Preparing Your Hospital for a Successful Implementation to ICD … · 2012-10-04 · Preparing Your Hospital for a Successful Implementation to ICD-10-CM and ICD-10-PCS Saturday,

Preparing Your Hospital for a Successful Implementation to ICD-10-CM and ICD-10-PCS

Saturday, July 28, 2012 Taiwan Medical and Health Information

Management Association Nelly Leon-Chisen, RHIA

Director Coding and Classification

American Hospital Association

Objectives

• Understand how to build a strategy for implementing ICD-

10-CM/PCS in a hospital environment.

• Describe key elements required in a plan for successful

transition to the ICD-10-CM and ICD-10-PCS systems and

its impact to your facility.

• Make recommendations to organize your ICD-10 transition

team and develop the team’s ―to-do‖ list.

• Understand the role and function of different levels of

hospital staff: executive management, medical staff, health

information management and other departments.

Copyright (c) 2012 by American Hospital Association. All rights reserved.

2

Develop ICD-10 Strategy

• Communicate • Plan • What will it take? - Working on systems

- Time to test internally - Time to test with external

partners - Training • Determine training needs

(different levels) - Documentation improvement

Copyright (c) 2012 by American Hospital Association. All rights reserved

3

Large, Medium or Small

• The level of complexity to implement ICD-10-CM/PCS will

depend on a number of factors

including - hospital size - organization of the hospital - level of automation - the number of electronic databases and

- functional areas affected • But the basic components of the

implementation plan will be the same.


4

Implementation Phases

Implementation is divided into four phases:

Phase 4

Phase 1

Organizing the Effort

Phase 2 Planning and

Impact Analysis

Phase 3

Implementation

Post- implementation

Evaluation and

Ongoing Efforts


5

Sample ICD-10 Timeline Developed

Source: American Hospital Association, HIPAA Code Set Rule: ICD-10 Implementation, Executive Briefing


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Strategic Planning and Opportunities

• Successful transition requires careful strategic planning and coordination of resources across the entire hospital

• Begin by examining every application where diagnosis or procedure codes are captured, stored, analyzed or reported

• Engage executive leadership • Address challenges across a wide-range of functional areas • Address implications to current and future information

systems • Review current work flow and medical documentation practices


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Role of Executive ICD-10 Sponsor

• Organizational Executive ICD-10 Sponsor - Assist in prioritizing ICD-10 activities over other

organization-wide initiatives - Ensure collaboration among departments

- Ensure budgeting issues are considered organization-

wide - Report progress of ICD-10 implementation to CEO and

senior management - Report progress to rest of senior management group


8

Phase I - Organizing the Implementation Effort

• This phase will involve: - Organizing your cross

functional Steering

Committee - Selecting a Steering

Committee leader - Developing a meeting

schedule - Identifying required tasks

and developing timelines - Assigning tasks and

responsibilities


9

Communication!

• Organizational awareness • Sharing of information • Communicating and more

communicating


10

Organizing Your Cross Functional Steering Committee

• Not just a ―coding thing‖

• Who is in charge?

• Collaboration among departments will

be necessary to identify information

systems affected

• Members across clinical, financial and

information systems area

• Get support from executive

management

• Be sure to involve both HIM department

leaders as well as coders


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Cross-functional Team

• Convene a cross functional Steering Committee to:

- Identify system applications

affected - Assign tasks and responsibilities to carry-out the necessary

changes • Approach will vary from hospital to

hospital, but cross functional team is a necessity!


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ICD-10 Steering Committee Composition

• Leadership - Sponsorship and support from a senior

level manager to ensure coordination

across departments • Core Steering Committee Members

- Health Information Management - Information Systems and Technology - Billing - Finance - Compliance - Revenue Cycle Management


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ICD-10 Steering Committee Composition (cont.)

