Professional Documents
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2015 ICD-10 ImplementationTraining 032415
2015 ICD-10 ImplementationTraining 032415
Implementation
training
2015
Disclaimer
This course was current at the time it was published. This course was prepared as a tool to assist the
participant in understanding how to prepare for ICD-10-CM. Although every reasonable effort has
been made to assure the accuracy of the information within these pages, the ultimate responsibility
of the use of this information lies with the student. AAPC does not accept responsibility or liability
with regard to errors, omissions, misuse, and misinterpretation. AAPC employees, agents, and staff
make no representation, warranty, or guarantee that this compilation of information is error-free
and will bear no responsibility, or liability for the results or consequences of the use of this course.
AAPC does not accept responsibility or liability for any adverse outcome from using this study
program for any reason including undetected inaccuracy, opinion, and analysis that might prove
erroneous or amended, or the coders misunderstanding or misapplication of topics. Application
of the information in this text does not imply or guarantee claims payment. Inquiries of your
local carrier(s) bulletins, policy announcements, etc., should be made to resolve local billing
requirements. Payers interpretations may vary from those in this program. Finally, the law,
applicable regulations, payers instructions, interpretations, enforcement, etc., may change at any
time in any particular area.
This manual may not be copied, reproduced, dismantled, quoted, or presented without the
expressed written approval of the AAPC and the sources contained within. No part of this
publication covered by the copyright herein may be reproduced, stored in a retrieval system or
transmitted in any form or by any means (graphically, electronically, or mechanically, i ncluding
photocopying, recording, or taping) without the expressed written permission from AAPC and the
sources contained within.
ICD-10 Experts
Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, CPEDC, CENTC, COBGC
VP, ICD-10 Training and Education
Betty Hovey, CPC, CPMA, CPC-I, COC, CPB, CPCD
Director, ICD-10 Development and Training
Jackie Stack, CPC, CPB, CPC-I, CEMC, CFPC, CIMC, CPEDC
Director, ICD-10 Development and Training
Peggy Stilley, CPC, CPB, CPMA, CPC-I, COBGC
Director, ICD-10 Development and Training
2015 AAPC
2480 South 3850 West, Suite B, Salt Lake City, Utah 84120
800-626-2633, Fax 801-236-2258, www.aapc.com
Printed 032415. All rights reserved.
CPC, CIC, COC, CPC-P, CPMA, CPCO, and CPPM are trademarks of AAPC.
ii
Introduction
AAPC is the largest medical coding certification body with more than 100,000 credentialed coders.
AAPCs certification allows medical coders, billers, and other healthcare professionals including
those working for insurers to demonstrate superior knowledge and expertise of current outpatient
medical coding principles.
AAPC understands the magnitude of the proposed coding changes that ICD-10-CM will have on
physicians and medical practices and has devised suggested implementation plans, benchmarks,
and timelines that include planning, education, and execution. These materials will take you
through every stage of ICD-10 implementation.
Along with distance learning, webinars, workshops, and national and regional conference sessions,
the AAPC has created an intensive curriculum.
Executive Summary
Final Rule for the Adoption of ICD-10-CM and ICD-10-PCS
On Jan. 15, 2009, the HHS released the final regulation to move from the current ICD-9-CM
coding system to the ICD-10-CM coding system beginning Oct. 1, 2013. This timeline allows for
time to plan and implement this regulatory change.
The final rule to update the current 4010 electronic transaction standard to the new 5010 electronic
transaction format for electronic healthcare transactions was also published with an implementation of Jan. 1, 2012. Version 5010 provided the framework needed to support ICD-10 diagnosis and
procedure codes and is the prerequisite to implementing ICD-10.
On Jan. 20, 2009, the White House released a memorandum placing a hold on all regulations that
included the ICD-10 rule. In March 2009, a determination was made that the effective date would
not be extended and the comment period would not be reopened for 5010 or ICD-10.
On April 9th, 2012 DHHS sent out notification of proposed rule indicating an extension on the
date for ICD-10 implementation for one year. The proposed date was set for October 1, 2014. This
extended timeframe was to give those in the industry more time to get ready. In August, 2012 the
proposed date became final.
On March 31, 2014, the Senate passed H.R. 4032 whose main purpose was to give a one-year fix
to the SGR. In the language of the bill they included language stating that ICD-10 could not be
mandated prior to October 1, 2015.
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iii
Introduction
ICD-10-PCS will replace the ICD-9-CM procedure codes rendered within the hospital
inpatient setting.
Current Procedural Terminology (CPT) and the Healthcare Common Procedural
Coding System (HCPCS Level II) will remain the official coding systems for outpatient
reporting for procedures and services.
After the implementation of the ICD-10 code set, general acute care inpatient reimbursement for Medicare patients will be based on Medicare severity-based diagnosis-related
groups (MS-DRGs) using the ICD-10 classification system and not ICD-9.
Successful transition to ICD-10-CM and ICD-10-PCS is anticipated to meet the
increased level of detail required to recognize advancements in medicine and technology, appropriate reimbursement, improved data quality for clinical and financial
decision making, to support value based purchasing, and facilitate quality reporting.
The ICD-10-CM code set is maintained by the National Center for Health Statistics
(NCHS) of the Centers for Disease Control and Prevention (CDC) for use in the
United States. It is based on ICD-10, which was developed by the World Health
Organization (WHO) and is used internationally. The ICD-10-PCS code set was
developed by the 3M HIS for the Centers for Medicare & Medicaid Services (CMS) and
is maintained by CMS.
Mapping files that allow the industry to convert from ICD-9-CM to ICD-10-CM and
ICD-10-PCS codes and vice versa were created and are available on the CMS website.
35 characters in length
37 characters in length
Lacks detail
Very specific
Lacks laterality
Has laterality
Does not support interoperability because it is Supports interoperability and the exchange of
not used in other countries
healthcare data between other countries and the
United States
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Introduction
ICD-10-PCS
34 numbers in length
Lacks detail
Very specific
Lacks laterality
Has laterality
Dept of Health and Human Services, Federal Register; Vol. 73, No. 164, Friday, August 22, 2008
Table 1.1
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Contents
Chapter 1
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Chapter 2
Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Communication Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Roles and Responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
The Communication Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Developing Your Communication Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
The Communication Effort. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
ICD-10 Communication Strategy Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Resources and Templates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Terminology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Chapter 3
Information Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Transaction Sets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Electronic Data Interchange (EDI)/5010 Accommodates ICD-10s Size . . . . . . 48
Structural Changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Anticipated Benefits of ICD-10-CM/PCS Implementation to Analytics. . . . . . 49
Business Intelligence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Information Technology Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Software Updates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Budgetary Implications of ICD-10-CM/PCS to Information Technology. . . . . 52
General Equivalence Mappings (GEMs). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Procedure Code Mapping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Limitations of the GEMS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Reimbursement Mappings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Vendor Solutions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Resources and Templates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Chapter 4
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Budgeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Implementation Costs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
ICD-10-CM Project Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Planning the ICD-10-CM Budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Planning Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
ICD-10 Steering Committee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Resources and Templates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
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Contents
Chapter 7
Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
The Importance of Performing an Outcome Measurement. . . . . . . . . . . . . . . . 141
Productivity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Resources and Tools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Chapter 9
Go Live . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Testing and Deployment of Code. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Go-live. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Implementation Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Chapter
Introduction
This chapter introduces the necessary steps to organize the ICD-10 implementation effort. It begins by
providing direction on the implementation by suggesting the creation of steering committees. Having
the right committee in place for ICD-10 implementation will provide strategic direction, manage risk
appropriately, and ensure resources are used responsibly. Because ICD-10 implementation involves
many of the practices business areas, specific structures are used to organize the project.
The beginning steps towards a successful ICD-10 implementation effort begin with establishing
committees comprised of the following:
1. ICD-10 Governance Entities
Executive Sponsor
Strategic Steering Committee
Education Steering Committee
Communication Steering Committee
Business Area Project Teams
Note: This step will be modified for a small practice and may in some circumstances only include
the manager and a doctor. Scale the size of your committees to meet your practice size.
Coordinate with Business Partners
A successful, strategic ICD-10 implementation plan must encompass the entire practice. It should
identify specific actions and assign responsibilities and deadlines for achieving results including
changes in processes, procedures, policies as well as budget, education, and communication needs.
Resources for the ICD-10-CM implementation effort need to be identified and the potential need
for temporary staff and/or consulting services should be considered.
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Chapter 1
Key Obstacles
One key obstacle to overcome is the resistance to change. For many providers and coders, just
finding the time to learn the new system is a challenge. The challenge of updating skills and
learning a new system will be enough to drive some providers out of the profession. On the positive
side, however, the advantage of greater specificity in the new codes and of accuracy due to migration to electronic medical records (EMRs) is a sign of encouragement. The need to update skills
is not limited to medical coders. The medical staff also must be educated on ICD-10-CM, which
includes the appropriate level of specificity in the documentation.
In addition to training, information systems will need to be updated or changed and the workflow and processes many medical practices have been using for years may need to be changed or
adjusted. There are many variables and issues to consider when moving to the new code set. This
will be one of the largest changes impacting the healthcare industry in over 20 years. Waiting until
the last minute will impact a medical practices livelihood and financial stability. The time to begin
preparing for this massive undertaking is today.
Begin the implementation process step-by-step. Dont focus on all elements that need to be
addressed at one time or you may become overwhelmed. Begin by systematically focusing on one
step at a time and create a timeline to phase in ICD-10-CM to help ease the transition.
Transitioning to ICD-10-CM is more complex than implementation of new code sets in the past
because the coded data is more complex than those designed for ICD-9-CM. Early preparation
using a phased approach has proven to be the key to success in countries where ICD-10 currently is
used. It also allows for resource allocation over a number of years, rather than all at once.
The first step to successful implementation is to create a project team or steering committee within
your practice to begin the planning process. For many implementation projects in larger practices
or facilities, a cross functional team represents various departments plans and oversees the efforts.
Clear leadership is critical. Establishing the steering committee in your practice to spearhead the
ICD-10-CM transition effort is highly recommended. The team should be comprised of high-level
stakeholders and/or reputed experts who will be asked to provide guidance on the overall strategic
direction of ICD-10-CM implementation. Project team members should include managers or directors who are involved with the business objectives. This leadership group should work independently but should get help from executive level staff when needed, and report periodically to the
practices strategic team. The team should also include at least one physician, an administrator or
manager, coders, billers, and other key staff members. In a smaller practice it is not necessary to
develop multiple committees.
The practice will need physician support for successful implementation. Involve physicians early
so they understand the importance of preparation as the migration to ICD-10-CM occurs. The
team should meet initially to begin to identify the elements necessary for a smooth transition. The
project team will be an integral part of the program now and through compliance in 2015.
Chapter 1
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Chapter 1
5. PlanningCreate a project plan with milestones and identify who is responsible for what and
when.
6. Reporting to the strategy teamCreate an avenue to periodically update the plans strategy team.
7. CommunicationIdentify how the steering committee will inform and engage others in the
organization with a stake in the committees work.
Figure 1.1
Chapter 1
It is the role of the project team to ascertain the business areas impacted by implementation. The
first round is done at a very high level to create awareness and gain buy-in to the work necessary for
now and as well as for compliance later.
Various-sized projects require different organization of the people involved. In small projects, little
organizational structure is needed. There might be a project manager, and project team, or in the
case of a small practice only a manager. Large projects such as the implementation of ICD-10-CM,
however, require the involvement of people from every department in the practice. Those involved
must understand the ongoing commitment they are making and the role they are undertaking.
The strategic steering committee is a group of high-level stakeholders that is responsible for
providing guidance on overall strategic direction. The project lead should form the strategic steering
committee from representatives of different operational areas of the practice impacted by the code
set change. Further organization of this group should identify one person as a lead or chairperson.
Having an ICD-10-CM expert on the committee is a good idea. This expert should have in-depth
knowledge of the current ICD-9-CM coding system and familiarity with ICD-10-CM. Acting as
the ICD-10-CM expert to the strategic steering committee; they will proactively identify actual and
potential coding issues. When issues are identified the ICD-10-CM expert should be able to provide
relevant solutions either through personal expertise or research. Due to the projects complexity, the
expert should also have working knowledge of the practices operations.
Composition of the strategic steering committee should be comprised of representatives from all
key departments including the practice administrator or a core group of administrators (in the case
of a large organization with multiple departments and administrators). The committee also should
include several physicians from various specialty areas, billing and coding, information technology,
compliance, quality, and nursing. The committee members should be experts in their respective
areas. They should be taught about ICD-10-CM and how ICD-10-CM differs from ICD-9-CM and
they should assess the short term and long-term impact to process, technology, and people. The
strategic steering committee must develop a strategic implementation plan with deliverables, timeframes, and milestones.
With the introduction of the ICD-10-CM codes and the vast number of business areas impacted,
it is recommended that large practices or facilities form an educational steering committee. The
committee should conduct a detailed assessment of all staff educational needs. Education cannot
focus solely on clinical staff. ICD-10-CM education must be delivered to many business areas of
the practice. For example, provide education to information technology (IT) staff with a focus on
the differences between ICD-9-CM and ICD-10-CM so they can determine how current systems
will need to be modified to accommodate ICD-10-CM. Clinical staff require more intense
instruction and certified coders must successfully pass a proficiency examination to maintain his
or her credentials. Provide education at different levels of comprehension and at different times
between now and 2015. Upon completion of the assessment, the education committee needs to
finalize an educational plan to address immediate, ongoing, and future educational needs for a
number of audiences.
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The practice must work with their business partners, claims clearing houses, vendors, and others to
ensure compliance. Structured partnering establishes a commitment to cooperation, shared goals,
open communication, and rapid issue resolution. The benefits of partnering early in the ICD-10
implementation process will pay off long-term. Its all about two entities in a collaborative relationship
and working towards a mutually beneficial business outcomeon time ICD-10-CM compliance!
The project team needs to understand ICD-10 before it can lead an implementation plan. Review
the history of ICD as well as what ICD-10 is to provide a better understanding to team members.
You may also want to discuss the benefits of replacing ICD-9-CM.
What is ICD-10?
ICD is the international classification for all general epidemiological, many health management
purposes, and clinical use. These include the analysis of general health situations of populations
and groups and monitoring of the incidence and prevalence of diseases and other health problems.
ICD is published by the World Health Organization (WHO), which directs and coordinates health
authority in the world. ICD is used worldwide for morbidity and mortality statistics, reimbursement, resource allocation quality, guidelines, and intelligence used in healthcare data applications.
ICD was originally developed to classify mortality by promoting international comparability in the
collection, processing, classification, and presentation of mortality statistics, as well as providing
a format for reporting causes of death for death certificates. ICD was later expanded to classify
morbidity. As of Jan. 1, 1999, ICDs 10th revision, ICD-10-CM, has been used to code and classify
mortality data from death certificates; however, ICDs ninth revision, ICD-9-CM, remains the code
set used in the United States for use under the Health Insurance Portability and Accountability
Act (HIPAA) for reporting morbidities. Our focus is on the expected move from ICD-9-CM to
ICD-10-CM for reporting morbidity. Both ICD-9 and ICD-10 have been clinically modified (CM)
for use in the United States and its territories.
HHS has proposed adopting ICD-10 as the new code set for reporting morbidities. At this time,
ICD-9-CM remains the code set in use; however, the transition from ICD-9-CM to ICD-10-CM
will take place on Oct. 1, 2015. The final rule was published in the Federal Register on Jan. 16, 2009
and later amended on April 9th, 2012.
Chapter 1
ICD Background
Periodical WHO revisions to the ICD code set led to the tenth revision of ICD. Work on ICD-10
began in 1992 and was first released by WHO in 1993 and was implemented in the United States for
mortality reporting in 1999. The United States National Center for Health Statistics (NCHS) developed the first clinical modification to ICD-10 in 1997. This modification, known as ICD-10-CM,
was approved by the WHO because all modifications conformed to WHO conventions making it
compatible with ICD-10. This compatibility preserves the ability to compare data internationally.
ICD-10 involves two components: ICD-10-CM (Clinical Modification) for reporting diagnoses
and ICD-10-PCS (Procedural Coding System) for reporting procedures for inpatient hospital
facility services.
ICD-9-CM Volumes 1 and 2 are used to report diagnosis codes on insurance claim forms to
support medical necessity for services provided to patients. ICD-9-CM Volume 3 is for reporting
inpatient hospital procedures and services. ICD-9-CM Volume 3 is only used for inpatient hospital
services, whereas in the outpatient hospital setting the CPT published by the American Medical
Association (AMA) is used to report procedures and services.
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Chapter 1
First
1900
1900-1909
Second
1909
1910-1920
Third
1920
1921-1929
Fourth
1929
1930-1938
Fifth
1938
1939-1948
Sixth
1948
1949-1957
Seventh
1955
1958-1967
ICDA-7
1955
Eighth
1965
1968-1978
ICDA-8
1968-1978
HICDA-1
1968-1972
HICDA-2
1973-1978
Ninth
1975
1979-1998
ICD-9-CM
1979-
Tenth
1989
1999-
ICD-10-CM
2015-
Eleventh
~2015
Figure 1.2
The ICD-9-CM coding system has outgrown its intended level of specificity, which has an impact
on the ability to compare data efficiently and precisely for research, clinical support, and for appropriate reimbursement.
