Framing the issue:

• Hospitals and providers have less than 8 months to prepare for the delayed debut of ICD-10.
• By now, most hospitals have retrofitted their IT and software systems and are turning their attention to the staffing needs to implement ICD-10.
• Training programs are giving physicians, nurses and coders hands-on experience, not just classroom education.
• The competition for ICD-10-ready coders is heating up. Hospitals are looking for the right incentives to recruit and retain those staff members.
• Getting physicians to understand why and how they need to better document the care they provide each patient is tricky. It's not just about receiving the right reimbursement.


In preparation for the much-anticipated premiere of ICD-10 on Oct. 1, hospitals by now should have built the sets and props, cast the actors and annotated the scripts so many times they're dog-eared. Next up: dress rehearsals, a critical step given the financial pain of putting on a flop.

Health care organizations and their payers have had more than five years to get their acts together since the Centers for Medicare & Medicaid Services published final regulations on implementing ICD-10 — formally known as the International Classification of Diseases, 10th Revision, CM [Clinical Module, for diagnoses and symptoms] and PCS [Procedure Coding System, for both the activities and purposes of inpatient procedures]. That includes a year's extension to allow the industry more time to prepare for what is, after all, a top-to-bottom conversion of how clinical care, quality and claims are quantified.

At this point, providers already should have finished the laborious work of redesigning and building information technology — the props — and moved onto the equally laborious phase of getting the key actors — physicians and other clinicians — to articulate their patients' stories in ways that allow coders to perform their own roles effectively. Suddenly, those coders have a lot more lines to learn; on Oct. 1, the number of codes will jump from about 14,000 under the current ICD-9 system to more than 72,000 under ICD-10.

Training physicians to communicate essential facts in their documentation for this much more nuanced and specific coding system is daunting; hospitals late to that task could be in for quite a challenge, says Stephen Stewart, chief information officer at Henry County Health Center, Mount Pleasant, Iowa.

Stewart's critical access hospital initiated physician training last August, "and they're not wild about what we're telling them; they don't embrace it with open arms," he says. "Even in my hospital, where I think we're very far along, at every meeting and every training session with physicians, there is pushback and there is negativity."

'You don't have to wait until October'

But effective ICD-10 training is absolutely essential. "The biggest priority for these last eight months is education, not only physician education, but bringing your coding professionals, documentation professionals and your outpatient arena up to speed," says Melinda Tully, vice president of clinical services and compliance at Nuance Communications.

That involves not only classroom and computer training, but true-to-life exercises. "You can go to all the classes you want, but if you're not practicing, you're not going to be successful when the switch is pulled," Tully says.

Even though coders at Boca Raton (Fla.) Regional Hospital finished formal training last July, they'll continue to receive refresher classes, says Rudy Braccili Jr., executive director for revenue cycle services. The hospital also bought documentation training modules expressly for physicians to use at their own pace throughout this year, supplemented with specialty-specific, peer-to-peer classroom sessions in May and July.

Additionally, Boca Raton Regional in November started to have coders process a select number of charts for coding under both the current ICD-9 system and the upcoming ICD-10 version. Such "dual coding" serves a number of purposes, says Braccili, including basic practice, checking for coding quality, and assessing the financial impact of the coding switch, including what documentation is missing. It also prompts physicians early on to express themselves in more exact terms than the ICD-9 era required. "There's no reason physicians shouldn't actually be documenting today in ICD-10 terms," Braccili says. "You don't have to wait until October to do that."

Most larger health systems have sent experienced personnel out for "train-the-trainer" programs; they will then teach the rest of the staff. "Some are considering having contract coders do the day-to-day ICD-9 coding to get the claims out the door, and have their permanent employees practice on ICD-10, so they can see where the documentation gaps are, where the knowledge gaps are for the coders, whether they need additional training," says Nelly Leon-Chisen, director of coding and classification for the American Hospital Association.

