Title of paper - IFHIMA



Preparation Activities for Implementation of ICD-10-CM in the United States

Rita Scichilone, Donnamaria Pickett, Sue Bowman, Margaret Skurka

Abstract

At last, ICD-10-CM has been named a standard for use in the United States for morbidity coding. The transition from ICD-9-CM to ICD-10 will have a tremendous and pervasive impact on every operational process across all healthcare related business. Planning is underway for a successful transition from ICD-9-CM to the ICD-10-CM by October 1, 2013. This paper presents an overview of the educational strategy, planning activities and resource development underway to ensure implementation success for all stakeholders.

We will cover the following topics:

• Transition planning and preparation steps the US healthcare industry must take to leverage opportunities for strategic advantage

• Educational assessment methods and tools helpful to identify training needs

• Stakeholder identification and categorization of users for program design and educational approach

• Recommendations for timing and hours of training by stakeholder group

• Use of mapping tools to link ICD-9-CM to ICD-10-CM for data transition or comparison

• Curriculum recommendations for ICD-10-CM educator use

• Documentation improvement education to optimize ICD-10-CM characteristics and features

In conclusion this paper will summarize the challenges and rewards of providing educational support for converting the US healthcare delivery system to the latest release of ICD in 2013.

Introduction

Within the United States health care delivery system change is the order of the day. Our country began 2009 with good news. The Department of Health and Human Services published regulatory rules to require use of the Clinical Modification of the Tenth edition of the International Classification of Diseases (ICD-10-CM) to replace all uses of ICD-9-CM. The Health Insurance Portability and Accountability (HIPAA) Electronic Transactions regulations were modified to enable this change for standard insurance plan processing. A replacement for the ICD-9-CM procedure classification system was also named as a standard. This is called ICD-10-PCS (procedure coding system) to indicate its role as a replacement for the current ICD-9-CM Volume III code set. ICD-10-CM will be used in all health care settings while the ICD-10-PCS system for procedure classification is limited to acute care hospitals. Health care encounters and hospital discharges are required to use the new code sets beginning with October 1, 2013 services or discharges. There is considerable activity already underway since ICD is used for so many different health care information management tasks. This includes playing a major role in both private and public health plan payment and financing, which has been a factor in moving to the new classification.

Transition Planning Activities

The US transition to new codes is a transformational effort affecting many systems, people and processes. Transition planning activities created early in this decade have been dusted off to prepare for implementation by the compliance deadline. Due to the widespread use of computer systems for many years, the inclusion of ICD-9-CM codes as data element have created a major challenges for conversion to another version with different character formats. Some have compared this challenge to the turn of the century date issues (also known as Y2K). The additional characters and format changes require examination of many software applications for compatibility. Also, all contracts that link payment or eligibility for insurance coverage to a particular code must be reviewed and revised. Some health insurance plans indicate they have thousands of systems, policies and processes that require attention creating significant resources to accomplish conversion by the compliance date. This requires a serious approach to providing ICD-10-CM orientation and training for some healthcare workers early enough in the process to complete transition tasks by the compliance date. Impact assessment activities are already occurring within many health care organizations as the first step in transition planning. Tools and checklists have been published to guide this effort since the list of systems and software applications affected is lengthy.

Educational Assessment Methods and Tools

Those who train others were prioritized as the first stakeholder group requiring ICD-10-CM orientation and training, since they will be tasked with providing educational programs and assessments to everyone else. Current students in healthcare professions must learn about ICD-10-CM to be effective in their roles. January 1, 2010 has been recommended as the target date when the education community should be evaluating readiness of faculty or trainers to teach ICD-10-CM and/or ICD-10-PCS to others. August, 2010 is the recommended date for curriculum content changes in academic courses related to use of ICD. Graduates then in HIM programs from 2012 on would have education and training in both ICD-10-CM and ICD-10-PCS A number of organizations and institutions are offering both in-person and Internet-based training programs that provide awareness training to familiarize users with the new systems. Distance education courses and proficiency assessments are available to meet specific learning needs for a variety of groups.