ICD-9-CM has been in use since 1979 and no longer reflects advances in medical treatment. Many
argue an expandable system is necessary. Terminology and classification from the 1970s no longer
fit with the 21st century healthcare system as numerous conditions and procedures are outdated
and inconsistent with current medical knowledge and application. New advances in medicine and
medical technology and the growing need for quality data cannot be accommodated.
The need to replace ICD-9-CM was identified in 1993 and steps were taken by the National
Committee on Vital and Health Statistics (NCVHS), a body that advises HHS on HIPAA matters,
and CMS, to develop a migration plan to ICD-10 for morbidity and mortality coding.
Chapter 1
ICD-9-CM:
Lacks specificity and detail for reporting diagnoses.
Doesnt reflect new services and technology that must be acknowledged in CMS payment
systems according to the Benefits Improvement and Protection Act of 2000 (BIPA).
BIPA modifies Medicares payment rates for many services and adds coverage of
certain preventive and therapeutic services. It also makes changes to both Medicaid
and the State Childrens Health Insurance Program (SCHIP).
No longer reflects current knowledge of disease processes.
Hampers the ability to compare costs and outcomes of different medical technologies.
Significant costs are incurred by continued use of severely outdated and limited coding systems.
For example, failure of our coding systems to keep pace with medical advances results in the use
of vague or incorrect codes often taken from the claims form and requiring excessive reliance on
supporting paper documentation (attachments or copies of the health record).
According to the May 4, 2001 Federal Register, the ICD-9-CM procedure coding system is limited
to a maximum of 10,000 codes, most of which are already assigned. ICD-9-CM has limitations with
a four-digit structure that does not allow for much change. In 1993, NCVHS indicated to HHS that
ICD-9-CM was running out of code numbers. ICD-9-CM deficiencies are as below:
In the HHS proposed rule for electronic transactions and code sets under HIPAA, it was noted that
ICD-9-CM lacks the desirable level of flexibility and steps should be taken to improve the flexibility of these code sets or replace them with more flexible options sometime after the year 2000.
ICD-9-CM has become outdated and obsolete beyond its original scope.
Providers are consistently required to use multiple coding systems to meet the needs of multiple
payers for reimbursement, research, profiling, outcomes measurement, and case-mix management.
Some of the pertinent reasons we use coding data today is to:
Progress toward ICD-10-CM adoption began well over a decade ago. Extensive work and dedication
has gone into developing and evaluating these systems as replacements for ICD-9-CM. While there
is significant support for this change, many healthcare organizations believe the cost of moving to
ICD-10-CM and ICD-10-PCS will be enormous and the move is unnecessary. Physicians and other
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Chapter 1
The steering committee should begin with the key areas of focus in:
10
Chapter 1
The steering committee should begin assessing the impact to the practice with ICD-10 implementation. Information technology should review systems hardware and software requirements for
ICD-10-CM. The organization should review all areas that ICD-10 will impact. By having various
department members on the steering committee the process can be much smoother. For example, it
might be a good idea for a larger practice to create a readiness survey to share and complete within
all departments that will help identify areas of concern. Once the survey results are compiled the
steering committee will have a good understanding of the initial impact of ICD-10 within the
organization.
A readiness survey is a very high-level assessment and creates a snapshot of where the practice
is in terms of its readiness and commitment to the implementation of ICD-10-CM. The survey
should be distributed to all of the practice business areas. Summarization of the information from
the returned assessments should identify strengths and shortcomings in terms of implementation
readiness. Results should be linked to specific areas of change management to provide a basis for
tailoring the change management activities. Figure 1.3 is an example of the readiness survey.
The purpose and importance of the readiness survey should be explained to all who are completing
the survey. The most important question to ask is Have you heard about ICD-10? Next, ask for
input, We need your input to help ensure all users are ready for the diagnosis and procedure code
changes being implemented October 2015. This information is critical and will be used by the
leadership team to make sure everyone is well prepared for the changes and that the right people
have been identified to assist in this implementation effort. Once the readiness survey is completed,
the information provided can assist in the development of a high-level business impact analysis and
determine the specific training and communication plans necessary for the practice.
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Chapter 1
Readiness Survey
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Chapter 1
Assessing Awareness
The implication of the ICD-10 mandate will encompass all aspects of practices internal and
external business and technology processes and operations. Now that the steering committee has
acquired basic ICD-10 knowledge and an understanding about why we must migrate from ICD-9 to
ICD-10, it is essential for them to manage the awareness. This includes a business implications and
timeframe of changes assessment. The assessment includes the following (Figure 1.4).
Assessment Mobilization
INPUTS
ASSESSMENT
OUTPUTS
Business area
interviews
Impact assessment of
Inventory of
impacted areas
Communication
and education
materials
Infrastructure
Review
People,
processes, and
technology via
group
facilitated
sessions
List of vendors
Cost estimates
Action plans for
next steps
Figure 1.4
Once the preliminary assessment information has been gathered and aggregated, the practice
should assess the relationship of ICD-10-CM and each department or business area for:
Operational Complexity
System Complexity
Vendor Maturity
Internal Maturity
Organizational Impact
This more structured assessment can be performed using the following tool, which provides more
detail (Figure 1.5).
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Chapter 1
For each section, please check only one response and provide an explanation for your selection.
Process (Operational
Complexity): Assesses
operational impact or degree
of change for core processes.
[ ] N/A
Technology (System
Complexity): Assesses
the technical complexity;
alignment with technical
architecture; and experience
level with technology and
processes.
Vendor/Internal Maturity:
Assesses the business
maturity level of the vendor
and confidence in its viability
and ability to continuously
deliver and/or assesses our
internal experience level with
the capability and processes.
[ ] Not experienced
[ ] Limited experience
[ ] Experienced
[ ] Very experienced
What is the confidence level with external vendors or our internal experience with the capability and supporting processes?
Explain:
Vendor:
[ ] Little confidence
[ ] Low confidence
[ ] High confidence
[ ] N/A
[ ] Moderate confidence
Internal:
People (Organizational
Impact): Assesses level of
formal change management
required to support project
delivery.
[ ] Little confidence
[ ] Low confidence
[ ] High confidence
[ ] N/A
[ ] Moderate confidence
[ ] Minor training
[ ] Formal training
[ ] Extensive training
Figure 1.5
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Chapter 1
Once the steering team has conducted the initial assessment in relation to the impact ICD-10-CM
implementation will have on each department or business area, it is imperative senior management
support is obtained. It is suggested that as soon as all data has been collected, findings are presented
to senior management. It is beneficial to create a white paper and a slide presentation. Keep the
slide presentation to very high-level concepts.
The presentation outline may include:
Moving from approximately 14,000 diagnosis codes to approximately 69,000 codes is a massive
effort calling for an impact analysis and potential reworking of operations of billing processes,
clinical documentation, coding and contracting, information technology, and other activities.
The Future
Consider the cost and potential disruption caused by ICD-10-CM implementation; however, the
benefits can be greater. ICD-10-CM and ICD-10-PCS incorporate greater specificity and clinical
detail to provide information for clinical decision-making and outcomes research. The ICD-10-CM
code set can potentially reveal more about quality of care, and the data can be used in a more
meaningful way to better understand complications and better track outcomes. Many providers may
see better results with health plans that use quality measures and disease management tracking.
Todays practices have entered a new business era with a rapidly changing environment and
emerging technology. With this rapidly changing business model, medical practices are forced
to produce in a timely manner. There is a never-ending pursuit for perfection without room
for error. In most medium to large medical practices, the structure may be rigidly segregated,
extremely hierarchical, and decision-making is placed in the hands of very few in the practice.
Today, practices with narrow functional middle managers operating within rigid, vertical, and
functional alignments are rapidly becoming obsolete. Cross-departmental collaboration is
replacing this rigid functional structure. Hierarchical medical groups are being flattened, with
many middle-management positions becoming obsolete. A powerful few are being replaced with
self-empowerment of all workers.
At the forefront of the new business model is embracing teamwork. Teamwork concepts quickly
are taking over nearly all business aspects. Implementing team concepts in the workforce enables
practices to move beyond the original organizational and functional boundaries, to focus on solving
problems, and to assure patient and staff satisfaction.
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Chapter 1
Teams that prove most successful have multi-disciplinary team members, which are known as
cross-functional teams. A cross-functional team usually is responsible for all or some segment
of a work process within the organization. Because a work process requires input from several
functional areas, group collaboration is essential. When managed properly, cross-functional teams
provide flexibility, control, efficiency, and multi-disciplinary knowledge.
To understand teamwork, first, realize the difference between a group and a team. A group is only a
collection of individuals who are brought together for a specified purpose. A team, on other hand,
is a group of individuals sharing a common goal who together formulate, define, and agree on
their purpose, and then work toward that purpose. Groups rely on the sum of individual efforts to
accomplish tasks; whereas, teams collectively work together to complete joint assignments.
Teams are committed to communication, collaboration, and constructive conflict. People working
on teams also develop mutual accountability for the teams success or failure.
Cross-functional teams are a group of employees from a medical practice facilitys functional areas.
A cross-functional team might include physicians, nurses, administrative and financial personnel,
coders, etc., who are focused on a specific objective and who work together to improve coordination
and innovation across divisions and to resolve mutual problems.
To face ICD-10s complex challenges, incorporate a wide range of styles, skills, and perspectives.
Cross-functional teams are a way to manage social collaboration and concept creation. No project
of this size can be handled alone or without including representatives who will be impacted by
ICD-10 implementation. Look for leaders in each department to make up your cross-functional
team for a seamless transition.
Examples of cross-functional team usage in ICD-10 development are:
Synergy
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Chapter 1
Synergy can be derived from combining ICD-10 training and cross-functional team elements so the
combinations performance is a much higher than expected outcome. The teamwork of the crossfunctional team will enhance the development and implementation efforts. Picking team members
who work well together and relate to the other departments is essential to achieving synergy. No one
person is the team and optimal success only happens when the teams dynamics achieve the goal.
Organizational Efforts
Organization is the key to any project including planning your cross-functional team for the
ICD-10 project. Make the organizational structure as loose or as formal as necessary for your
practice or facility so there is a good mix of involvement and all involved departments contribute
and participate equally.
Once you choose the required structure for your team, develop an organizational chart to fit your
size and needs. There are numerous organizational documents available for use and samples are
included on the CD with this curriculum.
If your team lacks organized direction, you could miss vital deadlines. Make sure your team understands the organizational chart flow, who to report to and their responsibilities.
Being an effective team player involves overcoming many obstacles and making sacrifices. In the
past, employees thrived on personal recognition and achievements for their individual effort and
performance. This inner pursuit for personal recognition must be suppressed to be an effective
team member. There is no room for heroes in a team setting.
Each team member must contribute to the team effort by pushing aside their personal interest for
the overall team benefit and performance. Team members must conform to group behavior standards to become a valuable and effective part of the team. A team of effective members, regardless
of their functional background, performs better than a group of individuals.
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Chapter 1
SMEs should be individuals representing your practice or facilitys department or functional areas
and should be very knowledgeable about that areas policies, practices, and operations. Smaller
practices may have fewer people in the team with heavy crossover into other departments. Gauge
your team to make sure it fits your practices needs and include only members who work well in a
group. Do not have unnecessary members weighing down the group.
To build an effective team, thoughtfully select SMEs to represent various areas of your practice or
facility. Because the team will work on ICD-10 for a long period of time, this is vital.
When selecting SMEs, other normally performed duties may need to be delegated to another
person within the practice or facility to allow for time to work on cross-functional organization
team tasks. Have someone available for the SMEs to delegate normal working duties to during
this time. This may mean hiring departmental temporary or part time help during this transition
period. If you decide additional help will be necessary, train the help early enough as not to take
time away from the SME. If you dont train the SMEs relief person early on, you will overburden
your team members and delay the implementation progress. This could hinder your implementation efforts. Again, careful organization is necessary throughout the project.
Teamwork
Teamwork is the joint action of two or more people where each person contributes different skills
and expresses their individuality and interests. Opinions are welcome by the group to achieve those
common goals.
This means individual team members are important because a more effective team goes beyond
individual goals and accomplishments. Teamwork is achieved when all involved team members
come together towards that common goal.
Teamwork is fundamental for competing in todays global arena. Build a star team, not a team of
stars. Experienced people are great but avoid choosing those who only want to be the star of the
team and their own ultimate success.
Diverse thoughts, concepts, perception, and experiences enhance creativity and innovation. Diversity is good, if you make the most of it. If you wish to harness the true power of diversity, involve
everyone and cross their ideas to build and empower your cross-functional team. Challenge people
from different disciplines and cultures to create something better and unique to achieve breakthroughs.
Each team member brings unique skills and abilities to the team, and plays a different role in
ICD-10 development. Skills in all areas of ICD-10 are not necessary since the team provides assessments and knowledge in all areas of your practice or facility. Consider and value each idea.
As Henry Ford said, Coming together is a beginning, keeping together is progress, and working
together is success.
Organizational Structure
In past years, it was believed that organizational structure was needed to make strategic, tactical,
and operational decisions.
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Chapter 1
Cross-functional teams require a wide range of information to reach decisions. They need to draw
on information from all parts of a practice or facilitys information base, including information
from all functional departments. Transparency of operations is a must. System integration is much
more important as it makes all information accessible through a single interface.
Cross-functional teams require information from all levels of management. Self-directed teams
need information traditionally used in strategic, tactical, and operational decisions. For example,
ICD-10 training plans are a tactical procedure, getting strategic development from administration
or physicians and using operational departments like nursing or coding.
Flow Charts
Information must take a form that all persons in the practice or facility can understand. Flow
charts for tracking progress and issues are necessary to facilitate timelines and obstacles. Sometimes when a flowchart is used, too many different people, departments, or functional areas are
involved which makes it difficult to keep track of who is responsible for each step.
Another useful technique for tracking progress and for analyzing the number of times a process is
handed over to different people is to divide the flowchart into columns. Name each column with
the person or function involved in the process, and each time they carry out an action show it in
their column. Review Figure 1.6.
Function
Team
Member
Areas
Communications Target
Impacted
Date
Completion
Date
Implementation
Plan
Susan
Parkins
All
workgroup
to be
TBD
determined
(TBD)
Communication Delaney
Plan
Breland
All
emails
TBD
TBD
Impact Analysis
workgroup
TBD
TBD
Cross-functional Analysis
TBD
TBD
TBD
spreadsheets
TBD
TBD
Figure 1.6
Build and manipulate flowcharts to serve your needs. The Figure 1.6 is just one of many your can
create and use for your cross-functional team. Review the example of an organization chart for
ABC Medical Group in Figure 1.7 and Figure 1.8, which identify the organization and the crossfunctional team for ICD-10-CM implementation.
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Chapter 1
Vice President
Jeffrey Buson, MD
Administrator
Director Finance
Director Information
Technology Manager
Clinical Director
Susan Parkins
Kevin Piccolo
Rick Jameson
Martin Short, MD
Executive Assistant
Coding Manager
IT Manager
Physician
Maly Lee
Cara Parkinson
Mike Sherlock
Thomas Jordan, MD
Coding Staff
Senior Programmer
Nurse/MA
Theresa Resemheimer,
CPC
Anna Baisle
Mary Smythe, RN
Jim Clover
Physician
Programmers
Nancy Mitenhoff, MD
Scott Beam
Billing Manager
Tina Lai
Delaney Breland
Mike Forrest
Nurse/MA
Tonya Jones, CMA
John Highwagon
Billing Staff
Physician
Theresa Resemheimer,
CPC
John Maynard, MD
Nurse/MA
Physician Assistant
Steven Hardison, PA
Physician
Marilyn Smirnall, MD
Nurse Practitioner
Jennifer Rothwell, CNP
Physician
Jeremy Swift, MD
Nurse/MA
Rhonda Martin, CMA
Physician
Natalie Wooden, MD
Physician Assistant
Karen Fortner, PA
Figure 1.7
20
Chapter 1
Martin Short, MD
Cross Functional
Analysis
Cara Parkinson
Rick Jameson
Impact Analysis
Mike Sherlock
Delaney Breland
Kevin Piccola
Susan Parkins
Communication Plan
Chair
Jeffrey Buson, MD
Martin Short, MD
Kevin Piccola
Budget
Development
Susan Parkins
Susan Parkins
Kevin Piccola
Implementation
Planning
Rick Jameson
Figure 1.8
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Chapter 1
Transparency
22
Chapter 1
prevent a problem from happening than to perform damage control later. Up-front teambuilding
sessions, where members concerns, problems, and issues come out are a healthy way of preventing
problems. These sessions also can deal with problem areas during the project. This teambuilding is
especially important in cross-functional teams. Old department rivalries and current personality
clashes can create explosions with the simplest of issues.
