Service, Internal Audit and Fraud Detection, Health Care Services, Sales and Marketing, Analytics and Business Intelligence, and Provider Network Management.  In many of these areas key people will need training on implementation and strategies, while others will need code set training on both ICD-10-CM and ICD-10-PCS.
For hospitals, coders must be trained to understand the new code sets, ICD-10-CM, ICD-10-PCS and the Ms DRG conversion.  The ICD-10 Executive Steering Committee within the hospital setting must be fully involved with implementation and training key staff people and departments on implementation issues.
For providers and medical practices small to large, the implementation effort will require a person or team to oversee implementation.  Training on the elements to execute the migration to ICD-10-CM smoothly will be a key factor in the ongoing health of the medical practice. Provider groups and networks will need to understand the key implementation steps, and enable the appropriate staff and resources to accomplish this goal.
Code set training will be an important element of implementation as all health plans, hospitals, providers, coders, billers, including clinical and administrative staff that will need to have an understanding of ICD-10-CM.  The provider will not be reporting procedures with ICD-10-PCS, and will continue to use the Current Procedural Terminology (CPT©) to report procedures.  Learning one code set versus two code sets will shorten the learning time for the provider groups. However, code set training should not begin until the fourth quarter of 2012 and beyond.  The industry needs to focus on implementation education, training and execution of implementation right now.

Training Methods and Training Delivery

Training on the ICD-10-CM/PCS code sets may be delivered in a variety of methods.  There are advantages and disadvantages to various types of training.  Consideration should be taken into account when training is selected by an organization as to what type of learner is taking the training course.  Visual learners will learn more and retain information in a classroom.  This is the preferred method to learn coding as an instructor can provide guidance and clear up an inconsistencies or and provide clarity as coding is not an exact science.  However, some people are auditory learners and can do well attending a webinar, virtual meeting, or distance learning.  Other good methods include workshops/seminars and conferences that include ICD-10-CM/PCS topics.
A provider, coder, or other individual who is experienced in ICD-9-CM coding will have a much easier transition to ICD-10-CM/PCS and might benefit from a distance learning, virtual meeting or webinar module.  However many providers and coders in the industry will most likely employ more than one method for training.  A provider might take a distance learning course or attend a seminar in additional to a webinar to enhance his/her knowledge.

Using Web Based Training to Maximize Reach and Reduce Cost

The web is an important tool used for training in the health care industry.  There are several web-based methods, which include webinars, and distance learning.  Webinars are a great way to gain knowledge in a short period of time.  These meetings are typically no longer than one hour.  If a provider, health plan, or other person wants to learn about a specific ICD-10 topic this is a good training mechanism.  However, this method is not comprehensive with in many cases the learner does not get all his/her questions answered.  This method is relatively inexpensive and can be recorded and produced on demand if the learner is not available when the virtual meeting/webinar is live.
A distance-learning course is typically comprised of several modules with record virtual learning and training can occur at the user’s convenience.  It is also relatively inexpensive.  Typically there are questions at the end of each module and often a final examination to test the learner’s comprehensive of the course.  The problem with distance learning as with webinars/virtual meeting sometimes getting questions answered can be difficult.
With webinars and distance learning methods, training can occur based on the learner’s schedule, whereas in a classroom or workshop/seminar setting these dates and times are preset and might not always be convenient.


We at the AAPC have take the pro-active approach and have developed implementation training for both health plans and providers, web based training including webinars, and distance learning modules for both implementation and code set training based on provider specialty along with general code set training.  We have also developed 15-15 minute webinars for providers, administrators, and managers, and others on topics relative to ICD-10-CM implementation.
We have taken training a step farther and will be offering ICD-10 implementation boot camps, workshops/seminars and in 2013 eight regional conferences across the country to ensure every health care professional has the opportunity for ICD-10 training.
Moving to ICD-10 CM/PCS will require a tremendous effort and incur incredible cost for healthcare organizations. The major hurdles to overcome with implementation of ICD 10-CM/PCS for all health care organization include cost, timing, and complexity.  The largest problem area currently is that many health care organizations have not begun the implementation process and are expecting the date for implementation to be delayed which is a misconception and could affect the health of the organization.
The countdown is now.  Don’t delay planning for implementation.  The health of your organization depends on it!


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