• Ad Hoc Team Members - Quality

- Registration - Nursing - Clinics - Emergency Department - Pharmacy - Medical Staff Affairs - Outpatient Surgery

- Ancillary services such as:

• Imaging • Laboratory Services • Cardiology - Rehabilitation

- Home Health - Urgent Care - Therapies - Utilization Review

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Organizing the Implementation Effort

Tasks

Develop implementation goals Develop plan for assessing implementation

impact Develop implementation strategy Develop tools to assess impact on affected

functional areas Identify Steering Committee’s required

tasks Develop timelines Assign responsibility for tasks

Educate IS staff on code sets


15

ICD-10-CM/PCS Implementation Meeting

• Bring together IT and HIM - leaders • Include other key stakeholders - Develop a contact list

• Agenda to include what the 5010 and ICD-10 initiatives are • IT areas of concern—discuss • IT tasks for next 60-90 days • HIM areas of concern—discuss • HIM tasks for the next 60-90 days • Other areas of concern—discuss • Action to be taken - Develop assessment tool(s)

• Working project plan and timelines • Budget considerations • Next meeting


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Large Hospitals May Need Additional Work Groups

• Work Group - Communications • Work Group - HIPAA v5010 • Work Group - Budget and Standardization • Work Group - IT Enterprise Planning - Work Group - IT Integration

• Work Group - ICD-10 Coding • Work Group - ICD-10 Business Process Change • Work Group - Vendor Relations • Work Group - Patient Financial Service/Business Office • Work Group - Managed Care Contracting • Work Group - Clinical


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ICD-10-CM/PCS Awareness

• Important to have the

―correct‖ awareness and facts

about ICD-10

• Prepare an ―Executive

Summary‖ (1-2 pages)

- What is ICD-10

- What is the impact

- How do we prepare

- Distribute to Executive

Management

• Prepare a high level overview

for HIM Coding staff


18

Role of ICD-10 Steering Committee Lead

• ICD-10 Steering Committee Lead - Convene ICD-10 Steering Committee meetings

- Set ICD-10 Steering Committee meeting agendas - Report progress to ICD-10 sponsor - Keep track of implementation progress


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Phase 4

Phase 1



Impact Analysis

Phase 3

Implementation


Evaluation and

Ongoing Efforts

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Phase II - Planning and Impact Analysis

• This phase will involve performing an organizational assessment and developing an implementation schedule

including: - Conducting an information systems inventory - Assessing vendor readiness and support - Conducting staff awareness sessions - Assessing and planning for staff training needs - Identifying necessary tools - Identifying areas requiring operational and policy changes

- Evaluating health plan contract implications - Budget planning - Identifying gaps in health record documentation


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Organize Departmental Assessment

• ICD-10 will impact different departments differently • Each department should conduct internal assessment and report findings back to the ICD-10 Steering Committee

• Develop a detailed ―master to-do list‖ • Departmental assessment to include - Inventory of information systems

- Assessment of training needs - Identification of areas requiring operational and policy changes

- Identification of necessary tools


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Sample ICD-10 Implementation Department Assessment

Department: Health Information Management

Application Name

Vendor

Application

Frequency of

Under

Diagnosis or

Codes Entered

Lead Person Maintainer

Regular Updates

Maintenance

Procedure

Directly Into Contract

Codes, or Both

Application or Downloaded from Other Systems?

Encoder

ABC, Inc.

ABC, Inc.

Quarterly

Yes

Both

Entered directly

K. Jackson

Abstracting

DEF

DEF

Quarterly

Yes

Both

Downloaded from System

encoder

DRG Grouper

GHI

GHI

Annual

Yes

Both

Downloaded from encoder

Outpatient Code

Quarterly

Yes

Diagnosis

Entered directly Editor

Present on

In-house

IS&T

Annual

No

Diagnosis

Downloaded from Admission

abstracting Database

system

Birth Registrations

State

State

Annual

Yes

Diagnosis

Entered directly

Trauma Registry

State

State

Annual

Yes

Diagnosis

Entered directly


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Public Reporting Across the Continuum-

Where are ICD-9 and ICD-10 Codes?