Stakeholder Identification for Educational Approach Requirements

Identifying stakeholders is important to accomplish before designing educational programs. In the U.S. healthcare delivery system it is helpful to divide educational requirements and methods of instruction into primary and secondary groups. Primary stakeholders are comprised of individuals or groups with job responsibility for assigning codes, performing data analysis using codes or otherwise directly working with the new code set(s). Secondary stakeholders are those individuals or groups dependent on use of the codes to accomplish tasks required for their work.

The education needs are different for each type and stakeholders within each group have unique needs for content coverage and learning methods. Examples of primary stakeholders include:

• Educators

• Certified trainers

• Consultants and auditors

• Coding professionals

• Physicians or other clinicians who assign codes

• Public health departments

Examples of secondary stakeholders include:

• Healthcare organization leaders

• Clinicians, therapists or all other health care providers affected by coded data use

• Financial management personnel for health care related organizations

• Information technology companies and personnel

• Systems and software developers that serve the healthcare market

• Business associates, contractors and health plans involved in health care delivery

• Standards development organizations who use ICD in value sets or other purposes

ICD is used for a wide variety of tasks important to healthcare delivery in the US:

• Measuring the quality, safety and efficacy of care

• Designing payment systems and as data elements in claims for reimbursement

• Supporting research, epidemiological studies and clinical trials

• Setting health policy

• Tracking public health issues

• Facilitating information retrieval for consumers of care concerning cost or outcomes for selected diseases or treatments

• Population of value sets for designated data elements in electronic environments

Recommendations for Training

Awareness training has already started with the US so both primary and secondary stakeholder groups are aware of resources to access for more information when it is important to their role. This includes referencing authoritative sources in accessible locations for all stakeholders.

In general, primary stakeholders should receive code assignment training no more than six months before the use of the codes sets is required. In the US the ICD-9-CM code sets will be used until October 1, 2013 so training too early will make it difficult to retain ICD-10-CM coding conventions and guidelines while still using ICD-9-CM. The secondary stakeholder groups training content and timing is expected to vary widely depending on specific use of the codes and the depth of understanding required t use ICD correctly. Some secondary users have already received ICD-10-CM overview and awareness training to guide their organizations towards successful implementation of information systems using ICD as a key data element. Others may benefit from training closer to the compliance date for better retention of knowledge when it is needed for their roles.

The amount of time to budget for training varies with the job role due to the level of detail that must be covered. For coders, the anticipated training hours required for ICD-10-CM and ICD-10-PCS is 40 hours (both systems) and 16 hours for ICD-10-CM alone.

Use of Mapping Tools

As organizations prepare for data migration from one version of ICD to another mapping tools are used to facilitate the process. The Centers for Medicare and Medicaid Services and the National Center for Health Statistics have developed general equivalence maps (GEMs) as a tool to assist with the conversion of ICD-9-CM codes to ICD-10-CM codes and from ICD-10-CM to ICD-9-CM. These mapping files are available at no cost for users on their web site. The GEMs are a comprehensive translation dictionary that can be used to accurately and effectively translate large amounts of data from one code set to the other. The GEMs can be used to convert multiple databases from ICD-9-CM to ICD-10-CM, including payment systems, payment and coverage edits, risk adjustment logic, quality measures, disease management programs, financial modeling, and a variety of research applications involving trend data. The GEMs are the foundation on which applied mappings for specific use cases can be built.

The general equivalent maps include all plausible translations for each code in the system so there are circumstances where a one-to-many relationship exists. This requires the user to determine the best link to use depending on the use case.

Curriculum Development

Use of the classification for health information management is an important component in US academic and professional programs. Planning and preparation has already begun in institutions providing courses providing ICD-9-CM related content. Program changes, faculty training, and curriculum development have been initiated this year in anticipation of implementation in 2013 when current students will benefit. The American Health Information Management Association has published a “readiness checklist” and an educational timeline to promote inclusion of the new code sets and guidelines for use in courses related to health data management. Due to the increased granularity and clinical relevancy available in ICD-10-CM, educational programs have been encouraged to strengthen biomedical science course content to increase student competencies in anatomy, physiology, pharmacology and clinical terminology use. Curriculum will continue to address legacy data management using both ICD-9-CM and ICD-10-CM for effective comparison of clinical across time.