Though the majority of providers large and small are progressing adequately toward the ICD-10 kickoff, too many others remain behind the curve, says Ed Hock, senior director at the Advisory Board Co. "We see such a wide range of organizations [following] best practices: beginning to dual-code, all set up to perform end-to-end testing — really where they should be." But even in late 2013, he encountered "major health systems that did not have an ICD-10 team or a project plan."

"I hear from people all the time who are just now thinking about doing a readiness assessment," says Stewart. "Whatever we can do to shock them into some sense of urgency would be a service to the industry."

Making up for lost time

Leaders at Mee Memorial Hospital, a small, rural facility in King City, Calif., were aware that ICD-10 was looming, but had other pressing matters.. CIO Rena Salamacha remembers news alerts in 2011, when the ICD-10 deadline was still 2013. "Back then, we read many of those same articles that said, 'We have two years, we have two years,' and pretty soon we've got less than a year and it's like, 'Wow, we're really late in the game.' "

With the urgency recognized, Mee executives engaged the Advisory Board Co. to get them up to speed. If it had started two years earlier, "we wouldn't have had to look for outside help as we have," says Salamacha. "We needed to fast-track to a project plan — we needed one almost the very next day."

Doing a technology and process gap analysis is "not as simple as it sounds," she says. Even though Mee Memorial had few IT applications to assess compared with those of large health networks, "we also don't have the resources to test even the small number of applications that we have," Salamacha says, "because here in a small, rural facility, you have managers who wear multiple hats."

The outside consultant supplied a blueprint, which created a steering committee and five cross-functional teams for revenue cycle/patient access, quality/risk management, physician documentation, health information management and information technology. Salamacha leads the IT committee while doubling as the overall ICD-10 project leader. The first steering committee meeting, to set priorities for the tasks each group identified, was in November 2013.

"Sometimes I think we're the last ones on the planet who are so behind," Salamacha says, "but the more and more I speak with other facilities, some of them are in the same situation as we are."

Mee Memorial's dearth of staff and technology actually shortens the to-do list between now and October. Its hospital coding function is contracted out, so the company it hired is responsible for training those professionals. Its outpatient clinics recently moved to an EHR system, but the hospital still has paper-based clinical documentation and ordering, with computerized provider order entry scheduled in early 2015.

"In some kind of twisted, weird way, I think we're not in a bad spot," Salamacha says. "The coding is outsourced … we don't have a ton of applications; we have one major [health care information system]; I can probably count on one hand the number of IT applications we have to test." Still, she acknowledges, there's a lot of work ahead.

Stewart agrees that the IT upgrade for core systems won't be the biggest challenge. If an organization has a certified EHR, fixing it for ICD-10 will be the vendor's responsibility. Henry County finished the update in early November, leaving 11 months to work with it, including dual ICD-9 and ICD-10 coding that started before the year's end.

However, identifying IT problems is a small part of the total task. "There are some I've talked with who feel the assessment is the solution, and it's really not," he says. "Assessing and then doing something with the results of the assessment are two entirely different things."

Those who are just getting started "are going to be way behind the eight ball," Stewart warns. "They're going to have to implement in an abbreviated or abridged fashion, really devote a lot of resources to it." Moreover, "they're going to have far, far less time to prepare their physicians."

Educate, don't talk in code

Every type of health care organization has its own variation of crucial education needs. "The largest health systems certainly have a massive problem," says Hock, "because they have to educate thousands of physicians on hundreds of different procedures and nuanced diagnoses that they receive. But, they're likely to have resources; they're more likely to have personnel assigned to this. So even though it's a massive task, it's still something they can tackle bit by bit."

A 200-bed community hospital may not have as many complex cases, but it still needs an approach that covers both simple and sophisticated concepts. For the smaller hospital, Hock says the central question may be, "How do I — across a small staff at a time when margin pressure is high — educate my physicians in a way that will protect our revenues and ensure that our documentation and quality metrics are up to speed?"

A key starting point is to emphasize documentation, not the coding. "Physicians should never be presented with codes; they should be presented with requests and education to improve clinical documentation," says Nuance Communications' Tully. Another important tactic: The education should be physician-to-physician and relevant to a particular specialty, not general to all doctors. "If they're cardiologists, [give them] cardiology education for ICD-10, because they don't give a rip about total hip replacement," she says.