AHRQ Publication: 07 0033 EF March 2007

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Conducting Information Systems Inventory

• Survey all departments to conduct an inventory of the applications used.

• Commercial vs. in-house application - Diagnosis vs. procedure codes or both

- Codes entered directly into application or transferred

from another application - Interfaces - Frequency of updates - Updates included as part of maintenance contract • Storage capability

• Field size changes


25

Systems Likely To Be Affected

• Accounting systems • Advanced Beneficiary Software

• Birth defect registries • Billing • Case management system • Claims submission • Clinical data reporting • Clinical department systems • Clinical protocols • Clinical reminder systems • Compliance checking systems

• Databases • Decision support systems • Disease management • DRG grouper • Electronic processing systems • Encoder software • E-prescribing • Financial systems • Hospital information system • Interface engines • Inpatient rehab facility patient assessment instrument data

collection

26


Systems Likely To Be Affected (cont.)

• Managed care (HEDIS) reporting system

• Medical abstracting system

• Medical necessity • Minimum data set collection system

• OASIS system • Outpatient Code Editor • Pharmacy systems • POA systems • Provider profiling

• Quality management • Reports • Registration and scheduling

• Research databases • State birth registration systems

• State reporting systems • Test ordering systems • Utilization management

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Assessing Legacy Systems

• Currently in use? • What is it used for? • Is the system still currently in use? • What is the system used for? • Does the system work satisfactorily? • Is there another application currently available that can

perform a similar function as the current system? • Is there current staff capable of redesigning the system? • Is the system documented fully enough to allow another designer to update the system?

• On what hardware does the system run? • On what software platform does the system run?


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• Is the system difficult to maintain or improve? • Can the system be integrated with newer systems? • What is the cost of updating the system? • What is the cost of replacing the system with a new

application? • With what other systems or programs does the legacy

system interface? • What impact would a change in the legacy system have on these other systems or programs?

• With how many legacy systems is your organization

contending? • If multiple systems, what is the priority among the legacy systems?


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Question

Answer/Comments

Is the system still currently in use?

What is the system used for?

Does the system work satisfactorily?

Is there another application currently available that can perform a similar function as the current

system? Is there current staff capable of redesigning the system? Is the system documented fully enough to allow another designer to update the system?

On what hardware does the system run?

On what software platform does the system run? Is the system difficult to maintain or improve? Can the system be integrated with newer systems?

What is the cost of updating the system?

What is the cost of replacing the system with a new application?


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Assessing Vendor Readiness and Support

Identify which vendor systems

are affected Develop a master list of all

vendors affected Contact vendors to determine

whether changes to existing systems are forthcoming and

when they plan to have available upgrades to support

ICD-10

Determine whether the

upgrade to ICD-10 is included with your maintenance

agreement

Ask vendor to share their

plans for readiness Make certain that the vendor

intends to continue to provide support for the application

Determine whether the

application requires any

special or custom developed

edits

Identify special terms in

contracts to cover custom edits, if any

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Commercial vs. Homegrown Software

• Work with major commercial vendors to ensure they are aware

- Technical issues - Contractual issues - Costs - Timelines • Homegrown Systems

- Technical issues - Costs

Copyright (c) 2012 by American Hospital Association. All rights reserve

32

Data Conversion

• Decisions, decisions, decisions - Cost/benefit analysis

regarding database uses - Convert?

- Cross-walk? - Dual systems?

Copyright (c) 2012 by American Hospital Association. All rights reserve

33

IT Implementation Issues

• Interact with all vendors to ensure each one provides an ICD-10-CM/PCS

update for current system—

assessments and readiness • Evaluate interfaces that lie between

code entry in HIM and electronic billing • Inventory department databases and

decision support systems - Patient Financial Services

• Determine retention needs for ICD-9-CM


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Consider Storage Capabilities

• Consider storage capabilities of all

systems and plans for

maintaining both code

sets for a period of time • Determine need to store

historical data • Consider expanded

number of available codes for ICD-9-CM vs.

ICD-10-CM/PCS.