Documentation Improvement Education

Within the US there are a number of political and technology factors working to improve the data quality and information capture in our healthcare delivery system. Better documentation of conditions requiring care and the interventions prescribed for treatment inform quality improvement, decision support, cost control and efficacy of health care services.

Use of ICD-10-CM is a critical factor in this effort due to its role in data capture, storage and reporting requirements for a number of secondary uses impacting our system. Without suitable documentation to take advantage of features available in ICD-10-CM not used in ICD-9-CM, full benefits of conversion will not be achieved. Increased efforts by health care providers to provide training, tools and resources to clinicians responsible for documentation are now including references to the utility of ICD-10-CM‘s precision to improve the value of the encoded data in current systems. Professional groups and stakeholders interested in data integrity assurance are actively working to identify improved methods for information capture and health record accuracy and utility in serving both patient and provider needs.

Conclusion

To date there have been many challenges in advocating for changes required for successful implementation of the ICD-10-CM in the United States. Due to the integration of codes into payment systems our nation has identified areas of potential concern. Proper planning and preparation can mitigate many of these unwelcome consequences:

• Huge coding backlogs due to productivity challenges with a new system or health plans not being ready by the compliance date to accept claims for payment with ICD-10-CM or ICD-10-PCS codes

• Increased health insurance claims rejections and denials for coverage due to misalignment of payer and provider use of the codes

• Increased delays in processing authorizations for coverage and reimbursement claims

• Improper insurance plan payment due to incorrect code submission

• Compliance issues involving inaccurate coding resulting in incorrect payments

• Decisions based on faulty data due to misunderstanding of the differences in the codes, coding conventions or guidelines for use

A variety of groups have developed guidance for preparation that begins in 2009 for full implementation in 2013. Challenges include the costs of conversion for primary users of the code sets including government agencies, health insurance plans, information systems vendors, health care providers and the extent of training required to make sure all users of ICD are prepared to use the classification appropriately. Data integrity challenges are expected as the conversion between the systems is required, so steps are being taken to minimize the impact and loss of important information in the process. Workforce training includes use of the classification in an increasingly electronic environment with the availability of new technology tools that enhance ease of use and enhance code assignment consistency and accuracy of classification.

The rewards of using a more contemporary system are becoming more evident as users within the US discover the improvements available in the code set. The key to a graceful evolution from one version of ICD to another is early planning for curriculum revision, workforce training, creative use of teaching tools including distance education using the internet and a generous amount of collaboration between stakeholders in the process. We welcome the opportunity to begin using ICD-10-CM to contribute more fully to comparable health information activities using ICD-10.

Annex

Resources

1. AHIMA. “Preparation is the Key to Success”. ICD-10 web page available online from

2. AHIMA Practice Brief: "Transitioning to ICD-10-CM/PCS— An Academic Timeline" Journal of AHIMA 80, no.4 (April 2009): 59-64 or available online at

3. Bowman, Sue, “Coordination of SNOMED-CT and ICD-10: Getting the Most out of Electronic Health Record Systems “ Perspectives in Health Information Management Spring 2005, available online at

4. Bowman, Sue, Zeisset, Ann, “ICD-10 Preparation Checklist” (June 2007) available online at

5. United States National Center for Health Statistics “About the International Classification of Diseases, Tenth Revision, Clinical Modification”. Available online at  (ICD-10-CM)

6. United States Centers for Medicare and Medicaid Systems (CMS). 2009 ICD-10-PCS. Available online at

7. Department of Health and Human Services, CMS “ “HIPAA Administrative Simplification: Modifications to Medical Data Code Set Standards To Adopt ICD–10–CM andICD–10–PCS” Federal Register, January 16, 2009, Available online at

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