Such teambuilding sessions have two parts. The first part concerns training the team in the tools
they will use: problem solving, statistical process control, flowcharts, etc. After an initial overview, this training is best delivered in a just in time fashion, where trainers teach the members
the specific tool just before they use it. For example, a team might receive an overview of problem
solving as part of their initial teambuilding, and then they learn how to develop flowcharts just
before they use them.
The second part of teambuilding involves training in the usual set of group skills: meeting management, stages of group development, avoiding groupthink, the Abilene paradox, etc. For the most
part, though, the second part involves facilitation around specific issues a particular team faces.
This training/facilitation is best done when the entire cross-functional team is present in a room
while receiving the training/facilitation at the same time. Many practices do not realize this, and
mix and match class room attendance, and train individuals from a variety of groups. This way
may make the scheduling of training easier and more efficient, but it does not promote spirit within
a particular teamisnt that the point of teambuilding?
Look at the very different situation of promoting cross-functional teamwork across the organization. Changes to support cross-functional teamwork do not involve individual teams, but their
supporting systems. These systems include organizational structure, performance appraisal/hiring/
promotion criteria, and compensation systems.
There is a belief that a corporate culture is relatively stable and enduring. But research shows that
during the non-routine tasks which cross-functional teams perform, culture is managed. There is
an opportunity for leadership in this area.
Conclusion
By collecting peoples thoughts and ideas about ICD-10-CM within the group and documenting
that information, the discovery phase will deepen the practices understanding of the challenges
faced with implementation. Through readiness surveys, high-level impact assessments, and
completed business cases, the strategic steering committee and administration will learn not only
about the challenges they face but about the organizational resources necessary for project. This
assessment approach assists in staff planning to help the practice better prepare, and budget prior
to embarking on this multi-year project. The information collected during this phase serves as
collateral for subsequent phases and helps ensure nothing slips through the cracks. Spending time
discovering what ICD-10-CM implementation will bring can help the practice focus the design
efforts and get to compliance.
Remember: Each suggested committee must provide sharp strategic thinking, cultivate productive
working relationships, communicate with influence, and achieve results.
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Chapter 1
Resources
and
Templates
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Chapter 1
Templates
26
Chapter 1
Readiness Survey
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Chapter 1
For each section, please check only one response and provide an explanation for your selection.
Process (Operational
Complexity): Assesses operational impact or degree of
change for core processes.
[ ] N/A
Technology (System
Indicate experience level with technology and supporting processes related
to this effort?
Complexity): Assesses the
technical complexity; alignment with technical architec- Explain:
ture; and experience level with
technology and processes.
Vendor/Internal Maturity:
Assesses the business maturity level of the vendor and
confidence in its viability and
ability to continuously deliver
and/or assesses our internal
experience level with the
capability and processes.
[ ] Not experienced
[ ] Limited experience
[ ] Experienced
[ ] Very experienced
What is the confidence level with external vendors or our internal experience with the capability and supporting processes?
Explain:
Vendor:
[ ] Little confidence
[ ] Low confidence
[ ] High confidence
[ ] N/A
[ ] Moderate confidence
Internal:
People (Organizational
Impact): Assesses level of
formal change management
required to support project
delivery.
28
[ ] Little confidence
[ ] Low confidence
[ ] High confidence
[ ] N/A
[ ] Moderate confidence
[ ] Minor training
[ ] Formal training
[ ] Extensive training
Chapter
Communication
Objectives:
Introduction
While there are many important factors to a successful implementation, the ability to communicate
effectively during the implementation lifecycle is one that takes precedence. This chapter will help
you execute effective communication for your practices ICD-10-CM implementation.
All ICD-10-CM projects, large or small, will require proactive communication. Its important for
the person responsible for communicationor the project managerto ensure all departments,
providers, and staff will receive sufficient information during the transition. Communication is
also a vital way to manage expectations about the progress of ICD-10-CM implementation, and to
delegate who needs to do what. This can be as simple as talking to your providers and staff about
the progress of implementation.
On small projects, communication is simple and does not require as much effort as larger projects.
The larger your team is, the stronger your communication plan needs to be. Large projects require
communication planned in advance, taking into account the particular needs of the people
involved. This is where a communication plan is useful. A communication plan allows you to
think through how to inform all those involved constituents most efficiently and effectively about
ICD-10-CM implementation. Effective communication means you provide information in the right
format, at the right time, and with the right impact. Efficient communication means you provide
the necessary information and nothing more.
A solid communication plan is essential to establish a clear line of communication when implementing ICD-10-CM in large practices. Effective communication is an art form and steps must be
taken to keep it organized and flowing effortlessly in your practice.
A communication plan provides an ICD-10 focus and provides a sense of order and control. It gives
your medical practice priorities and milestones and prevents an incorrect message from being
delivered to the staff. A good communication plan also creates a team atmosphere and establishes a
chain of command.
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Communication
Chapter 2
Communication Planning
Proactive communication in your practice will help you determine your needs and how information will be collected and shared. These plans will also cover:
Figure 2.1 outlines the roles and responsibilities of staff undertaking communications activities.
You can use this template to include in the project plan for communication.
Name
Mary Smythe
Mark Rodgers
For ICD-10 implementation, methods of communication will depend on the size of the practice.
Now is the best time to develop your communication plan for ICD-10-CM implementation in your
30
Chapter 2
Communication
practice. Delaying the communication plan and its implementation could hinder your final goals
and objectives. Consider and determine all employees and business areas first when developing
a communication plan. Determine what people or groups of people within the practice you will
include in the communication plan. For all groups identified, determine what their communication needs are. For example, certain managers may have a need for status updates more often than
physicians and staff. The steering committee or project team members might need more information than others within the practice, such as project status, strategy, or vision.
Communication can take many shapes and forms. In each step, formulate a plan of how to fulfill
the communication needs for each department, employee, vendor, etc. When possible, look for
types of communication that will encompass all the practice needs.
The communication plan sets the communication framework for ICD-10-CM implementation,
and it will serve as a compass for communications throughout the life of the project and should be
updated as communication needs change. The plan should identify and define the roles of persons
involved in this project, and should include a communications matrix which maps the communication requirements of the project in those larger practices.
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Communication
Chapter 2
Determine how much effort is required for each of the communication methods used within the
practice. Some of the activities might be relatively easy to perform. Others will require more effort.
If the communication is ongoing, estimate the effort over the timespan of the ICD-10 implementation period. For instance, a status report might only take one hour to create, but might be needed
twice a month. The total effort would be two hours per month.
Some communication activities are more valuable than others. The practice needs to prioritize the
items to determine which provide the most value for the least cost. If a communication activity
takes a lot of time and provides little or marginal communication value, it should be discarded.
If a communication option takes little effort and provides a lot of value, it should be included in
the final communication plan. If a communication activity is mandatory, include it no matter
what the cost.
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Chapter 2
Communication
Communications Calendar
Tasks, Activities
JAN
Mary Smythe
FEB
Mark Rodgers
MAR
Send email updates to the CFO and CEO of organization identifying progress
Mark Rodgers
APR
MAY
Conduct monthly staff meetings with physicians and other department managers regarding
progress
Mark Rodgers
JUN
Send email updates to the CFO and CEO of organization identifying progress
Mark Rodgers
JUL
AUG
Conduct monthly staff meetings with physicians and other department managers regarding
progress
Mark Rodgers
SEP
Send email updates to the CFO and CEO of organization identifying progress
Mark Rodgers
OCT
NOV
Conduct monthly staff meetings with physicians and other department managers regarding
progress
Mark Rodgers
DEC
Send email updates to the CFO and CEO of organization identifying progress
Mark Rodgers
Evaluate Results
Build into your ICD-10-CM implementation communication plan a method for measuring results.
Tools to evaluate can include:
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Communication
Chapter 2
Results Analysis
Figure 2.3 is a useful tool to analyze communication outcomes in the organization:
Stakeholder
Objective
Key Messages
Communication
Vehicles
Feedback
Mechanisms
Internal Stakeholders
CEO/CFO
Monthly
meeting
with senior
management
Physicians
Quarterly
update
regarding
documentation
guidance for
ICD-10-CM
One-on-one
meetings with the
physicians and
group staff meeting
Quarterly
physician
meeting
following
documentation
review
Communicate
based on
audit results
documentation
deficiencies
and areas of
improvement
Figure 2.3
How do you get people within your practice to pay attention to issues and recognize the importance
of ICD-10 and its implementation? And once internal staff becomes aware of the message, how do
you communicate in a way that will resonate? Although these questions may seem obvious when
thinking about ongoing communication, they can be complex when carrying out the communication. It is essential to clearly get your message across to your team.
WHO are the key employees involved in ICD-10 implementation? Since this is such a large project,
there will be many business areas represented; they can be administrators, team members, coders,
billers, providers, nursing, etc.
WHAT details must be communicated to each group involved in the implementation? Depending
on the practices level of involvement, each will require different kinds of details tailored to meet
each contributor.
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Chapter 2
Communication
WHEN must the project team communicate to those involved in the implementation? The implementation team will require daily, weekly, bi-weekly, or monthly updates while other staff may need
an update every few months.
WHERE will the practice receive communications? Will it be an email, a newsletter, staff meeting
etc., or a combination of efforts? To be effective, communication will most likely come from a
variety of media; it is the communicators job to identify how key team members will receive
information.
HOW will the project team communicate to the practice or facility? Sometimes project mangers
choose to answer this by identifying another who. For instance, the team may set up a communication coordinator and all information is delivered from that person via all media. In another
structure, the project manager may assume communication responsibility and utilize trusted
individuals within the organization.
By asking the right question: who, what, when, where, and how, the ICD-10 implementation
project manager can build workflows, plans, and monitor strategies for effective communication.
Not establishing a communication plan that clearly spells out the information flow will negatively
impact the project and could hinder implementation in larger practices.
Disseminating Information
The communication plan for the ICD-10 implementation requires funneling the information
from the stream of daily activity into a set of usable nuggets. Disseminating the information
appropriately involves identifying key issues and decisions and transforming it into concise
information. In your communication plan, consider funneling information through the following
avenues:
Regular ReportsWhat are a set of regular reports that must be distributed and to whom and
how often? What is the process for setting up new reports? Who handles this and who verifies the
content before distribution?
Event Driven AlertsWhat milestone or event will trigger necessary communication and what is
the alert distribution? Will there be a process or rules surrounding the delivery of messages?
Audience RequestsFrom time-to-time in the ICD-10 implementation effort, there will be
requests from other interested parties for updates and/or presentations on a variety of information
about ICD-10 or on your progress in the implementation effort. Think about how to handle those
audience driven requests, the content of the message, and where all archived data should be stored.
Equally important is to decide when the project team may decline a request for information.
The communication steering committee might find it useful to complete the following structural
tools for their communication efforts.
Communication Strategy Template
Communication Schedule
Communication Plan Template
Communication is a critical component of project management and needs to be controlled
for the duration of the effort. Communication management for such a large project as the
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Communication
Chapter 2
implementation of ICD-10 can be time consuming. The communication strategy and plan should
identify who needs what information, when they need it, and in what form it will be given to them.
Communication needs to be clear and everyone involved in the ICD-10 implementation effort
should understand how communication affects the project as a whole.
Purpose: Identify key audiences, regular and specific channels for communicating with each
audience, timing of the messages, and the people responsible for providing the communication.
Conclusion
ICD-10 implementation is one of those large projects that will require long-term planning and
open communication. Successful implementation will require strategic goals. A well-defined and
effective communication plan will be a big help in overcoming obstacles along the way.
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Chapter 2
Communication
Resources
and
Templates
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Communication
Chapter 2
Communication Calendar
Communications Calendar
Tasks, Activities
Events
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
Figure 2.2 Communication Schedule
38
Chapter 2
Communication
Results Analysis
Stakeholder
Objective
Key Messages
Communication
Vehicles
Feedback
Mechanisms
Internal Stakeholders
External Stakeholders
Figure 2.3
Objective: [Objectives are specific ends, conditions, or states that are intermediate steps
toward attaining a goal. They should be achievable and, when possible, measurable, and
time-specific. An objective may only pertain to one particular aspect of a goal or it may be
one of several successive steps toward goal achievement. Consequently, there may be more
than one objective for each goal.]
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Communication
Chapter 2
Key Messages/Themes
[Describe the key messages or themes that must be employed throughout the entire communications program. These are themes you want reinforced repeatedly.]
Communication Phases
[Describe what phases the communications program will employ. Will messages be directly
related to the release strategy or phases of the project?]
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Chapter 2
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Instructions: Begin to plan all communications messages by identifying the audience, phase,
objectives of the message, key messages, media (email, newsletter, etc.), content, and frequency.
Phase
Figure 2.4
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Communication
Chapter 2
Communication Content
Method
Administration/
Board Members/
Providers
Presentation
Dates Responsible
Party
Core ICD-10
strategy team
Accounting
Regulatory awareness
ICD-10 code set awareness
Contract implications
Provider readiness
Budget implications
Nursing
Regulatory awareness
ICD-10 code set awareness
Timeline for implementation
Differences between ICD-9 and
ICD-10
Coding/Billing
Health Plans
Overview of contracts
Coverage determinations
Implementation delays
Vendors
Implementation issues
5010 readiness
Acceptance of code testing
Security
Figure 2.5
42
032415
Other
Vendors
Subcontractors
Employees
Project team
members
Physicians
Senior management
CEO/CFO
Key Stakeholders
(distribution
schedule)
ICD-10-CM
Issues
Key
Messages to
Communicate
Timing Issues
(project
schedule)
Other
Chapter 2
Communication
Figure 2.6
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Communication
Chapter 2
Communication Objective of
Medium Frequency Audience Owner Deliverable
Type
Communication
44
Kickoff Meeting
Introduce the
project team and
the project. Review
project objectives
and management
approach.
Face-to
Face
Review status of
the project with the
team.
Technical Design
Meetings
Project
Sponsor
Project
Team
Stake
holders
Project
Agenda
Manager Meeting
Minutes
Face-to
Weekly
Face
Confer
ence Call
Project
Team
Project
Agenda
Manager Meeting
Minutes
Face-to
Face
Project
Technical
Staff
Technical
Lead
Monthly Project
Status Meetings
Face-to
Monthly
Face
Confer
ence Call
PMO
Project
Manager
Project Status
Reports
Project
Sponsor
Project
Team
Stakeholders
PMO
Project
Project
Manager
Status
Report
Once
As Needed
Monthly
Agenda
Meeting
Minutes
Chapter 2
Communication
When? How?
(Format/Medium)
Who is
responsible?
Communication
As
pertaining to the
needed
objectives of the
managed events
Communication
pertaining to cost,
scope, quality, risks,
and time of event
Roadblocks and key
issues
Documents for review
Commencement,
Daily
progress and
completion of
scheduled tasks
Cross communication
in role hierarchy
Identification of new
stakeholders
New issues or risks
identified
Additional work
discovered
Impacts identified to
cost, scope, time
Approved vendors
and cost budgets
Documents for review
Project Team
Current work
assigned, time due
Communications
process
Work prioritization
Status of issues raised
Project Schedule
Available
Communications Plan
Project Schedule, Email,
Verbal
Issues Log, Written,
Verbal
Project Manager
Project Manager
Project Manager
Functional
Manager
Email CC
Project Team
/Volunteers
Employees
Current work
assigned, time due
Task Outline
Functional Manager
Project
Manager
Daily
Daily
Project Manager
Written Communication
Verbal Communication
Relevant Reports
Issues Log, Written
Written Documents
Email cc
Email, Verbal, Written
Email, Verbal, Written,
Issues Log
Email, Verbal, Written
Email, Verbal, Written
Project Manager
Project Team
/Functional
Project Team
/Functional
ALL
ALL
ALL
ALL
Procurement
Manager, Sponsors
Project Team
/Functional
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Chapter 2
Terminology
Key StakeholdersNormally, stakeholders include all individuals and organizations that are
impacted by the project. These are the stakeholders with whom we need to communicate. The key
stakeholders include executive management with an interest in the project and key users identified
for participation in the project.
Project Director-LeaderThe project director or leader is the champion of the project and has
authorized the project by signing the project charter. This person is responsible for the funding of
the project and is ultimately responsible for its success. Since the project director is at the executive
level, communications should be presented in summary format unless the project director requests
more detailed communications.
Project ManagerThe project manager has overall responsibility for the execution of the project.
The project manager manages day-to-day resources, provides project guidance, and monitors and
reports on the projects metrics as defined in the project management plan. As the person responsible for the execution of the project, the project manager is the primary communicator for the
project distributing information according to the communications management plan.
Project TeamThe project team is comprised of all persons who have a role performing work
on the project. The project team needs to have a clear understanding of the work to be completed
and the framework in which the project is to be executed. Since the project team is responsible
for completing the work for the project, they play a key role in creating the project plan including
defining its schedule and work packages. The project team requires a detailed level of communications which is achieved through day-to-day interactions with the project manager and other team
members, through weekly team meetings.
Steering CommitteeThe steering committee includes management representing the departments which make up the organization. The steering committee provides strategic oversight for
changes impacting the overall organization. The purpose of the steering committee is to ensure
changes within the practice are applied in such a way that it benefits the organization as a whole.