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Field Size Changes

• Field size changes associated with ICD-10-CM/PCS codes will also impact storage capabilities.


36

Evaluate Health Plan Contract Implications

• Prepare list of largest health plans • Review existing health plan contracts - Diagnosis or procedure based?

- DRG based? - Other basis? • Contact health plans and schedule meetings (can be done

collectively with other providers; if possible work with state

associations to schedule meetings) • Share hospital plans for readiness and dates when hospital will be ready to begin external testing

• Host periodic follow-up meetings to share implementation

progress and to validate plans for future testing


37

Budget Requirements

• Consider multi-year budgeting and reassess financial support that is needed on an annual basis.

• Budgeting requirements should include consideration for the following areas:

- Training and education - System changes - Staffing for internal changes - Updating of existing commercial software applications - Purchasing replacement applications that will not be upgraded internally

- Data conversion - Purchasing of electronic tools to assist in mapping or

conversions


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Budgetary Impact

• Operational - Education, staffing

• Capital - System/interface modifications

- Replacement/new systems • MS-DRG reimbursement

- Potential effect of delays, decrease in coder productivity - Lack of specificity in documentation - Payer not ready to process - Contingency planning


39

Provider Costs

• Personnel costs -- lost productivity, training - Dual coding?

• Hardware and software changes - Commercial vs. homegrown systems

- Vendor awareness - Technical issues - Contractual issues - Costs • Data conversion

- Cost/benefit analysis regarding database uses • Convert?

• Cross-walk? • Dual systems?


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Assessing and Planning for Staff Training Needs

Accounting

Ancillary departments

Auditors

Performance improvement

Business office

Claims analysts

Clinicians

Coders

Clinical department managers

Compliance

Patient access & registration

Data analysts

Infection control

Medical staff

Other HIM department employees

Information systems

Billing

Quality management

Senior management

Utilization review


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Determine Need for Level of Understanding

Source: AHA


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Don’t Forget the Medical Staff

• Collaboration is key

- Training

- Documentation changes

- ICD-10 requires more

detailed documentation to

specify aspects of diagnoses

and procedures required for more detailed codes

• Partnering

- Help them understand the

impact

- Include their office staff in training

- Assist them to convert their ―super bills‖

43

Copyright (c) 2012 by American Hospital Association. All rights reserved

Case of the Missing Documentation

• Paper vs. electronic • Hybrid • Documentation in multiple

locations - Difficult to find

- Coders may need to log into multiple

systems or paper - Easy to miss important

information - Coders are too

valuable to spend time

playing detectives

• Centralized records

- Scanning

- Electronic health

records • Technology can be a

coder’s best friend (if done right) • Enable remote chart

reviews and audits • Dealing with shortage of qualified coders

Copyright (c) 2012 by American Hospital Association. All rights reserved 44

ICD-10 MS-DRG Conversion

• Conversion goals: - Coded in ICD-9-CM or ICD-10, the same patient is

assigned to the same MS-DRG - Clinically equivalent - Definitions manual has familiar look and feel • Over time DRGs could be refined to take advantage of

additional specificity. • Version 28.0 (FY 2012) of the ICD-10 MS-DRGs is posted

on CMS web site. • Final version of ICD-10 MS-DRGs to be implemented will be subject to rulemaking.


45



Phase 4

Phase 1



Impact Analysis

Phase 3

Implementation


Evaluation and

Ongoing Efforts

46


Phase 3: Implementation

• This phase will involve executing, monitoring and overseeing the implementation schedule including:

- Outlining specific tasks and monitoring timeline for

completion - Reviewing budget requirements - Developing metrics and monitoring progress - Routine reporting of progress towards completion - Implementing changes to system design and development

- Testing and validation of system changes - Conducting the staff training - Conducting physician training to address documentation

gaps


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Phase 3 - Implementation (cont.)

- Conducting physician training to address documentation gaps

- Monitoring current work flow volumes during the training

period so backlogs are a minimum prior to go live. This will result in less time needed to maintain dual

coding systems if old accounts

are processed prior to implementation.