For physicians, make ICD-10 about storytelling, not code selection, Stewart advises. When physician education started at Henry County, "their reactions in some instances were almost visceral: 'I didn't go to medical school to be a coder, I'm not a coder.' " Stewart's response: "We understand that, we're not asking you to assign a seven-digit code. We're asking you to provide the level of granularity in your documentation that is required."

Education options might not work at all, especially for independent practitioners. "We can't ever force the medical staff of nonemployed physicians to do anything," Braccili says. To bridge the gap between the physician and coder, some hospitals are hiring clinical documentation improvement specialists, or CDIs.

"There will definitely be physicians who don't go through the training, so the nature of the clinical documentation improvement program is to have the CDIs coach the docs on a case-by-case basis in terms of queries and record reviews," Braccili says. "So, some of them will learn that way, and others will experience a combination of the classroom and the computer and the CDIs."

The Boca Raton CDI program has a 95 percent compliance rate with queries, which means nearly all get a response from the doctor before the bill is sent under the current ICD-9 process. The agreement rate is 80 percent, which is the proportion of the time doctors agree with and accept the documentation point made by the CDI staffer, says Braccili.

CDI personnel stand out from other staff: They wear lavender clothes and have become known as the Lavender Team or "Lavender Ladies," since they're all female nurses, he says. Physicians "have come to know and like, actually, through a nice physician-nurse relationship, that the Lavender Ladies are the CDI people, their queries are on lavender paper, everything about them is lavender, and it's a very cohesive working relationship," Braccilli says.

John Morrissey is a freelance writer in Mount Prospect, Ill.


Executive Corner

Take the lead

Years and years of ICD-10 talk can create executive fatigue at the worst possible time. Until now, the hub of activity may have been at a subcommittee level, but now the CEO and CFO have to shake off any institutional ICD-10 hangovers and articulate how critical the final push is.

Automate away the pain

Executive leaders owe it to their physicians to mitigate whatever pain they can by exploring technologies such as computer-assisted coding, natural language processing and audio-based dictation templates to guide the progression of a clinical report that covers all ICD-10 angles.

Hold your place in line

A lot of critical action is still beyond a CEO's direct control: implementation of technology by vendors, testing with payer partners, contracting for supplemental coding help. Beat the rush by arranging that action in time to incorporate new processes and react to problems that turn up.

End game: end-to-end

The ultimate objective is to get IT systems in place that can accurately handle ICD-10 codes, with information provided digitally by physicians, checked and refined by clinical documentation specialists, recorded fully by coders, billed cleanly by patient accounting, and accepted by payers. Any inability to test all points of that process well in advance means financial jeopardy.


Finding and keeping those valuable coders

Hospitals first need doctors to deliver documentation that meets ICD-10's more nuanced needs, but without enough trained coders, the workload will pile up and be coded incompletely or unacceptably. And even if your facility has assembled the staff of coders it needs, others may try to lure them away as awareness of the coder's importance grows.

"The coder path is absolutely an issue — having enough, having enough experienced folks, and retaining them between now and the transition," says the Advisory Board Co.'s Ed Hock. If you don't have enough, you need to correct the situation now, by developing those roles internally or contracting with coder companies.

Just as important is a thoughtful plan for retention. "All of a sudden, those individuals are fairly valuable," Hock says, "so we're seeing retention bonuses, we're seeing increased attention being paid to quality of work life for coders, such as working from home or flexible hours or other things that make the role in a particular organization attractive."

Boca Raton (Fla.) Regional Hospital had one certified coder on a team of 16 two years ago, and neither the medical records director nor the health information management coding manager had been certified. "For all the right reasons and all the respectful ways, we went about replacing our management team, finding a director who was certified, an HIM manager who was certified," says Boca Raton's Rudy Braccili.