The steering committee requires communication on matters which will change the scope of the
project and its deliverables.
Technical LeadThe technical lead is a person on the project team who is designated to be responsible for ensuring all technical aspects of the project are addressed and the project is implemented
in a technically sound manner. The technical lead is responsible for all technical designs, overseeing
the implementation of the designs, and developing as-built documentation. The technical lead
requires close communications with the project manager and the project team.
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Objectives
Recognize the benefits of the 5010 transition for the electronic data interchange (EDI)
business area
Understand the importance of the transition to the 5010 EDI format
Recognize the relationship 5010 has with ICD-10 implementation
Learn about the D.0 conversion and how it affects health plans
Understand the importance of the Medicaid 3.0 transition and how it impacts
subrogation
Analyze the Centers for Medicare & Medicaid Services (CMS) plan for 5010/D.0/3.0
implementation
Recognize the improvements of 5010 compared to the current 4010 standard
Explore what General Equivalence Mappings are in relation to analytical purposes
Illustrate how General Equivalence Mappings work for analytical purposes
Understand the details of General Equivalence Mappings such as flags, attributes, flat
files, and file layouts
Explore Reimbursement Mappings and reimbursement equivalents
Understand the details of Reimbursement Mappings and file structure
Transaction Sets
According to CMS Overview of Transaction and Code Sets Standards found at www.cms.hhs.
gov/TransactionCodeSetsStands/, Transactions are electronic exchanges involving the transfer
of healthcare information between two parties for specific purposes, such as a healthcare provider
submitting medical claims to a health plan for payment. The Health Insurance Portability &
Accountability Act of 1996 (HIPAA) named certain types of organizations as covered entities,
including health plans, healthcare clearinghouses, and certain healthcare providers. HIPAA also
adopted certain standard transactions for Electronic Data Interchange (EDI) for the transmission
of healthcare data. These transactions are: claims and encounter information, payment and remittance advice, and claims status, eligibility, enrollment and disenrollment, referrals and authorizations, and premium payment. Under HIPAA, if a covered entity conducts one of the adopted
transactions, they must comply with the adopted standard. This means that they must adhere to the
content and format requirements that are specified in the HIPAA standards. HIPAA also requires
every covered entity to use certain codes to identify specific diagnosis and clinical procedures on
claims, encounter forms and other transactions. The HCPCS (Ancillary Services/Procedures), CPT
(Physicians Procedures), CDT (Dental Terminology), ICD-9 (Diagnosis and hospital inpatient
Procedures), ICD-10 (After October 1, 2015) and NDC (National Drug Codes) codes with which
providers are familiar, are examples of code sets for procedures, diagnoses, and drugs. Finally,
HIPAA adopted standards for unique identifiers for Employers and Providers.
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Successful ICD-10 implementation relies on sharing of information systems progress about the
5010 transition.
Definitions:
Version 5010the new version of the x12 standards for HIPAA transactions
Version D.0the new version of the NCPDP standards for pharmacy and supplier transactions
Version 3.0a new NCPDP standard for Medicaid pharmacy subrogation
OESSOffice of E-Health Standards & Services
Source:
www.cms.hhs.gov/Versions5010andD0/10_background.asp#TopOfPage
Under HIPAA, the electronic transaction standard used is the version ASC X12N 4010A1. The
latest upgrade of the electronic submission architecture is version ASC X12N 5010, more commonly
known as 5010. The new submission standard will accommodate the increased size and complexity
of ICD-10 codes and will relate almost entirely to healthcare transactions in the same way 4010
currently does.
The 5010 standard implementation required changes to software, systems, and procedures currently
used to bill Medicare and other payers. Part of preparing for ICD-10 implementation naturally
includes the 5010/D.0/3.0 progressions as milestones in the overall implementation process. Those
affected by the upgrades include all HIPAA covered entities; this means providers, health plans,
and clearinghouses. Business associates of these covered entities using covered transactions are, for
example, billing companies or service firms.
Structural Changes
There are important structural changes with the 5010 transition, which include changes to front
end data and technical content. The reason for these changes is to provide greater accuracy
in search inquiries and to improve eligibility responses. Unlike the previous version of 4010
transaction set, 5010 is much more specific in data collection and transmission over the course of
a transaction. Some improvements in the 5010 transactions include clearer instructions, reduced
ambiguity among common data elements used in different transactions, and elimination of
redundant and unnecessary data elements.
The updated version of the transactions has data reporting requirements that differ somewhat from
the previous transactions. These changes may require you to collect additional data or report data
in a different format. For example, in the 4010A1 version of the professional claim transaction,
anesthesia services may be reported in actual minutes or in units of time. In the 5010 version, only
actual minutes may be reported. Another example of a difference in the professional claim transaction is the reporting of the billing provider address. In 5010, the address can no longer be a PO Box
or lockbox address.
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5010 increased the ICD field size to accommodate the increased size of ICD-10 codes. The changes
include a version indicator to distinguish between ICD-9 and ICD-10 codes. The 5010 format
increases the number of diagnosis codes allowed on a claim. Interestingly, the 5010 format does not
require the use of ICD-10 codes; however, it recognizes and distinguishes between the ICD-9 and
ICD-10 code sets by using a version indicator. For paper claims the revised CMS1500 allows for
reporting of up to 12 diagnosis codes.
Changes must be made to systems that submit claims, receive remittances, and exchange claim
status information. Eligibility inquiries and responses must be analyzed to identify software and
business process changes. Changes will be made to transactions as well. Functional Acknowledgement transaction 997 will be replaced by 999 and the Claims Acknowledgement 277-CA will
replace proprietary error reporting. The following table lists affected transactions, those that must
be upgraded from 4010 to 5010 and from NCPDP 5.1 to D.0:
Transaction
Affected Types
Claims
Remittance
835
276, 277
Eligibility Inquiry/Response
270, 271
Functional Acknowledgement
997
Transaction Acknowledgement
TA1
Important: 5010 does not add intelligence to process ICD-10 codes; rather, it simply allows the
codes to be submitted in the new format. Version 5010 does not in anyway offer crosswalks between
ICD-9 and ICD-10. Because of 5010s indicator digit, ICD-10 codes arent required; rather, it makes
room for them and allows the two code sets to be distinguished from one another.
Anticipated Benefits of
ICD-10-CM/PCS Implementation to Analytics
In this data driven world, most practices rely heavily on data and information to assist in their
analytics and decision-making. The data they use is their claims and financial data available to
them from their data warehouse through applications and analytics. As such, many large healthcare organizations invest a lot of money and effort to create and maintain their corporate business
intelligence systems.
ICD-10-CM/PCS will improve the value of the huge investments being made to facilitate the collection, reporting, and exchange of diagnosis and procedure data. The demand for diagnosis and
procedure data is growing while the information value deteriorates due to obsolete code sets. Many
quality measures rely on ICD-9-CM codes. ICD-10-CM will provide far greater value by better
describing conditions, co-morbidity, and complications.
For facilities, ICD-10-PCS will permit comparative effectiveness research on new medical technologies. The finer detail and cleaner logic of the codes will better support clinical research. For
instance, knowing whether and under what circumstances laparoscopic surgery improves healthcare outcomes as compared with open surgery would affect thousands of lives and could save
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billions of dollars. There are many other similar examples of very important improvements that
will add real value and aid decision-making.
ICD-10-CM/PCS will allow improved reporting capabilities by allowing for more increased granularity of the data. Some of the benefits include:
Improved clinical reporting
Enhanced demographic reporting of disease states
Greater specificity of trend reporting from a disease, procedure, and financial perspective
Another benefit will come from the ability to do comparative analyses with other countries that
have been using ICD-10 for some time. Researchers and public health officials have long been
awaiting this opportunity.
With the addition of tens of thousands of codes, new trends could be determined and new ways to
look at data will be the standard. Moving forward, data within a vague category can be analyzed
more in detail to determine the specific set influencing the overall composition.
Business Intelligence
Just what is business intelligence and how will business intelligence be impacted by ICD-10-CM/
PCS? For a medical practice, business intelligence is an environment in which enterprise users
receive data that is reliable, consistent, understandable, easily manipulated, and timely. Business
intelligence consists of applications, technologies, databases, and practice management systems
allowing users to access and analyze their data and information. And finally, it includes analysis of
code utilization. It monitors the financial and operational health of the practice through reports,
alerts, alarms, analysis tools, key performance indicators, and dashboards. Since claims are a key
component of many of the attributes of business intelligence, ICD-10 will have a huge impact to
many of the practices applications, systems, repositories, tables, databases, extracts, and reports.
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Creating a list of changes through the use of a Change Log will assist in ensuring that nothing
slips through the cracks and compliance is met. This change log can also be used for testing. Figure
3.1 is a Change Log template example.
J. Taylor
Publish Date:
01/05/10
Figure 3.1
Vendor Systems
Often over time many small to large medical practices have made the conscious decision to buy
rather than build applications and/or systems. Vendor readiness will have to be closely managed
by the practice. Due to application and systems complexity, IT staff will have to assign staff to
oversee and manage its vendors. Internal IT will work closely with the vendors to ensure thorough
testing within the practices platform before going live.
Staffing this effort may become an issue. IT staff is constantly subject to supply and demand. As
Y2K demonstrated, when there are periods where certain talents are in high demand, the cost of
those services increases. This may occur with ICD-10-CM/PCS implementation and compliance
mandated for after October 1, 2015. ICD-10-CM/PCS impacts a number of systems, and retooling
is a given. There will be a feeding frenzy for IT resources with a broad spectrum of skills due to the
complexity of this implementation effort.
Software Updates
The transition from ICD-9-CM to ICD-10-CM/PCS will be significant to software that utilizes
diagnosis and procedure codes. Logic changes will have to be evaluated and changes to diagnosis
and procedure algorithms will have to be revised and tested. This effort may rest on the software
vendors but the practice needs to make sure they have a consistent vendor strategy that includes
ongoing monitoring.
Testing
No matter what approach the practice undertakes, devotion to the time necessary to perform
adequate testing during the implementation period is important to ensure that all issues are
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remediated and that the practice is ready to roll live. Every change to a system or application must
be tested before it goes into production. Testing can be broken into the following:
Quality assurance
Answers the question Do all of the changes made provide the expected outcome?
User acceptance
Testing is an evaluation by the users that the systems are working.
Integration testing
Testing of the combined parts to determine they are working together.
Regression testing
Retests the programs to ensure no faults.
Performance testing
Tests the compliance of a system and usually done with a large number of users.
End-to-end testing
Involves the full life cycle of a claim from receipt to payment to data storage.
The practice may create a task force to oversee the complex task of complete integrated testing
with representation from each testing effort. This would include internal or external IT, vendors,
clearinghouses, coding solutions, etc. Collaboration in developing test strategies, test cases, and test
scripts is strongly suggested. In larger practices or facilities, workgroups should develop specific
guidelines and standard operating procedures for testing and indicated end results for the modification made along the way. Creating a test environment separate from production will greatly
facilitate this effort. Extensive logs and tracking tools should be used throughout all testing. Use of
the Change Log is highly recommended to maintain control over individual changes and to track
the effects of those changes. (As a word of caution, the changes, especially to older systems, can
create new bugs and problems that were not foreseen and may be unrelated to the general work on
ICD-10-CM/PCS conversion.) Remember, the more robust the testing the better. It goes without
saying that keeping the Strategic Steering committee and administration apprised of the testing
efforts is a requirement.
Data Quality
Understanding the meaning of data helps practices interpret it properly. Quality of data definitions
is required for the IT business area to capture it correctly and completely. There is no such thing as
business intelligence without the people to interpret the meaning and significance of information and
to act on their knowledge gained, especially in healthcare. So, those involved in data quality, as well as
those involved in analytics will have to have a basic level of training in the ICD-10-CM/PCS code sets.
Budgetary Implications of
ICD-10-CM/PCS to Information Technology
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perform the necessary tasks should be taken into account, as should the internal downtime these
changes might create. Even though an upgrade to a new technology is quite costly, the returns on
investment due to the 5010 and ICD-10-CM/PCS changes may be well worth the cost. The standard
rule of thumb on IT is that if improvement cost exceeds half the cost of purchasing a new system
then its time to consider upgrading. New systems might be easier to upgrade down the line and
will open more possibilities for developing creative solutions to ICD-10-CM/PCS intricacies or to
take advantage of the enhanced information of the new code sets.
General Equivalence Mappings (GEMS) were the creation of work completed by the National
Center for Health Statistics (NCHS), the Centers for Medicare & Medicaid Services (CMS),
AHIMA, the American Hospital Association, and 3M Health Information Systems. The GEM
files were an attempt to convert coding between ICD-9 and ICD-10. Most recently, the National
Committee on Vital and Health Statistics (NCVHS) published the translation dictionary for
diagnoses. Similarly, the CMS published a translation dictionary for procedures. Collectively these
are called GEMs. This effort created a national version to ensure consistency in national data is
maintained. The GEM files can be used by anyone who wants to convert diagnoses and procedure
data including but not limited to:
Health Plans
Providers
Medical Researchers
Medical Software Vendors
These files were designed to give all sectors of the healthcare industry, using coded data, a tool
to convert and test systems, link data in long-term clinical studies, develop application-specific
mappings, and analyze data collected during the transition period and beyond.
These files were not developed for coding assistance.
Both NCVHS and CMS have stated that the GEMs will be updated annually reflecting the
ICD-10-CM and ICD-10-PCS changes. NCHS and CMS have stated that they will maintain the
GEM files for at least three years beyond the compliance date of Oct. 1, 2015.
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Table one shows the four GEM files that are available for use by the physician and others.
Source (from)
Target (to)
AKA
Source (from)
Target (to)
AKA
ICD-9-CM
ICD-10-CM
Diagnosis
forward
mapping
ICD-9-CM
ICD-10-PCS
Procedure
forward
mapping
ICD-10-CM
ICD-9-CM
Diagnosis
backward
mapping
ICD-10-PCS
ICD-9-CM
Procedure
backward
mapping
ICD-9-CM Source
ICD-10-CM Target
Figure 3.2
However, one ICD-9-CM code can translate into several ICD-10-CM codes, and visa versa More
often than not because of the nature of going from the general ICD-9-CM to the more specific
ICD-10-CM, these are more readily available. Below are examples of 1:2 mappings.
ICD-9-CM Source
ICD-10-CM Target
R22.0 Localized swelling, mass or lump head
ICD-10-CM Source
ICD-9-CM Target
995.92 Severe sepsis
AND
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ICD-10-CM Target
L56.0 Drug phototoxic response
ICD-10-CM Source
ICD-9-CM Target
785.4 Gangrene
Figur 3.6
Just as with diagnoses codes there are instances where the ICD-9-CM procedure and ICD-10-PCS
code translation is very straightforward and easily match one to the other.
Below is an example of a 1:1 match.
ICD-9-CM Source
ICD-10-PCS Target
0FT40ZZ Resection of the gallbladder,
percutaneous approach
Figure 3.7
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Just as with diagnosis codes, ICD-9-CM procedure codes often translate to several ICD-10-PCS
codes because of the nature of going from the more limited ICD-9-CM to a more specific
ICD-10-PCS. There are many instances of 1:2 mappings and below is an example.
ICD-9-CM Source
ICD-10-PCS Target
0BH17EZ Insertion endotracheal device into
trachea via natural or artificial opening
0BH18EZ Insertion endotracheal device into
trachea via natural or artificial opening,
endoscopic
Figure 3.8
ICD-10-PCS Target
0VTT0ZZ Resection of prepuce, open
approach
64.0 Circumcision
There are instances where there is no translation between ICD-9-CM code and an ICD-10-PCS
code and below is an example of such.
ICD-9-CM Source
ICD-10-PCS Target
89.8 Autopsy
No ICD-10-PCS Code
Figure 3.10
The GEMS files were not created for coding purposes, rather, more for the keeping of historical
data, transferring of information found in databases and such. Providers should use caution
when relying solely on use of the GEMS for code choice selection. There is very limited 1:1
mapping found within the two code-sets and even a 1:1 match does not guarantee the code
choice selection is the right choice. In many instances the GEMS files will not give all mapping
choices that could be available.
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Here are examples of some issues you may encounter when using the GEMS files that you need to
be aware of.
ICD-9-CM Code
214.1
Lipoma of skin or
subcutaneous tissue
ICD-10-CM Mapping
D17.1
Benign lipomatous neoplasm of
skin and subcutaneous tissue of
trunk
Issue
Does not link to all codes
D17.30
Benign lipomatous neoplasm of skin
and subcutaneous tissue of unspecified sites
D17.39
Benign lipomatous neoplasm of
skin and subcutaneous tissue of D17.0
Benign lipomatous neoplasm of skin
other sites
and subcutaneous tissue of head,
face and neck
D17.20D17.24
Benign lipomatous neoplasm of skin
and subcutaneous tissue of unspecified limb
Benign lipomatous neoplasm of skin
and subcutaneous tissue of right
arm
Benign lipomatous neoplasm of skin
and subcutaneous tissue of left arm
Benign lipomatous neoplasm of skin
and subcutaneous tissue of right leg
Benign lipomatous neoplasm of skin
and subcutaneous tissue of left leg
Figure 3.11
ICD-9-CM Code
250.60
Diabetes mellitus, type II,
non-insulin dependent,
neurological complications,
controlled
ICD-10-CM Mappings
E11.40
Type 2 diabetes mellitus
with diabetic neuropathy,
unspecified
Issue
Should map to
E11.49
Type 2 diabetes mellitus with
other diabetic neurological
complication
For neurological not
neuropathy
Figure 3.12
NOTE: An unspecified code in ICD-9-CM will map to an unspecified code in ICD-10-CM and will
not show you if there are better choices. In ICD-10-CM we have better choices available for many
clinical conditions then we did in ICD-9-CM.