48

Operational and Policy Changes

• As you make your plans for ICD-10- CM/PCS implementation also

review existing operations and policies. There may be a need to

change these - especially those dealing with coding and documentation instructions.


49

Useful Tools

• Commercial tools - Translation tools

- Conversion tools - Comparative assessment tools - Compliance tools • Free tools currently available

- General Equivalence Mappings (GEMs) - Reimbursement mappings • Designed to be used by all providers, payers, and

data users • Tools to assist in converting data

• Publicly available on the CMS & CDC websites


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Other Tools

• Data analysis and decision review tools - For example, a translation tool may be used to evaluate

revised health plan contracts (decision support, revenue

cycle, claims adjudication applications) and the

translation tool may convert the vast majority of the codes. - There are, however, a small number of codes that

will still require manual evaluation and expert

decision making about code list relationships to determine the most accurate mapping.

- The manual evaluation may require data analysis support and other tools that can look at the provider’s

patient population, past contracts, or other pertinent

information.


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Execute Implementation Schedule • Outline of the specific tasks to work on.

• Develop a master ―to-do‖ list with specific timelines for

completion.

- Identify responsible individuals

- Identify required tools

- Appoint project manager to ensure timing and

interdependent milestones are flawless for ―on time‖

implementation.

• The ICD-10-CM/PCS Steering Committee can assist with

prioritization of tasks in collaboration with the affected

departments.


52

Metrics and Monitoring Progress

• Establish and monitor timelines and progress. Report findings to the ICD-10-CM/PCS Steering Committee on a

monthly basis. Timelines may need to be adjusted as

necessary.


53

Routine Reporting

• Routine reporting on implementation progress - Integral component of the ICD-10-CM/PCS Steering

Committee meetings. - Report progress at organization-wide meetings

- Share among departments to ensure staff is apprised of

progress. • Manager and Department Involvement

- Specific tasks for individual departments will be completed by department managers and their staff.

- Whenever possible, activities should be incorporated

into individual performance evaluations.


54

System Design Development - Internal Testing Process

• Populate files used for testing purposes. • Examine whether all of the format configuration changes have been properly modified.

• Validate whether these changes are properly recorded in

the specific section of the HIPAA transaction standard. • Test the accuracy of the changes by creating edits that specifically focus on these changes and how and when they

should occur as information flows during the population of

data into the files.

55


System Design Development - Internal Validation Process

• Examine whether supporting documentation is gathered and is available to support the coded information.

• Monitor whether appropriate security methods are used,

including log-in and tracking of individuals. • Ensure that the appropriate communication protocols are being utilized during the transmission of data.


56

System Design Development - External Testing Process

• Prepare for external testing by communicating

with the health plans. • Register with the health plans for testing. • Establish dates for conducting testing • Identify the various production scenarios that should be used during the testing period.


57

System Design Development - External Validation Process

• Consider the results that should be achieved from a reimbursement perspective.

• Validate that the results should yield similar reimbursement

results to that of using ICD-9-CM. • Ensure health plans demonstrate that they are processing

the claim using the ICD-10-CM/PCS information rather than

relying on the GEMS to convert an ICD-10-CM/PCS code

back to an ICD-9-CM and then process the claim for

payment. • Verify that the health plan has not redone their edit logic for reimbursement using ICD-10-CM/PCS as their basis to drive

the reimbursement formula. This is important because the

GEMS will not be maintained indefinitely and at some point

in the near future the maintenance for these GEMS will

cease. •


58

System Design Development - External Validation Process

• Ensure the production scenarios reflect real-world situations - typical billing scenarios reflecting the most common type

of claims. • Generate reports on the results of the external testing

process. • Review the security and connectivity profiles as well as any additional resulting transaction that is generated from the

submitted transaction. That includes the acknowledgment

transaction as well as other transactions. For instance if the claim is submitted it then is processed using the ICD-10- CM/PCS codes, once processed it produces the remittance

transaction to describe how reimbursement occurred. This

end-to-end testing is needed to ensure appropriate changes have been made.


