The ICD-10 implementation will result in a slowdown at every level of coding. The question remains, how much of a slowdown?
Numerous speakers at the AHIMA National Conference in Atlanta October 26-30 addressed the projected coder productivity loss with estimates ranging from 20% to 60%.
Coders will be less productive in ICD-10-CM in part because they can’t use just the keypad to type in codes, said Elaine O’Bleness, MBA, RHIA, CHP, AHIMA-approved ICD-10-CM/PCS trainer, revenue cycle executive for Cerner Corporation in North Kansas City, Mo.
In Canada, coder productivity dropped by 50% after the initial transition to ICD-10 that began in 2001, O’Bleness said. Coder productivity has only rebounded to approximately 80% of pre-ICD-10 levels.
The biggest questions surround inpatient procedure coding productivity. No other country uses ICD-10-PCS and no other country codes for reimbursement, O’Bleness said. So what can healthcare organizations and coders do to prepare for and minimize productivity losses in ICD-10?
Coders are creatures of habit. Many already know the codes they commonly report without having to look them up. As a result, they can code faster, O’Bleness said.
In addition, ICD-9 codes are all numbers, so coders can use the keypad to report codes. ICD-10 codes are comprised of both letters and numbers.
Initially coders will be slower in ICD-10-CM simply because they have to look up the codes. As they become more familiar with the codes, their productivity will increase.
Early adoption allows coders more time to get comfortable with ICD-10. It also allows coders to cover for each other while they are learning ICD-10, said Migdalia Hernandez, RHIT, corporate director of health information management services for Adventist Health Systems in Altamonte Springs, Fla.
While some coders are working on ICD-10 training, other coders continue with the daily workflow of coding current charts. That decreases the productivity hit Adventist Health takes while coders are out of their normal jobs.
Approximately 70% of the coders at Adventist Health are already trained on ICD-10 and Hernandez’s goal is to have all 275 coders trained by the first quarter of 2014.
Adventist Health coders will begin dual coding in December once testing of a software upgrade is completed, Hernandez said. She plans to have coders dual code every fifth record in ICD-9 and ICD-10.
Hernandez expects to see a 40% initial decline in coder productivity, with 20% becoming permanent.
Dual coding is one way for coders to become familiar with and proficient in ICD-10 coding. However, you can’t dual code every chart, said Kimberly Carr, RHIT, CCS, CDIP, manager of clinical documentation for HRS in Baltimore.
Identify the most common cases at your facility and dual code those cases. If you treat a large number of orthopedic patients, but few pregnant patients, have coders practice mainly on the orthopedic cases.
Resist the urge to pigeonhole coders into one specialty, Carr said. “Every coder needs to learn to code every service line in ICD-10,” she said.
Also make sure you are using the correct guidelines and conventions. Don’t code in ICD-10-CM using ICD-9-CM guidelines, Carr said. The majority of the guidelines remain the same, but some change. Those changes can impact MS-DRG assignment.
· Concurrent, meaning coders assign both ICD-9 and ICD-10 codes before the bill is dropped
· Retrospective, meaning coders code in ICD-9, then go back and natively code in ICD-10
Use dual coding to compare MS-DRG assignments in ICD-9 and ICD-10, Carr said. If the MS-DRGs are different, determine why. Is it because the coding rules are different or is the documentation insufficient for ICD-10?
For example, in ICD-9, when a patient comes in for treatment for anemia due to a neoplasm, the ICD-9-CM Official Guidelines for Coding and Reporting state:
When the admission/encounter is for management of anemia associated with a malignancy and the treatment is only for anemia, the appropriate anemia code (such as code 285.22, anemia in neoplastic disease) is designated as the principal diagnosis and is followed by the appropriate code(s) for the malignancy.
The ICD-10-CM Official Guidelines for Coding and Reporting state:
When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by code D63.0, anemia in neoplastic disease.
Another potential problem in ICD-10-PCS is root operation selection. Coders must determine the correct root operation based on the intent of the procedure. If the coder selects the wrong root operation, he or she will assign an incorrect code, which could lead to assigning the wrong MS-DRG.
In ICD-9-CM, procedure code 45.62 represents other partial resection of the small intestine. The procedure could be either a resection or an excision in ICD-10-PCS, said Carr.
If coders select the wrong root operation, they will assign the wrong MS-DRG. The facility could lose reimbursement because the code mapped to a lower-paying MS-DRG. An auditor could also recoup payment if the code mapped to a higher-paying MS-DRG than the procedure represented.
Perform a baseline coding time study, Carr suggested. This is not the same as a productivity report. Determine how long it actually takes to code a record and how much time coders spend on noncoding tasks such as answering questions from case managers and querying physicians.
Dual coding will also allow you to drill down and identify documentation shortcomings. The clinical documentation improvement specialists (CDI) at your facility likely know where documentation deficiencies currently exist, Carr said. If documentation is insufficient in ICD-9, it will continue to be insufficient in ICD-10.
“Look for low-hanging fruit,” Carr said. “If you know you have a problem, go after it.”
Validate codes and provide feedback
Dual coding alone is like “shooting hoops in the dark, you don’t know if you are accurate,” said Rachel Chebeleu, MBA, RHIA, corporate director of professional fee abstraction at the University of Pennsylvania Health System in Philadelphia.
“You can’t just be dual coding, because you don’t know how things are going,” she added.
Coders need feedback on whether they are coding correctly in ICD-10. Accuracy is as important as speed, which makes immediate feedback extremely important, Chebeleu said. “You need feedback while the information is still in your memory.”
At the Hospital of the University of Pennsylvania (HOP), Chebeleu and her team have changed the way they train coders. The training is still in place, but now after coders practice coding a case, the trainers loop back to verify the accuracy. That allows them to determine what education the coder needs going forward.
You don’t need a significant software investment to help with coding training and feedback. The training team at HOP took a group of charts and pre-reviewed them. They took notes on the cases so they could point to where coders can find information. Coders then coded the records and received immediate feedback on their accuracy, Chebeleu said.
Coders need early training followed by diligent practice on records that mean the most to your facility, Chebeleu said. “Make sure you give feedback. If coders don’t hear back immediately, they will make the same mistakes over and over.”
Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.