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Reimbursement Mappings
The Reimbursement Mappings were developed by CMS in response to the healthcare industry
requests for a standard reimbursement crosswalk. The intent was to create a temporary mechanism
for mapping ICD-10-CM/PCS codes submitted on or after October 1, 2015 back to the reimbursement ICD-9-CM code equivalent. The reimbursement mappings are different from the GEMs. The
GEMs include all plausible translation alternatives for each code in the system. The Reimbursement Mappings offer a single recommended mapping of an ICD-10 diagnosis or procedure code
to a single ICD-9-CM alternative. All ICD-10-CM/PCS codes are in the Reimbursement Mapping;
however, all ICD-9-CM codes are not in the Reimbursement Mappings.
The Reimbursement Mappings consist of two crosswalks:
ICD-10-CM to ICD-9-CM for diagnosis codes and
ICD-10-PCS to ICD-9-CM for procedure codes
Code Set
Total
Mapped
Mapped to
Number to a single a two code
of Codes ICD-9-CM cluster
code
Mapped
to a three
code
cluster
Mapped
to a four
code
cluster
Mapped
to a five
code
cluster
ICD-10-CM
Diagnosis
69,101
65,767
3,302
26
ICD-10-PCS
Procedure
71,957
69,657
1,211
583
458
36
Figure 3.13
Vendor Solutions
Many vendors have begun to make the transition to ICD-10-CM in their products and software
such as encoders, practice management systems, and even code books. However, vendors should
be queried as to how they have reached their conclusion on mappings and providers should be
very critical of any vendor solutions offered since the GEMS were not created for coding purposes.
There is no easy fix to transitioning to the new code sets for providers or coders. Only careful
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consideration of the guidelines, index, documentation and the actual codes themselves can keep a
provider compliant in ICD-10-CM.
Appendix A contains the technical specifications for manipulating the GEMS files.
Conclusion
Overall, the transition to ICD-10-CM/PCS will have a high impact to the information technology
of the practice. Each system, application, interface, program, extract, algorithm, and report must
be evaluated to determine diagnosis and procedure code dependencies. For some components of
the practices information technology, there will be vendor dependence that will have to be monitored. Other modifications will have to be performed by the practice and IT staffing may become
an issue. Robust testing is a must. Juggling all these initiatives will require considerable effort to
maintain the ability to make wise business decisions post ICD-10-CM/PCS implementation. Only
by developing a well thought-out plan with the necessary steps in advance will practices be able to
perform a complete and thorough review of the changes. This step-by-step approach can help ease
the transition into ICD-10-CM/PCS.
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Resources
and
Templates
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Templates
ICD-10 Implementation in Healthcare Services
Code Change Log
Project Manager:
J. Taylor
Publish Date:
01/05/10
Diabetes and Osteoarthritis Reports for Healthcare Services
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Chapter
Introduction
The discovery phase will reveal the tools youll need to assess department and business area
readiness; show the impact ICD-10 will have to the people, processes, and technology by business
area/department; and assist in designing a business case or plan for the implementation effort for
ICD-10 implementation. By reviewing the readiness survey from each department developed in
Chapter 1, each department or business area will have an idea as to the current progress of ICD10-CM understanding. This will allow us to create the impact analysis. In a smaller practice this
team may consist of only one or two individuals.
The goal of an impact analysis is to determine which areas and systems within the practice will be
impacted and require changes. Information relevant to each of the practices departments must
be obtained to understand the current environment and to assist in mapping out what needs to be
addressed for successful ICD-10-CM implementation.
The ICD-10-CM steering committee or project team for each business area in a large practice is
responsible for making sure the impact analysis is conducted in his or her business area or department. Once the analysis is completed in all departments, the steering committee can analyze each
department or business areas needs and develop the budget for ICD-10 implementation.
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Hardware
Software
Upgrading systems
Customization
Staffing and overtime
Software Changes
Software modifications will include the following:
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System interfaces
Expansion of flat files containing diagnosis codes
Redefinition of code values and their interpretation
Other system changes and applications using coding data that must be analyzed include:
Identify which forms and reports the practice uses that will need to be reformatted or revised. IT
will also need to evaluate if each system used by the practice has the storage capacity sufficient to
support ICD-9-CM and ICD-10-CM simultaneously during the transition or if the capacity will
need to be increased. Also consider how long ICD-9-CM will be accessible, what staff will need to
access ICD-9-CM, and how long the legacy data will need to be available. Dual systems may need
to be maintained several years past ICD-10 implementation.
System Vendors
Contact system vendors during this phase to determine whether they can support both the legacy
and the new coding system and for how long. Contact your vendors immediately upon beginning
the implementation planning to find out their schedule for ICD-10-CM implementation. This is an
ideal time to identify costs for upgrading software and storage capacity as well as contract issues
with the vendor. This will help with the system conversion budget over the next several years.
This is also the time to ensure the vendor will be able to assist with the transition and scheduling
the testing and conversion. Vendors will be extremely busy with testing and installing new hardware and software for up to two years prior to ICD-10 implementation, so getting on the vendors
schedule early will give your practice a great advantage.
Determine if software upgrades are included in the current contract or if there are any additional
costs. Check contract language to see if governmental updates are included at no charge. If
upgrades are not included, inquire as to what costs will be incurred. Coordinate with the vendor on
their timeline for testing and installation of the new or upgraded software or systems. Dont forget
training on new systems if the decision is made to change or upgrade. Make sure these costs are
included in the budget. If the vendor has user group meetings, this is an ideal time to participate.
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User group meetings can be extremely helpful to practices during this transition. Meeting with
others who are going through the same changes can help with the sharing of ideas, and what has or
has not worked for others.
Other IT system considerations might include a conversion to EHRs or EMRs during this transition if the practice has not previously converted. Keep in mind that if you are going to transition
to an electronic system you may want to speed up your search and implement earlier so that you
are not trying to implement both an EMR/EHR and ICD-10 at the same time. Transitions to each
system will be time consuming itself.
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The CMS outlined meaningful use in three stages. Only Stage 1 criteria, for use in years 2011 and
2012, have been finalized as of now. Meaningful use criteria for Stages 2 and 3 will be defined in
future rules, and is expected to become progressively more stringent and harder for practices to
implement.
Electronic data capture is the goal of meaningful use in Stage 1. Key technologies and capabilities
required include:
Clinical Data RepositoryStore, retrieve and manage medications, and laboratory and
radiology results
Clinical DocumentationProvide appropriate drug referrals, problem lists and current
medication lists
Clinical Decision SupportImplement drug-drug, drug-allergy and drug-formulary
checks
Computerized Physician Order Entry (CPOE)Medications, laboratories, radiology/
imaging and provider referrals
ePrescribingRequires electronic generation and transmission of permissible
prescriptions
Financial Information SystemsAbility to check insurance eligibility and submit
claims electronically (front-end practice management software)
Patient CommunicationAbility to electronically generate reminders, provide test
results
Currently, conversations centering on delay of Stage II for meaningful use have been going on.
These conversations are centered on allowing physicians to focus on ICD-10 implementation and
giving them adequate time to accomplish this. In the Stage 1 meaningful use regulations, CMS had
established a timeline that required providers to progress to Stage 2 criteria after two program years
under the Stage 1 criteria.
This original timeline would have required Medicare providers who first demonstrated meaningful
use in 2011 to meet the Stage 2 criteria in 2013. However, they have delayed the onset of Stage
2 criteria. The earliest that the Stage 2 criteria will be effective is in fiscal year 2014 for eligible
hospitals and CAHs or calendar year 2014 for EPs.
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All providers regardless of their stage of meaningful use are only required to demonstrate meaningful use for a three-month EHR reporting period.
For Medicare providers, this 3-month reporting period is fixed to the quarter of either the fiscal (for
eligible hospitals and CAHs) or calendar (for EPs) year in order to align with existing CMS quality
measurement programs, such as the Physician Quality Reporting System (PQRS) and Hospital
Inpatient Quality Reporting (IQR).
For Medicaid providers only eligible to receive Medicaid EHR incentives, the 3-month reporting
period is not fixed, where providers do not have the same alignment needs.
CMS is permitting this one-time three-month reporting period in 2014 only so that all providers
who must upgrade to 2014 Certified EHR Technology will have adequate time to implement their
new Certified EHR systems.
Processes can have a significant impact on the performance of a medical practice, and process
improvement can improve the overall health of the medical practices operations.
The first step to improving a process is to analyze it to understand the activities, their relationships,
and the values of relevant metrics. Process analysis generally involves the following tasks:
Define the process boundaries, marking the entry points of the process inputs and the
exit points of the process outputs.
Construct a process flow diagram that illustrates the various process activities and their
interrelationships.
Determine the capacity of each step in the process. Calculate other measures of interest.
Identify the bottleneck, that is, the step having the lowest capacity.
Evaluate further limitations in order to quantify the impact of the bottleneck.
Use the analysis to make operating decisions and to improve the process.
In analyzing what processes might be affected by ICD-10 implementation, begin with the clinical
area and then move to the business area and systems impacted. The wide scope of the impact of
ICD-10 will probably surprise most healthcare practices. It is estimated this process will most likely
take three to four months at minimum to complete depending on the size of the practice. Figure 4.1
is an illustration of the analysis process for ICD-10-CM/PCS implementation.
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Test
Plan
Implement
Analyze
Design
Figure 4.1-Process Flow Diagram
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Impact: (1-10) None (0), Low (2), Med (5), (High 10)
Date: 02/1/20xx
Clinical/ Description
Business
Function
Process
Clinical Medical Policy
Impact Internal/
Status
External
Disruption to
Staff
10
External
Coding
Internal
Will need
to review all
policies assign
to billing
department
Staff will need
to attend
ICD-10-CM
training
courses
Training
Clinical
Provider
10
Documentation
Internal
Clinical
Patient Impact
Internal/
External
Doc.
Auditing
of clinical
Guidelines
documentation
for ICD-10
Readiness
Will need to
review clinical
treatment
protocols with
health plan
policy
Schedule training
for clinical staff
Administrative
staff
Coding and
billing staff in
2012
Continuous audits
May need to
discuss coverage
issues with
patients
Figure 4.2
The clinical area of the medical practice will be impacted with ICD-10-CM implementation. Even
though professional services are paid based on the procedure code (CPT and HCPCS Level II
codes), the diagnosis code supports medical necessity for the services rendered.
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audits. For example, in a surgeons practice, evaluation and management (E/M) services, surgical
procedures, and other diagnostic services should be reviewed. Make sure the current documentation adequately supports ICD-10-CM. A clinical documentation assessment tool should be utilized.
Take an in-depth look at the current level of documentation in the medical record. Review any lack
of specificity in the documentation and analyze how to begin the improvement process. Based on
your practices specialty, review the most common diagnosis codes used and the frequency of each.
Most practice management billing software is capable of running a frequency report of the most
used procedures and diagnosis codes, which is helpful for reviewing diagnosis code utilization in
the practice.
In the past, providers used the medical record to document the patients problems and conditions.
In recent years, however, medical records have become a tool to document medical histories and to
provide a method to track health statistics, to act as a legal document, to justify charges to insurance companies based on medical necessity, and to assess quality of care.
Medical records are currently kept in either paper or electronic format. Some examples of services
found in the medical record are:
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The auditor must be familiar with ICD-10-CM codes and guidelines to make this determination.
Once the audit has been conducted and analyzed, the practice will have a good assessment of documentation deficiencies, and can develop a priority list of diagnoses requiring more detail. The audit
also helps identify providers who will benefit from focused training using ICD-10-CM.
Implement a documentation improvement program within the practice and monitor the documentation on an on-going basis. This will ensure improvement and identify areas where providers are
deficient and who needs more assistance and training. These audits should be conducted periodically to validate ICD-10-CM compliance. As with any audit, submit a report summary to senior
management and the provider.
Review the following example:
Timmy is seen in my office today following sticking a Lego in his ear. Under direct
visualization, using alligators, the Lego was successfully grasped and removed with
no damage noted to the ear canal.
ICD-10-CM
T16.1XXA
T16.1XXD
T16.1XXS
T16.2XXA
T16.2XXD
T16.2XXS
T16.9XXA
T16.9XXD
T16.9XXS
Based on the documentation in the medical record, using ICD-10-CM, the physician will report
T16.9XXA for the foreign body in the ear. Note that laterality was not documented and is part of
this code choice selection as well as the stage of the encounter. Provider education would need
to include the changes in requirements to documentation necessary to assign the appropriate
ICD-10-CM.
ICD-9-CM
ICD-10-CM
931 T16.9XXA
Review this example
S: She presents today after having a cabinet fall on her last night, suffering a concussion, as well
as some cervicalgia. She did not seek immediate care. She states that the people that put in the
cabinet missed the stud by about two inches. The patient continues to have cephalgias, primarily
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occipital, extending up into the bilateral occipital and parietal regions. The patient denies any
vision changes, any taste changes, any smell changes. The patient has marked amount of tenderness across the superior trapezius.
O: H
er weight is 188, which is up 5 pounds from last time, blood pressure 144/82, pulse rate 70,
respirations are 18. She has full strength in her upper extremities. DTRs in the biceps and
triceps are adequate. Grip strength is adequate. Heart is a regular rate. Lungs are clear. She is
clearly demonstrating signs of dorsal somatic dysfunction.
A: 1. Status post concussion with persistent headache
2. Cervicalgia
3. Dorsal somatic dysfunction
P: Th
e plan at this time is to send her for physical therapy, three times a week times four weeks for
cervical soft tissue muscle massage, as well as upper dorsal. Well recheck her in one month.
ICD-10-CM
S06.0X0A Concussion without loss of
consciousness initial encounter
M54.2 Cervicalgia
M99.01 Dysfunction; somatic; cervical
region
W20.8XXA Other cause of strike by thrown,
projected or falling object, initial
encounter
Figure 4.4
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Figure 4.5 is a simple sample audit tool you can use to assess documentation:
Physician Name: Raymond Smith, MD Date of Audit: 10/20/200x
Reviewer (Auditor): Mary Ellen Ellis, CPC, CPC-H
Chart Patient ID
Documented
ICD-9-CM diagnosis
diagnosis
documented
(description)
1.
Jody Marsh
Gastroesophageal 530.81
reflux (GERD)
2.
691.10
ICD-10-CM diagnosis
documented
K21.9 Gastroesophageal reflux disease
without esophagitis
L22-Diaper dermatitis
Diaper rash
Figure 4.5
Note that with patient Jody Marsh, that GERD is coded 580.81 in ICD-9-CM, but in ICD-10-CM
more information is required. The code includes options for GERD with our without esophagitis
and the provider would need to be educated on those options.
One way to identify how the practice will be directly affected by ICD-10-CM is to run a practice
management report of your current most frequently used ICD-9-CM codes in the practice and pull
corresponding charts starting with the highest ranked ICD-9-CM code and assign ICD-10-CM
codes accordingly. Another way to become familiar with ICD-10-CM codes and how they will
directly affect your practice is to begin coding problem lists for each patient. By doing this proactively, not only do you have an idea of how to assign the new codes, you will be one step ahead of
the process on go live date and all that will be required for the practice is to replace any ICD9-CM codes in the EMR with ICD-10-CM codes to update problem lists.
Review at least 10 records per quarter for each practitioner to help you identify problem areas such
as diagnosis deficiencies and to help improve diagnosis specificity for ICD-10-CM. Keep in mind:
You are only assessing the diagnosis documentation for this audit, try not to get caught up on other
issues in the record if possible. If you routinely audit your physician now, you can begin adding
ICD-10 as part of your reporting process through implementation so as not to cause additional
audit workloads.
Once you have finished the audits and compiled the results, sit down with each provider and review
the chart note with the documented ICD-9-CM code versus the ICD-10-CM code (if you can code
it). You may encounter a significant issue as in many cases, you cant assign a diagnosis code in
ICD-10-CM due to lack of documented specificity in the medical record; however, there will also be
times that an unspecified code will need to be assigned because some element of information may
be missing. It is recommended to use the unspecified codes with caution because if there is a code
available that is more specific the payer may look at the practice as disregarding the coding guidelines and may result in unfavorable determinations for future payments. It may also raise a red flag
to the payer to review documentation to question the integrity of the providers notes.
Example: If a provider bills an insurance company for an ear infection they would expect the
provider to know which ear was having a problem and receiving treatment.