59



Phase 4

Phase 1



Impact Analysis

Phase 3

Implementation


Evaluation and

Ongoing Efforts

60


Phase 4: Post Implementation Evaluation and Ongoing Efforts

• This phase will involve an evaluation to determine the success of the implementation, as well as fine-tuning any

additional changes required including: - Evaluating software upgrades - Reviewing quality of coded data - Conducting additional staff training - Reinforcing physician documentation training - Assessing case mix impact


61

Phase 4 - Post-implementation Evaluation and Ongoing Efforts • Software Upgrades

- Evaluate software applications to ensure applications

are working appropriately.

• If necessary, software upgrades or enhancements

may be needed to correct any post implementation

―glitches‖ or system errors.

•

Training

- Conduct additional training based on findings of quality

coding audits.

- Conduct physician training based on coding staff

identification of high volume areas requiring additional

physician queries.

62


Phase 4 - Post-implementation Evaluation and Ongoing Efforts (cont.)

• Quality Improvements - Conduct an audit of coded data post implementation to

identify any potential coding errors or areas. - Work with coding staff to determine the high volume

areas requiring additional physician queries and develop

physician documentation training accordingly. • Comparative Assessments

- Review coded data to ensure that cases continue to be reimbursed at the same rate or grouped to the same

MS-DRG they would have been with ICD-9-CM. - Monitor reimbursements to avoid any unintended

consequences of coding change.

63


Roles by Function

• HIM/Coding - Participate as a member of ICD-10 Steering Committee

- Conduct ICD-10 awareness training throughout

organization - Complete information systems assessment inventory - Identify training and budgeting issues for department - Determine physician documentation areas requiring

improvement - Identify areas in coding and documentation requiring operational and policy changes

- Identify gaps in health record documentation


64

Roles by Function

• Billing - Participate as a member of ICD-10-CM/PCS Steering

Committee - Attend ICD-10-CM/PCS awareness training sessions

- Complete information systems assessment inventory - Identify training and budgeting issues for department - Identify areas requiring operational and policy changes


65

Roles by Function

• Finance - Participate as a member of ICD-10-CM/PCS Steering


- Complete information systems assessment inventory - Identify training and budgeting issues for department - Identify areas requiring operational and policy changes - Review current contractual agreements with health plans - Analyze impact of ICD-10-CM/PCS on health plan agreements


66

Roles by Function

• Information Systems - Participate as a member of ICD-10-CM/PCS Steering


- Complete information systems assessment inventory - Assess vendor readiness and support - Review contractual agreements with software vendors - Ensure ICD-10-CM/PCS implementation is considered in all future software application purchases

- Identify training and budgeting issues for department - Identify areas requiring operational and policy changes


67

Roles by Function

• Quality - Participate as a member of ICD-10-CM/PCS Steering


- Complete information systems assessment inventory - Identify training and budgeting issues for department - Identify areas requiring operational and policy changes - Identify areas where physician documentation improvement may be necessary

- Assess opportunities with availability of granular data for

quality improvement


68

Roles by Function

• Medical Staff Liaison - Participate as a member of ICD-10-CM/PCS Steering


- Complete information systems assessment inventory - Identify training and budgeting issues - Participate in documentation improvement training


69

AHA Member Benefit Executive Briefing and Advisories

Available on www.aha.org and www.ahacentraloffice.org

70

Resources and References

• Centers for Medicare and Medicaid Services

ICD-10-PCS

www.cms.hhs.gov/ICD10

• National Center for Health Statistics - CDC ICD-10-CM

http://www.cdc.gov/nchs/icd/icd10cm.htm

• AHIMA www.ahima.org/icd10

• AHA

http://www.ahacentraloffice.org/ICD-10


71

Questions?


72

Preparing Your Hospital for a Successful Implementation to ICD … · 2012-10-04 · Preparing Your Hospital for a Successful Implementation to ICD-10-CM and ICD-10-PCS Saturday,

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