The director redefined job descriptions, creating a ladder with three levels and higher salaries based on a check of the market. The highest- and best-paid position went to the most knowledgeable coders who did inpatient charts. Level 2 covered somewhat less complicated cases such as ambulatory surgery, and Level 3 was entry level for emergency department treat-and-release cases and others without much need for analysis. All incumbents had one year to obtain certification; training was reimbursed. All coders are certified now, and the hospital has a sunk investment in them, says Braccili. That's a cause for both cheer and worry.

Expecting a tight supply and exploding demand for coders by the end of this summer, Boca Raton has added four progressively higher incentive and loyalty payments for all coders and clinical documentation specialists, in return for a signed agreement, says Braccili. The first one on March 31, "in the single-digit thousands," is conditional: It has to be repaid if the employee leaves before Jan. 1, 2015. On that date, staffers "get another chunk of change for having stayed that long," and a third payment on Oct. 1, 2015, is "a notably higher payment amount than the first two." The final payment on Oct. 1, 2016, is the highest of all.

Total cost to the organization for the retention program is "in the neighborhood of $200,000," which is an amount it could lose in no time from departures, he says. Right off, the loss of an experienced coder could lead to inaccurate coding and delayed cash flow, while also requiring contract labor "at more than twice the cost of an employed full-time coder."

For health systems not yet bolstering their coding ranks and expertise, "It's never too late to take on the project," Braccili emphasizes. "This is not Y2K, where it's one moment in time and then all the hullaballoo is over. This starts on Oct. 1 and stays with us forever." — John Morrissey


Getting physicians to give a darn

The slickest, most informative educational program for physicians may not win them over. They have to be aware of why they should be motivated to learn ICD-10 documentation — not so the hospital can bill effectively, or coders can find the information they're looking for, but so doctors can look good and do well.

"It's one thing to say you're going to train your physicians for ICD-10, but what if your physicians don't see documentation as a priority? Not only do we need them to learn ICD-10, but we have to get them to actually care in the first place," says Ed Hock of the Advisory Board Co.

An effective approach is to pick the top 5 to 10 percent of what a physician does and conduct a cost analysis, says Stephen Stewart of Henry County Health Center, Mount Pleasant, Iowa. Demonstrate what a current ICD-9-based payment is when based on documentation the physician provides, and then in ICD-10, show how, when lacking the full documentation, the claim has to be downgraded and receives a lower payment or goes unprocessed. Then show how more complete documentation could increase the payment substantially.

Another approach is to make physicians aware of how documentation and the resultant coding affects how they're judged, from reporting to insurers to being scored in online reviews such as HealthGrades. "Just show a physician what the individual quality looks like," says Hock. Then show several examples of where the doctor didn't get credit for what he did because the coded evidence was not there. "That changes the motivation to, 'We need to fix that.' "

Suddenly, physicians say, "Wait a minute, this isn't all about [the hospital] getting paid, it's about how I look" Hock explains. "And we say, 'It's about getting paid, but also about how you look.' " — John Morrissey


The nice-to-haves vs. the need-to-haves

For late starters, it all comes down to being able to file claims and continue receiving revenue when ICD-10 goes live. "The single most important thing every hospital needs to be able to do is to get a bill out the door on Oct. 1, 2014. You can work back from there," says Ed Hock of the Advisory Board Co. "Prioritize in a ruthless way [and] understand what is critical to occur ... because there won't be time to do everything."

Codes have to be updated in all kinds of clinical quality, research and reporting applications, but those are "nice-to-haves" rather than "need-to-haves," he says. "I need my billing systems to be upgraded, I need to be able to exchange information with my [claims] clearinghouse, and I need to have talked to my payers and understand their situation."

"And the next stage is that I need that bill to be accurate. Now we're talking about training for coders, training for physicians." Once that's under control, "then you start backing into what all the other metrics are that my hospital depends on related to ICD-10, whether it's quality metrics, whether it's reports that different users depend on throughout the hospital. That would be the third level."

Include the financial managers, advises Melinda Tully of Nuance Communications. Attention to "the highest level of clinical documentation integrity for everything that goes into the patient's story" is not only important to accurate quality metrics, but also justifying the same level of revenue coming in now. — John Morrissey