Educate the provider by showing a comparison of both coding systems. Encourage the provider
to get specific with documentation to match ICD-10-CMs detail. Keep your results each time and
2015 AAPC. All rights reserved.
032415
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comprise a summary. This summary should identify the percentage of correct documentation for
both ICD-9-CM and ICD-10-CM. If the provider can see what mistakes he or she has made by
reviewing the medical record and the audit results, it helps to clarify muddy areas. This will also
give you the opportunity to perform focused training for the provider on ICD-10-CM.
Figure 4.6 illustrates what an audit report might look like:
Physician Name: Raymond Smith, MD
10
100%
20%
80%
Figure 4.6
As indicated from the report above, only 20 percent of the medical records reviewed may support
ICD-10-CM coding.
How do you solve the documentation problem?
1. Educate the provider by showing him or her the comparison between both coding systems.
2. Encourage the provider to begin documenting more specifically for ICD-10-CM.
3. Keep results and comprise a monthly summary. This summary should identify the percentage
of correct documentation for both ICD-9-CM and ICD-10-CM with recommendation for
improving documentation.
4. Provide retraining when needed.
A very important method in working with a provider on documentation is communication.
After reviewing documentation, it will be evident that a lot of work must be completed to get
ready for ICD-10-CM. Keep auditing the providers diagnosis documentation for each quarter
until ICD-10-CM is implemented. Track deficiencies and improvement on a spreadsheet and
share it with your practice. This will help identify education needs for the practice and the target
risk areas in the practice and it will promote discussion and resolution for the implementation
committee. Develop the project strategy for documentation improvement.
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The Patient
The patient may also be affected by the transition to ICD-10-CM. Insurance coverage determinations should be reviewed based on ICD-10-CM. It is anticipated that health plans will review
coverage determinations and what types of conditions they will cover. Treatment decisions a
provider makes may be driven by coverage policies, as they are changed to reflect the level of
specificity in ICD-10-CM. This change could evolve in changes to insurance coverage and documentation requirements. While a patients condition may be covered today with ICD-9-CM codes
to support medical necessity, the condition might not be covered with ICD-10-CM. The medical
practice will need to review treatment plans for patients to determine if the patients insurance will
cover their conditions.
Practices may have to develop written material that assists in explaining what changes have been
made, why they were made, and also what changes patients may see in their explanation of benefits
from health plans. Coverage changes may also need to be explained to patients. Some changes to
patient registration or history forms may also be needed. One major benefit of educating the patient
about the some of the potential challenges of ICD-10-CM is that they will have a basic under-
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standing of potential problems, and if they receive a bill or an explanation of benefits (EOB) indicating that their services were not paid, they will have a basic understanding as to the challenges
the office may be facing. They will be much more likely to call the office to have a discussion rather
than to call in a state of irritation. If we, in the healthcare industry, are struggling with the implementation of ICD-10-CM imagine how confusing it would be to a patient who does not understand
any of it.
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2. Does the person responsible for handling the ABN have training on executing a valid ABN?
3. Does the person responsible for ensuring the ABN is signed have any coding training or
knowledge of diagnosis codes?
NOTE: If Medicare doesnt pay for (D) ___________ below, you may have to pay.
Medicare does not pay for everything, even some care that you or your healthcare provider have
good reason to think you need. We expect Medicare may not pay for the (D) __________ below.
(D)
(F) Estimated
Cost:
Figure 4.7
In most cases in many practices, the nurse or medical assistant is responsible for obtaining a valid
ABN. Many times the clinical staff person is not trained on ABN guidelines for CMS nor do they
have a good working knowledge of diagnosis or procedure coding. This is one business process
that the practice should take a very detailed look at and make the appropriate changes to support
executing a valid ABN. These regulations can be found on the Centers for Medicare & Medicaid
Services (CMS) website at: www.cms.hhs.gov/manuals/downloads/clm104c30.pdf.
Performance Measures
Many insurance carriers and government payers require performance measures that are tied to
diagnosis codes. Under ICD-10-CM, performance measures will necessitate a review and potential change in reporting. It may take time for the healthcare industry to incorporate performance
measures based on ICD-10-CM codes.
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will list the most common procedures and diagnoses on a form that is the basis for recording
information into the practice management system for billing. The superbill/charge ticket is also a
mechanism for patients to submit charges to insurance companies or for record keeping. As the
ICD-10-CM code set contains at least five times as many diagnosis codes, much more specific
codes, and in some sections a new way of coding, these superbills will need to be revised. The one
page superbill will become a thing of the past and a five to seven page superbill will be impractical
for most practices.
The solution may be the development of an electronic code selection tool, important for both
paper-based practices and those with EHRs. Those practices with EHRs that allow for the selection
of an ICD-10-CM code will have to work with their vendors to determine how best to capture the
ICD-10-CM codes most likely to be used by the practice to ensure that the providers can easily
locate the code with the highest level of specificity.
The key issue when assessing coding and billing in the impact analysis is education and training on
the new ICD-10-CM code set.
Reimbursement Issues
Changes to reimbursement amounts are yet unknown. Currently reimbursement is tied to the
procedure or CPT/HCPCS Level II codes and the diagnosis code that supports medical necessity.
There is speculation in the industry that possibly health plans will conduct in-depth studies as to
how to tie reimbursement not only to the procedure but to the severity of the patients condition.
Many in the healthcare industry are concerned that the extent of reimbursement issues will not be
made known until closer to the implementation date or thereafter. With the proposed healthcare
reform, there are many unknown issues causing concern within the industry for not only providers
but to health plans as well.
How will cash flow be affected with implementation? Will all health plans be ready to Go-live on
October 1, 2015? Many health plans using old legacy systems do not plan on upgrading systems,
rather develop mapping from ICD-9-CM to ICD-10-CM/PCS for claims submission. This may
cause problems with payment. Not every ICD-9-CM code maps 1:1. Many map 1:2, 1:3, one to
many, etc., or not at all. This potentially will cause delay or denial of payment which in turn
will create a need to review more non-paid claims and increased time and effort to resolve these
issues. Claim delays and denials are expensive for any practice to resolve and typically can only be
resolved through a manual process. Any increase in the number of claim delays/denials or claims
not processed and paid will decrease cash flow, increasing both provider and staff workload to
process the denials.
If cash flow is disrupted or delayed, how will the practice continue to provide services, pay staff, pay
for supplies and services without funds? Planning for all potential problems prior to implementation is necessary. It might be necessary for the organization to establish a line of credit with the
bank to get over the first few months during the transition
Finance
Since reimbursement is tied to procedural and diagnosis coding, the finance area will be impacted
greatly. For example, after the implementation date, if an insurance carrier cannot yet accept
ICD-10-CM codes, the medical practice probably will not be paid. If your practice is not ready and
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cannot transmit claims, finances will be impacted as well. Review the current reporting for procedures and services using ICD-9-CM codes and compare them to ICD-10-CM codes.
All pending or denied claims submitted prior to Oct. 1, 2015 will still require ICD-9-CM codes.
This can cause extra workloads on staff to resubmit codes in dual systems and if productivity is not
met revenue will not come into the practice.
After implementation, this impact to coding will be felt and may be quite burdensome for practices.
Pended or denied claims are expensive for practices to deal with, and generally are dealt with
through a manual process. Any increase in the number of claims not processed or paid will first
decrease provider cash flow, and then increase both provider workload and time to process denials.
Providers will need to know the change in documentation and coverage requirements ahead
of time to adapt in time for implementation. HHS is predicting that claims-error rates will rise
between 6 and 10 percent, up from a normal 3 percent rate, typically seen for annual updates of
ICD-9-CM.
All panels that the practice currently participates with should be evaluated for transition to
ICD-10-CM. If a workers compensation or auto panel is not making the transition the practice may
want to reconsider participation as this will cause administrative headaches for the practice ongoing.
Information Technology
Before implementing ICD-10-CM, it is necessary to migrate to 5010. Though 5010 has seemingly
been given less notoriety than ICD-10 implementation, it is imperative to remember that without a
successful 5010 migration, ICD-10 implementation cannot succeed. The 5010 transition will affect
all covered entities, providers, health plans, clearinghouses and any business associates that use
EDI (Electronic Data Interchange) transactions.
Good mapping eases the cost of transition by permitting logic that is used for old codes to be
carried over to the new ones. It also permits old data to be meaningfully combined with new data
to create a smooth transition between code sets. Mapping between codes is a logical consequence of
mappings between conditions in the real world and their rendering as codes. NOT all ICD-9-CM
codes map 1:1 to an ICD-10-CM code. In some cases with new technology and new categories there
is no map from the ICD-9-CM code to the ICD-10-CM code.
Determine how to best utilize the mapping files internally for your practice or specialty and incorporate it into your trainings and day-to-day operations. Assign staff to work with the mapping files
and use those trained to help other staff in getting trained mapping from ICD-9-CM to ICD10-CM. The GEMs mapping files are not crosswalks but are good tools that map the ICD-9-CM
code to all matches or possibilities in ICD-10-CM. By taking this information and reviewing the
documentation and the superbill/charge ticket in the medical practice, the organization should
be able to develop a crosswalk appropriate to the specialty. Within implementation planning, a
member of the ICD-10 project team should be responsible for overseeing and ensuring this process
is completed during the planning phase.
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If the practice is conducting any type of trending or disease management tracking, an analysis
should be conducted to analyze how reporting and tracking might change with ICD-10-CM.
Medical practice forms might need updating to reflect the change. If performing disease
management tracking via practice management software or the electronic health record (EHR),
work with vendors to make sure that nothing is missed in translation. This could be a big task as
one ICD-9-CM code could translate into multiple ICD-10-CM codes (GEM mapping files).
Performance measures are linked to disease management, specifically those with chronic conditions such as diabetes, asthma, and heart disease to ensure they are receiving appropriate care and
quality is realized. If disease management is successful, it can reduce the risk of more complications and timely interventions. By utilizing more specific coding of patient conditions, it might be
possible for health insurers to identify which members require disease management and to tailor
programs more specifically to their conditions saving money and patient safety.
Practices participating in PQRS or other quality incentive plans need to work with vendors and
carriers prior to implementation to insure that systems are in place for proper reporting. At this
time it is not yet known how ICD-10-CM will be transitioned into PQRS. Keep a communication
process in place for both vendors and carriers to stay on top of new reporting requirements. You
can keep track of PQRS changes at http://www.cms.hhs.gov/PQRS/01_Overview.asp#TopOfPage.
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Example:
The practice currently utilizes paper superbills for capture of charges. In ICD-10-CM this may
no longer be a possibility due to the increase of available diagnosis codes. The business plan will
outline the issue, possible solutions and risk.
Issue: Superbills may not be a viable solution for ICD-10-CM
Possible alternatives:
1. Continue with paper superbills by removing the listing of diagnosis codes and including an
area for providers to write out diagnosis descriptions.
2. Utilize an EMR
Risk of each option:
1. Providers may not give enough information to accurately assign a code.
2. The practice is not able to finance an EMR at this time.
Based on information provided, administration can then begin to determine what the best possible
approach may be to move forward.
A useful business plan document does not end with the permission to move forward. Used properly
and reviewed regularly, it can serve as a barometer throughout the project to ensure the solution
still meets practice needs and the project is in tune with changing environments.
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Plan:
Using your implementation timelines develop your plans for transitioning to ICD-10-CM
Outline all areas that will be affected by implementation efforts
Take a careful look at all existing policies and procedures along with any health plan
contracts
Outline any instances where ICD-10-CM will intersect
Do:
Work on developing and revising policies that will be affected
Be sure to include key people from all departments and allow them to provide input
on how they will be affected
This will take some time
Be sure to do your research and follow through from the planning stages
Study:
Revisit the new policies and procedures often during the first several months. Monitor
any weak areas and look for where you may need to develop new policies. A cause and
effect diagram has a variety of benefits:
It helps teams understand that there are many causes that contribute to an effect
It graphically displays the relationship of the causes to the effect and to each other
It helps to identify areas for improvement
Once you have monitored a policy and it has consistently worked you may do less
frequent policy reviews
Act:
Monitoring will show you inadequacies or weak areas that need to be addressed.
Make sure you act on any findings and fix problem areas
Successful compliance will come only when all policies have been reviewed, addressed
and acted on
Conclusion
The discovery phase deepens the understanding of the challenges faced by collecting the knowledge
of the people within the practice, and documenting and storing that information. Through business
area readiness surveys, high-level impact assessments, and completed business plans, the strategic
steering committee and administration will learn more about the challenges they face and the
necessary organizational resources for ICD-10 allocation. This assessment approach will assist in
staff planning to help the practice better organize and budget prior to embarking on this multi-year
project. The information collected during this phase will serve as collateral for subsequent phases
and will help ensure that nothing slips through the cracks. During the onset of the ICD-10-CM/
PCS implementation effort, spend time in the discovery phase to help focus the design efforts and
promote compliance.
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Resources
and
Templates
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Business Plan
ICD-10-CM and ICD-10-PCS Implementation
Version:
Revision Date:
Approval of the business plan indicates an understanding of the purpose and content described
in this deliverable. Approval of the business plan constitutes analysis results and hereby certifies the overall accuracy, viability, and defensibility of the content and estimates. By signing
this deliverable, each individual agrees the proposed business solution has been analyzed
effectively as herein.
Administration
[Name]
[Email]
Signature
[Telephone]
Date:
[Email]
Signature
[Telephone]
Date
[Email]
Signature
[Telephone]
Date
[Email]
Signature
[Telephone]
Date
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[Email]
[Telephone]
Date
Chapter 4
Section 1.
Executive Summary
For a standard business plan, complete this section after completing all other sections. This will
describe what the business plan is about and is a proposed plan of action for ICD-10 implementation.
1.1 Issue
Briefly describe the business issue associated with the implementation of ICD-10 without
describing how the problem will be addressed for each department. Include a brief statement of
the mandate that requires operational and technology changes not currently in place.
1.2
Anticipated Outcomes
Describe the anticipated outcomes of implementing ICD-10 that specifically addresses the business
issue. The description should include answers to questions such as What are we aiming for?
1.3 Recommendation
Describe the project of ICD-10 implementation by summarizing the approach for how the
project will address the implementation of ICD-10. Identify the the employees involved in
determining whether the desired results are achievable by implementing the project.
1.4 Justification
Justify why a recommendation(s) should be implemented and including information about the
impact of not implementing the recommendation.
Determine and include analysis information that is necessary to provide a clear justification for the project. The type and extent of information included in the justification will
vary based on the best approach for making a compelling and accurate argument.
1.5 Assumptions
List and describe any assumptions relevant to the recommendation that is being suggested
to achieve ICD-10 compliance. List all the assumptions for which you cannot take for
granted that a reader would automatically make the same assumption. You can make
assumptions about average FTEs, salaries, overtime, training, cost of certain items-hardware, software, etc.
1.6 Limitations
List and describe any limiting factors, or constraints, relevant to the recommendation(s).
Section 2.
2.1 Governance
Describe the ICD-10 governance processes and structures within the practice or business area.
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2.2
Describe the roles on the business plan analysis team. Provide the names and titles of the
health plan staff that will fulfill them.
Role
Description
Section 3.
Name/Title
Problem Definition
3.1
Problem Statement
3.2
Business Environment
Knowing that ICD-10 has to be implemented by Oct. 1, 2015, describe the technology, processes
and/or services and people that will be impacted.
Stakeholders
Description
Describe the processes and/or services in the business area that will be impacted by ICD-10
implementation.
Processes/Services
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Impact Description
Chapter 4
3.3
3.3.1
Current Software
Describe the business areas existing software that will be modified or replaced with ICD-10
implementation.
Software Items
Description
Describe the business areas existing hardware that will be modified or replaced with ICD-10
implementation.
Hardware Items
Description
Describe the business areas existing applications that will be modified or replaced with
ICD-10 implementation.
Applications
Description
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Describe the business areas existing vendors that will be modified or replaced with ICD-10
implementation.
Vendors
Section 4.
4.1
Description
Project Overview
Project Description
Describe the approach this project will use to address the business problem.
Description of Project
4.2
Describe the business goals and objectives of this project. Ensure the goals and objectives
support business needs.
Business Goal/Objective
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Description
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4.3
Impact Analysis
For the business area, describe the practices core business processes that will be impacted by
the implementation of ICD-10. Enter a T (technology) or PR (Process) or PE (people)
Core Processes
Manage the Business
IT Systems
Vendors
Communication
Education and Training
Documentation
Compliance and Quality
Medical Policies
Costs
Enabling Processes eg, Change Management
Implementation Testing and Go-Live
4.4
Performance Measures
Describe performance measures that will be used to gauge the projects business outcomes for
key processes and services.
Key Process/Services
Performance Measure
4.5 Assumptions
List the assumptions regarding the business areas processes and/or services affected by the
implementation of ICD-10.
4.6 Constraints
List the limitations or constraints regarding the business areas processes and/or services
affected by ICD-10 implementation.
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4.7
4.7.1
Proposed Software
Describe business area specific software that will have to be procured for ICD-10 implementation.
Software Item
4.7.2
Description
Proposed Hardware
Describe business area-specific hardware that will have to be procured for ICD-10 implementation.
Hardware Item
4.7.3
Description
Vendor Analysis
Describe the vendor changes that will occur with ICD-10 implementation.
Vendor
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Description
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4.7.4
Application Analysis
Describe the application changes that will have to occur with ICD-10 implementation.
Applications
4.8
Description
Describe the business area-specific major milestones, deliverables, and target dates. See the AAPC
ICD-10 plan and adjust accordingly for the organization.
Milestones/Deliverables
Target Date
4.9 Budget
Describe the business area expenditures for implementing ICD-10. Ensure that people,
processes, and technology expenditures are captured.
Anticipated Expenditures
Equipment/Hardware
Application/ Software
Labor Costs (new staff and OT)
Consulting Costs
Vendor Costs
Training Costs
Other Costs
TOTAL
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Chapter
Introduction
Once you have completed your impact analysis it is time to move on to implementation and
building your ICD-10 action plan. The impact analysis and business plan will give you the tools to
move forward.
Vendor Importance
Vendors will play an important role in the implementation of ICD-10-CM from a system prospective. If your practice is using purchased applications, software will need to be upgraded and
installed along with electronic transaction modifications. If your practice has developed internal
system design customization, information technology should be involved with the ICD-10 project
team and work closely with vendors for the conversion.
Vendor readiness will play a large part in your successful implementation of both 5010 and ICD-10.
Without good communication and strategic planning with your current or future vendor delays in
successful implementation may occur leaving your practice without vital revenues.
ICD-10-CM will have a widespread impact for software vendors. Vendors will be required to make
various types of changes to screens, reports, databases, etc. Applications they currently develop
with ICD-9-CM will need to be changed to support the expanded size and alphanumeric structure
of ICD-10-CM. Everywhere in the system that ICD-9-CM currently exists will need to be adapted
to implement ICD-10-CM. Changes will include:
Field size expansion, which includes the field length format on the screens
Change to alphanumeric composition
Use of decimals
Complete redefinition of code values and their interpretation
Longer code descriptions
Edit and logic changes for applications that interrogate the content of the codes
Modifications of table structures that hold codes will need to be restructured
Report formats and layouts will need modification
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Figure 5.1
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It is important for the practice to understand how the data flows within the system to understand
its impact on ICD-10-CM. It is necessary to detail the importance of your workflows to communicate this to the vendor. Perform an analysis of how you use ICD-10-CM in your practice and
compile a list of needs such as:
Because ICD-10-CM is so different from ICD-9-CM, it could be difficult to relate data coded under
ICD-9-CM to data coded under ICD-10-CM. This would severely impact reports that compile
statistical data for trend analysis. Such reports might be used for rating purposes, effectiveness of
care, provider profiling, or for many other purposes.
Some backend reports use vendor software to compile statistics. It is possible that two versions of
the vendor package would be required simultaneously to deal with data coded under ICD-9-CM
and ICD-10-CM. There is a question whether data from one version could be blended with data
from the other. Some data is episode based. We would need to agree how to treat episodes that
lasted across the implementation period for a new code set.
Customer reports may require redefinition. Many ad hoc queries and reports are used by practices.
These are used to track utilization review, immunizations, maternity, transplants, disease management, cost savings, special customer requests and many other purposes. These are usually based on
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data stored within master files or databases. The ad hoc reporting process and the data storage used
must all be analyzed and modified to support the new (or dual) coding schemes. Physicians sometimes use lists or reports containing ICD information as a record of their case experience when
requesting board certification. However, ICD-10-CM should have little impact on this process.
It is also possible that your systems are currently not integrated such as the electronic medical
record may not currently be integrated with the practice management or financial system; but now
is the time to assess the value of integrating key systems during the conversion.
Providers use a variety of purchased applications to perform tasks such as examining historical
claim data to identify duplicate claims and unbundling. Purchased software is also used to determine appropriateness of setting and medical necessity. Significant cost savings are realized through
these processes. A change to ICD-10 would necessitate upgrades to these applications. This, of
course, would depend on the software vendors ability to provide an upgrade.
Software vendors will need time to evaluate, learn, and understand ICD-10-CM. ICD-9-CM codes
must be mapped to ICD-10-CM codes forward and backward. Any system logic that is diagnosisdependent must be changed. Training for the end user will also be necessary as well as providing
service and support. Many practice use software from various vendors within the practice and
software interfaces will be necessary at the same time. For outpatient facilities, such as hospital and
ambulatory surgery centers modification will be necessary for use with the ambulatory payment
classifications (APCs) under the Outpatient Prospective Payment System (OPPS). Product manuals
and user manuals will need to be updated or changed and clearinghouses will need to modify their
databases to accommodate ICD-10-CM and ICD-10-PCS.
Transaction formats need to have the correct field length to send into clearinghouses. For example,
the physician format defined by the CMS-1500 has five positions for their diagnosis field. If the
layout isnt changed, it could create problems for providers who have not changed their input to
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clearinghouses since they may send a layout that will not have enough field positions to send the
ICD-10. This would result in claim denials on or after the implementation date.
Vendor Planning
If the practice is using commercial software, they should discuss with the software vendor that they
are keeping up with announced changes. This is one area (like the transactions and code sets final
rule) in which assuming that someone else is fixing the problem has the potential to do real damage
to the practice.
Software vendors may have thousands of customers to serve, and the sooner the practice makes
contact and gets on a vendors schedule, the easier the transition will be. Contacting vendors early
will also assess vendor readiness and serve as confirmation of your own implementation timelines.
Some questions to ask the vendor during the initial contact include:
Timeline
Vendors that cannot offer you their own implementation timelines should be questioned as to their
commitment to upgrading their own systems. It is possible that you may have to find a new vendor
prior to implementation. Make sure you find a suitable vendor with a good reputation that has a
proven track record. Do the necessary research to determine that they will truly be able to suit
your needs. Choosing a vendor who is proactive in their approach will best protect your practice or
facility.
It is important to get on the vendors schedule for testing in the practice. Vendors will not typically
be ready to test ICD-10-CM upgrades and conversions until 2011 at the earliest. However, getting
the timeline identified early is important. Ask your vendor for their internal timeline step-by-step
and contact the vendor periodically to find out how they are progressing. Once you have determined the anticipated timeline for completion of software development, internal testing again, get
on their schedule for testing in your organization. Work with vendors to coordinate installation
of new or upgraded software and actively participate in any vendor user group meeting regarding
ICD-10-CM implementation.
Deployment of code is an important step. This is when the software vendor upgrades the software
in the practices system and tests the software for accuracy. Devote plenty of time to performing
adequate testing and ensuring that all issues are taken care of. Develop a task team to go item by
item of your proposed changes. Extensive logs and tracking should be used on your review of the
system. Changes, especially to older systems, could create new bugs and problems that were not
foreseen and can be unrelated to the general work on ICD-10-CM conversion.
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This function can completely and correctly be implemented only with the knowledge and help of
the application standing at the end points of the communication system. For the case of the data
communication system, this range includes encryption, duplicate message detection, message
sequencing, guaranteed message delivery, detecting host crashes, and delivery receipts.
End-to-end testing involves testing the system within the organization with transmissions to the
insurance carriers and other entities in which the practice transmits data. This should be done
many times to ensure a smooth conversion.
It is recommended that the vendor test the transmission end-to-end when the software is installed
initially and then again several times prior to the implementation date.
All transactions must pass data integrity, requirements, balancing, and situational compliance
testing. The above levels of compliance are required and must be tested. Compliance is accomplished when the transaction is processed without errors and either the response transaction or a
997 acknowledgement is produced.
The software used by the insurance carrier for compliance checking and the translation of the
HIPAA transaction is varied but most contain a HIPAA Accelerator, also known as HIPAA Toolkit.
Typically they encompass a translator which identifies information related to known issues, corrections and common compliance errors detected by the software used by the carrier.
Validation testing ensures that the segments or records that differ based on certain healthcare
services, are properly created and produced in the transaction data formats. Validation testing is
unique to specific relationships between entities and includes testing of field lengths, output, security, load/capacity/volume, and external code sets.
End-to-end testing ensures a successful round-trip completion of the transmission. It originates
from the sender as an inbound transaction, proceeds through system processing and ends with a
successful outbound transaction back to the sender. For example, for vendors set up to test both the
837 and 835 transactions, this level tests processing the inbound 837-Claims and Encounters transactions and follows through to create an outbound 835 Remittance Advice transaction.
Implementation Costs
Physicians practices may have to bear the costs associated with converting existing software and
possible upgrades of hardware. The possibility of delayed reimbursement during the transition to
ICD-10 could have a seriously detrimental effect on all medical practices.
Check for hardware changes that might be necessary if the systems to be upgraded are legacy or
older generation. Consulting costs to perform the necessary tasks should be taken into account as
the internal downtime these changes might create.
Maybe now is a good time to look at new investment into a more sophisticated and more current
practice management system or EMR if the current one will require intensive work to modify. The
new system should be easier to train to new staff and be more comprehensive on all the functions
that are required for the practice.
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The rule of thumb is that if improvement costs exceeds half the cost of purchasing a new system
then its time to consider upgrading. New systems might be easier to upgrade down the line and
will open more possibilities for developing creative solutions to ICD-10-CM intricacies.
What about cost to upgrade software or to purchase new software? A lot depends on vendor readiness, and your current contract situation with the vendor(s). It is important to confirm the cost
for upgrading hardware and software when developing the budget. You will be able to spread the
costs out more evenly over two year period than paying for it all at once. Costs are varied and can
range from $1,000 for a simple conversion to hundreds of thousands of dollars depending on your
systems, number of users, and complexity of your business operation.
Do not forget the cost of testing, loss of productivity, and training on the new software and
potential hardware upgrades. These costs should be included in the budget and will impact overall
productivity in the office.
Conclusion
Start conversations with vendors early to assure that all is in place and to determine what delays
your practice might need to plan for now during the implementation period. Starting the communication process early will also allow for you to budget for any vendor changes or upgrades necessary for compliance.
These would encompass functions such as billing, test ordering systems, scheduling of visits or
surgery, tracking/monitoring services, utilization management, and aggregate data reporting.
Longitudinal studies to assess finance and performance improvement may need upgrade to accommodate the new coding.
One of the benefits of ICD-10-CM is that it incorporates much greater specificity and clinical detail,
which will result in significant improvements in the quality of the data used. This greater detail
may help reduce the number of cases where copies of the medical record need to be submitted for
clarification for claim adjudication.
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Chapter
Budgeting
Objectives
Introduction
This chapter provides information to begin assessing the estimated cost of ICD-10-CM implementation. Cost estimates will expedite the development of business area specifics to ICD-10 budgets.
Budgeting requirements and reporting will vary depending on your practice or facility size.
Regardless, all practices must budget for ICD-10-CM implementation. Most physician-based practices utilize a cash-based accounting system while larger facilities and hospital-owned clinics utilize
accrual based accounting. Either accounting system will require detailed attention and planning
to successfully implement ICD-10. Involving yourself now in the budget process of your facility or
practice will help ensure future successful implementation. This chapter will help you prepare and
plan for ICD-10 through budget plans.
Implementation Costs
Studies have estimated ICD-10-CM implementation costs for small to large practices. A typical
small practice with three to five physicians could experience a total expenditure of approximately
$40,000 or more, according to a RAND Corporation study, a Robert E. Nolan Company study,
and a Hay Group study. Cost varies from study to study, but it is evident the ICD-10-CM transition will be costly for every practice. On average, a small medical practice should plan to spend
between $4,000 and $10,000 for system upgrades, depending on the systems used in the practice. A
very large practice could spend over $100,000 for information technology (IT) system costs alone.
Within this phase of implementation, it may take several months for a large medical practice to
assess full implementation costs.
Break down the costs into four categories:
1. Information systems including software and hardware upgrades/updates:
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Budgeting
Chapter 6
Project costs and project budgets are two different things. The medical practice may need to assess
ICD-10-CM implementations financial impact with an analysis methodology. In many cases,
analysis, such as this, is performed to support the business case for a projects adoption. With
ICD-10-CM, everyone must comply with the Oct. 1, 2015 compliance date so the cost estimates and
budget will stand on their own merit.
Project Budget
From cost estimates, create a budget. The budget is the total costs translated into a monetary
figure plus the total risk percentage of that cost. Budget documents should communicate the major
components of ICD-10-CM implementation and how it will be distributed across the implementation timeline. Dont get so caught up in budgetary details that your practice spends more time
estimating and tracking cost than they do getting the actual work done. By the end of the planning
phase, consider the budget a solid estimate. Because the strategic steering committee reports all
projected costs and budgets to the executive sponsor, they should review this information.
Develop a high-level, cost tracking system to help spot variances and trouble areas during the
implementation process. This can be completed by the finance area and periodically reviewed and
amended by the strategic steering committee as needed.
Cost of ICD-10-CM implementation largely depends on the practice size. The most costly expenditure will be in the IT area; particularly, the practice management system, and upgrading or
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Budgeting
purchasing an EMRif the practice chooses to implement an EMR concurrently with ICD-10.
Depending on what systems your practice uses, on average, plan to spend $4,000$10,000 for
system upgrades.
Be sure to budget costs for charge ticket review, utilization review, and crosswalks. The review and
crosswalks could take between 2030 hours to complete depending on how many diagnosis codes
are used in the practice and how the crosswalks are to be used.
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Budgeting
Chapter 6
If you have internal staff who audit and monitor provider services consider hiring a consultant to
validate that the auditors captured all the problem areas and have addressed the issues with the
providers. If you plan on using consulting, you should plan on budgeting $150$200 per hour for a
consult, which is the average cost for consultant time.
Mapping Costs
Crosswalking and mapping ICD-9-CM codes to ICD-10-CM codes is a time consuming process.
Think about how the practice currently uses ICD-9-CM and what changes need to be made for
ICD-10-CM and if any mappings can actually be useful to the practice.
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Budgeting
Planning Steps
Start a monetary assessment now and determine how much money in your practice should be
budgeted for each step of implementation. Areas to consider are:
1. Costs associated with staff trainings:
a. What departments will be impacted?
b. Will you provide trainings in-house or need to go to outside educational events?
c. How will providers in your practice or facility receive training?
d. Will your practice or facility require additional vendor training?
e. Will you need to hire additional staff to meet training needs?
2. Losses due to slower productivity:
a. How will changes in software impact workflow?
b. Will running of dual systems reduce work efforts?
c. Will payer policy changes effect practice implementations?
d. How will unpaid claims prior to Oct. 1, 2015 be resubmitted?
3. Fees associated with vendor updates:
a. How will 5010 implementation effect software and submissions?
b. Will vendors charge for testing?
c. Will vendors charge a fee for ICD-10 implementation updates?
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Budgeting
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Budgeting
Estimated
$5,000
$5,000
$5,000
$15,000
Estimated Time
30 hours
15 hours
Estimated
$3,000
$3,000
$6,000
$3,000
$1,500
$16,500
Estimated
$3,500
$1,600
$500
$3,000
$1,000
$9,600
Estimated Time
60 hours pre-and post implementation each
10 hours pre-and post implementation each
Office staff only
Totals
Information Systems
Consulting/Auditing/Crosswalking
Training
Staffing/Overtime
Total Estimated Expenses
Estimated
$2,000
$400
$16,000
$18,400
Estimated
$15,000
$16,500
$9,600
$18,400
$59,500
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Budgeting
Chapter 6
Estimated
$12,000
$12,000
$3,000
$10,000
$37,000
Auditing/Review/Crosswalking
General Consulting/Audit Year 1 @
500 Per Provider 2 x Year (2012)
General Consulting Audit Year 2 (2014)
General Consulting/Training
Review of System Process
Crosswalking and Mapping
Totals
Estimated Time
Estimated Time
Estimated
$5,000
$8,000
$8,000
$4,000
$5,000
$30,000
30 hours
30 hours
Estimated
$17,000
Coders/Billers 4
Management 1
Nurses/MA 12
Ancillary 5
Totals
$6,800
$500
$8,400
$2,500
$35,700
Estimated Time
60 hours pre-and post implementation each
10 hours pre-and post implementation each
Office staff only
Totals
Information Systems
Consulting/Auditing/Crosswalking
Training
Staffing/Overtime
Total Estimated Expenses
Estimated
$4,000
$800
$32,000
$36,800
Estimated
$37,000
$30,000
$35,700
$36,800
$139,500
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Chapter 6
Budgeting
Estimated
$20,000
$20,000
$3,000
$10,000
$53,000
Auditing/Review/Crosswalking
General Consulting/Audit Year 1 @
500 Per Provider 2 x Year (2012)
General Consulting Audit Year 2 (2014)
General Consulting/Training
Review of System Process
Crosswalking and Mapping
Totals
Estimated Time
Estimated Time
60 hours
45 hours
Totals
Estimated
$21,000
$18,000
$10,000
$4,000
$5,000
$58,000
Estimated
$35,000
$13,600
$1,000
$15,000
$3,500
$68,100
Estimated Time
60 hours pre-and post implementation each
10 hours pre-and post implementation each
Office staff only
Totals
Information Systems
Consulting/Auditing/Crosswalking
Training
Staffing/Overtime
Total Estimated Expenses
Estimated
$8,000
$3,000
$48,000
$59,000
Estimated
$53,000
$58,000
$68,100
$59,000
$238,100
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Budgeting
Chapter 6
Estimated
$20,000
$20,000
$11,200
$10,000
$61,200
700 x Coders
6 In house
Auditing/Review/Crosswalking
General Consulting/Audit Year 1 @
500 Per Provider 2 x Year (2012)
General Consulting Audit Year 2 (2014)
General Consulting/Training
Review of System Process
Crosswalking and Mapping
Totals
Estimated Time
Estimated Time
Estimated
$36,000
$30,000
$10,000
$6,000
$5,000
$87,000
Estimated
$50,000
$22,400
$2,000
$16,250
$6,000
Totals
$96,650
Estimated Time
60 hours pre-and post implementation each
10 hours pre-and post implementation each
Office staff only
Totals
Information Systems
Consulting/Auditing/Crosswalking
Training
Staffing/Overtime
Total Estimated Expenses
Estimated
$16,000
$6,000
$72,000
$94,000
Estimated
$61,200
$87,000
$96,650
$94,000
$338,850
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Chapter 6
Budgeting
Once the budget is developed based on each department or business area need and the implementation analysis, review it with the steering committee or project team. Periodically review the budget
and update the committee on budget expenditures to stay on target. Involve the finance department and/or administrator with budget development and approve it with the executive steering
committee or project team prior to spending funds.
Conclusion
The practice needs to budget for proper training, implementation, and vendor costs and also to
anticipate cash flow crunches during the transition period. It has been estimated that practices
should plan to keep at least a three to six month reserve to cover transitional issues between payers
and systems that could significantly delay payments to practices.
Project cost and budget management is crucial during ICD-10-CM implementation. This involves
planning, estimating cost, devising budgets, and controlling costs so the implementation can be
completed within the approved budget. Project cost management includes:
Cost Estimatingdeveloping an approximation of the costs of the resources needed to
complete the implementation
Budgetingaggregating the estimated cost of individual activities to establish a cost
baseline
Cost Controlsinfluencing the factors that creates cost variances and controlling
changes to the project budget
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Budgeting
Resources
and
Templates
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Budgeting
Chapter 6
Templates
Information Systems
Practice Management System Upgrade
Estimated
EMR Upgrade
Coding Software
IT and Consulting
Totals
Auditing/Review/Crosswalking
General Consulting/Audit Year 1 @
500 Per Provider (2012)
General Consulting Audit Year 2 (2014)
$0
Estimated Time
Estimated
General Consulting/Training
Review of System Process
Crosswalking and Mapping
Totals
Education and Training
Physicians
$0
Estimated Time
Estimated
Coders
Management
Nurses
Ancillary
Totals
Staffing and Overtime
Coders
$0
Estimated Time
Estimated
Ancillary Staff
Productivity Loss
Totals
Totals
Information Systems
$0
Estimated
Consulting/Auditing/Crosswalking
Training
Overtime
Total Estimated Expenses
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$0
Chapter 6
Budgeting
Year 1
Year 2
Actual
Year 1
Year 2
Actual
Year 1
Year 2
Actual
Year 1
Year 2
Actual
Year 1
Year 2
Actual
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Chapter
Introduction
The ICD-10-CM Education Steering Committee will serve to establish the strategies for the practices ICD-10-CM education plan. This committee should establish all program guidelines and each
member should be responsible for carrying out the essential functions of the plan. This committee
serves to fulfill a number of essential tasks and maintain the core responsibility for successful
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education and training on the ICD-10-CM code sets and ICD-10 implementation effort for the
organization.
An effective education strategy will build a foundation and understanding of the coding changes
and implementation effort and will continue throughout ICD-10-CM implementation.
Education will target four strategic education objectives:
Build diagnosis and procedure coding awareness across the practice
Maximize educational opportunities
Engage the practice staff and sustain their interest in ICD-10-CM coding and its significance in the implementation effort
Collaborate with others (internally and externally) to continue to enhance knowledge of
ICD-10-CM and code change implication to the implementation project
The education strategy team will have the challenge of addressing the budgetary consideration
for this effort. Education and training to learn special skills are generally included in a medical
practices annual budget, especially in areas that require technical knowledge to do the job. Often
management is reluctant to earmark funds for education and medical coding education and
training often fall into this forgotten category. If ICD-10-CM coding knowledge, skill, tools, and
techniques are not commonly applied across the practice, compliance is jeopardized. As a result, a
strong case can be made for a formalized ICD-10-CM education and training program.
Education objectives outline how the education effort will address the mastering of the ICD-10-CM
codes and implementation effort, and it will set direction for all education efforts so the messages to
all targeted audiences are consistent, effective, and clear.
Determining whether you will use external or internal trainings for ICD-10 implementation is your
first step toward your educational goals. Discussion of goals and budgets can help you determine
what is best for your practice or facility. It is possible that it may take you several months to a year
to develop a practical education and training plan for your practice.
The education strategy committee needs to formulate an education plan. The education plan will
need to address ICD-10-CM educational needs, budgetary estimates, and timing of educational
programs. Education will need to be devised for a number of varied audiences and training will
have to be established for multiple categories of users. IT staff will require education on the difference between ICD-9-CM and ICD-10-CM to determine whether current systems are impacted,
interfaces should be built, and modification made to ensure functionality with these new code
sets. Because ICD-10-CM is more granular and detailed, even those who considered themselves
knowledgeable and comfortable with ICD-9-CM will require specific training on the new diagnosis
codes, guidelines, and documentation requirements.
If the practice has certified coders on staff, they will be required to pass an ICD-10-CM proficiency test to maintain their certification. The practice will need to determine the best method of
providing education and the timing of education for each of these categories of users.
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To provide solid direction, the education and training plan should include the following:
Keeping the mission in mind, the education plan should be a written document with the following
elements addressed:
In answering the question What needs to be taught? the education steering committee should
create a disciplinarybased curriculum dealing with various aspects of coding and implementation. Suggested topics include the following.
Regulatory OverviewA regulatory overview would provide information on the proposed rule
with a 2011 compliance date to the issuance of the final rule on January 16, 2009.
ICD-10 Code Set AwarenessThe long awaited implementation of ICD-10 in the United States is
on the horizon. This should provide instruction on skills to make that transition happen.
5010 and ICD-10The Centers for Medicare & Medicaid (CMS) released a final rule for replacing
the ICD-9-CM code set with ICD-10-CM/PCS. A second rule related to the HIPAA transaction
standards-X12 version 5010 and NCPDP version D.0- establishes an effective date of January 1,
2012. This instruction would outline the interdependencies of 5010 and ICD-10.
ICD-10-CM OverviewThis would include information on ICD-10-CMs organization and structure and its similarities and differences with ICD-9-CM Volumes one and two.
ICD-10-PCS OverviewThis would include information on ICD-10-PCS organization and structure and its similarities and differences with ICD-9-CM Volume three.
ICD-10-CM/PCS Detailed InstructionThis would include information on ICD-10-CM, its
21-chapter organization, structure, and guidelines. It should address ICD-10-PCS organization and
structure vs. Volume 3. It should cover all 16 sections of ICD-10-PCS, the systems characters and
values, coding conventions, and guidelines.
ICD-10-CM GuidelinesThe National Center for Vital Health Statistics (NCVHS) has published
guidelines for coding and reporting using ICD-10-CM/PCS. These guidelines should be used as a
companion document to the official version of ICD-10-CM/PCS. These conventions and guidelines
apply to the proper use of ICD-10-CM/PCS for hospital inpatient and outpatient including physicians and in outpatient/office settings. It is necessary to fully understand all rules and instructions
needed to code properly.
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GEMsThe General Equivalence Mappings (GEM) files are two-way translation tables for diagnosis
and procedure codes. They can be used as a tool to convert data from ICD-9-CM to ICD-10-CM and
PCS and mapping from ICD-10-CM/PCS to ICD-9-CM.
Implementation of ICD-10 for the Medical PracticeWith the implementation date of after
October 1, 2015, education and training activities need to include instruction related to preparedness and implementation planning. This includes an understanding of the final rule, implementation timelines, a fundamental knowledge of the changes in the new codes sets, and acquiring skills
and tools needed to assess the practices staff and skills.
Instructional design is the practice of maximizing the effectiveness, efficiency, and appeal of
instruction. Training and education for professionals in the organization has taken on a sense of
urgency when it comes to mastering ICD-10.
1. Web-based TrainingOften in the form of e-learning with purely web-based instruction.
In this situation factual material is presented in a direct, logical manner and is useful in
educating large groups consistently. Scheduling is up to the person seeking the instruction as it
is initiated by the individual in need of the training.
2. Interactive distance learningOften in the form of bidirectional learning with instructor
proctoring. By instituting an interactive approach with web-based distance learning those
receiving the instruction can question, clarify, and challenge the materials. The instructor will
have to be well prepared in content preparation and have good oral communication skills. Due
to the interactivity, the instructor needs to anticipate questions and appropriate answers to
avoid shifting gears. With minimal investment distance learning enables the organization to
provide critical training for employees across multiple sites. Distance learning can also address
content retention concerns.
3. Classroom based hands-on instructionThis face-to-face training should include useful tools
such as code books, guidelines, and implementation curricula. This is most effective when
learners require a high degree of hands-on practice or require detailed explanations of the
new codes along with implementation steps. The instructor must be highly knowledgeable
about the content and have good oral communication skills. The advantage of this method of
learning is that there are very specific targets and goals that are easily measured educational
gains by utilizing testing materials.
There is no right or wrong method for training on a particular portion of the ICD-10 curriculum
but there are some criteria that pertain to each anticipated lesson that can help the practice make
the right decision on the instructional design and delivery.
The education steering committee may find it useful to complete the following tools to provide
structure to their education and training efforts. Review figure 7.2 and figure 7.3.
Education Strategy Template (figure 7.2)
Training Delivery Template (figure 7.3)
A development map can provide the executive steering committee as well as physician, administration, and other staff with a snapshot of methods of training. In developing a training plan map,
identify the training objectives along current skills that the coders and provider currently have in
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relation to ICD-9-CM along with the new competencies such as an increased level of anatomy and
terminology knowledge as well as development of skill in ICD-10-CM.
Find out how you or your staff learns. Some of us are visual learners, and we need an instructor to
guide us, while others learn well using self-study or e-learning as the preferred method. In many
cases a combination of classroom/seminar and self-study or e-learning is appropriate.
There are many self-study and on-line resources to update the coders knowledge base. Once you
determine the staff training or retraining needs develop a budget for training. So many medical
practices and organizations do not budget appropriately for ongoing training. Training is crucial to
keeping a medical practice viable and ensuring reimbursement will be accurate and compliant.
Review the specific skill sets your practice will need. For example, every practice no matter what
specialty will need training on the ICD-10-CM guidelines. Map out a time line for completion of
this step. You might work in a family practice environment where a full course on ICD-10-CM
would benefit the practice. If you work in a sub specialty practice such as ophthalmology or orthopedics for example, you might want to focus on the specific diagnosis code sets for your specialty.
Provide Training
Begin the training process in your practice. Dont wait until the last minute. Remember HIPAA?
Was your practice prepared well in advance or did you wait until the month before implementation
to prepare for this change? Allow at a minimum a year to complete training for your entire group.
For physicians, coders, and non physician practitioners, it is a good idea for this group to
participate in a full course, or have an instructor (internal or external) plan a curriculum over
several months to cover all avenues of ICD-10-CM coding. Use real case studies from the medical
record so the training makes sense to the providers and coders in the practice. Even if you
outsource the coding and have an instructor provide training in-house, provide them with copies
of your notes to use in their training handout. A post-test is helpful to determine if the participant
understands ICD-10-CM coding concepts.
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Keep in mind any documentation issues should be addressed in training with providers. Reinforce
the importance of specificity required in ICD-10-CM and documentation is the key. Formulate a
training schedule. For example, one year prior to implementation you might focus on e-learning,
audio conferences, and seminars to get ready for ICD-10-CM. Four to six months prior to
implementation, the training should be more in-depth so everyone has a good understanding of
ICD-10-CM.
Measure Productivity
In order to measure productivity, one suggestion is to have the coders and/or providers begin using
ICD-10-CM along with ICD-9-CM. This will assist you with evaluation of documentation deficiencies and the time it takes to code with ICD-10-CM. Keep in mind there is a learning curve and
productivity might be compromised for a short period of time. But with diligence the coders and
providers will become comfortable with ICD-10-CM which will increase productivity.
Outcomes Measurement
One month prior to implementation coders and providers should be measured on their understanding of ICD-10-CM and provide customized learning to fill any knowledge deficits. This will
also be a good time to formulate new policies and procedures as part of your compliance plan.
Communication will be important in making sure all employees in your practice are comfortable
with ICD-10-CM and can take their newly developed skill beyond implementation.
Training is a vital part of ensuring your success with ICD-10-CM. An ICD-10-CM training
development a map is included to help you map out your plan (see figure 7.1)
Learning Styles
There are three basic types of learning styles. The three most common are visual, auditory, and
kinesthetic. To learn, we depend on our senses to process the information around us. Most people
tend to use one of their senses more than the others.
Visual Learners
The visual style of learning is one of the three sensory learning styles along with auditory and
kinesthetic. Like the other two, visual learning relates to the fundamental ways in which people
take in information. As you can guess, visual learners learn predominantly with their eyes. They
prefer to see how to do things rather than just talk about them. Its the old monkey see, monkey do
kind of thing. Since about 60 percent of people are visual learners you can count on working with
them in every class you teach.
Visual learners prefer to watch demonstrations and will often get a lot out of videotaped instruction
as well. You can sometimes tell youre dealing with a visual learner when they ask, Can I see that
again? Other types of learners would ask if you could do it again, or explain it again. Its just a
little sign that the person youre coaching may be a visual learner.
How do visual learners learn? Visual learners often:
Take numerous detailed notes
Tend to sit in the front
Close their eyes to visualize or remember something
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Visual learners will do best in a classroom environment where they can both see the curriculum
and hear the instructor. Boot camps, individualized trainings, workshops, and similar situations
will enable them to learn and retain information.
Auditory Learners
Auditory people can often follow directions very precisely after being told only once or twice what
to do. Some auditory learners concentrate better when they have music or white noise in the background, or retain new information better when they talk it out.
Since hearing and speaking are so closely related, youll often find auditory learners using their
voice as well as their ears. Theyll often repeat what youve said right back to you. It helps them
process the information. They may also remember complex sets of information by putting them to
song or rhythm. Auditory people may also ask, Could you explain that again? Other types of
learners would ask you to do it again, or show it again.
Auditory learners like to:
Sit where they can hear but neednt pay attention to what is happening in front
Hum or talk to themselves or others when bored
Acquire knowledge by reading aloud
Remember by verbalizing lessons to themselves (if they dont they have difficulty reading
maps or diagrams or handling conceptual assignments like mathematics)
Auditory learning is a learning style in which a person learns through listening. They may struggle
to understand a chapter theyve read, but then experience a full understanding as they listen to the
class lecture. Auditory learners will do best with webinars and distance learning environments
where they can listen to recordings multiple times if necessary.
Kinesthetic Learners
Kinesthetic learners typically learn best by doing. They are naturally good at physical activities
like sports and dance. They enjoy learning through hands-on methods. They typically like how-to
guides and action-adventure stories. They might pace while on the phone or take breaks from
studying to get up and move around. Some kinesthetic learners seem fidgety, having a hard time
sitting still.
Kinesthetic learning is when someone learns things from doing or being part of them. Workshops,
distance learning, and methods that deploy hands on training will benefit these types of learners.
Kinesthetic learners will often:
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Conclusion
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Resources
and
Templates
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Figure 7.1
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Implementation of ICD-10-CM
Education Strategy
for ABC Medical Group
Date: January 2010
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Table of Contents
1. Introduction
1.1. Education Strategy
1.2. Education Objectives
2. Target Audience Groups
2.1. Target Audience
2.2. Objective and Target Audience
3. Instructional Design
3.1. Instructional Designs
4. Education Plan
4.1. Education Plan
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1. Introduction
1.1.
1.2.
Education Strategy
Education Objective
Education objectives outline how the education effort will address the mastering of
the ICD-10 codes and the implementation effort and set direction for all education
efforts so the messages to all targeted audiences are consistent, effective, and clear.
2.
2.1.
Target Audience
The target audience is defined as the person or group toward which the education is
intended and the individual or groups of individuals who need to receive the education.
Stakeholders include the following:
Target internal audience group 1: Executive Staff/Executive Leadership of
ABC Medical Group
Target internal audience group 2: Physicians and non-physician providers
of ABC Medical Group
Target internal audience group 3: Coders
Target internal audience group 4: Managers/Administrators/Finance of
ABC Medical Group
Target internal audience group 5: Clinical staff of ABC Medical Group
Target internal audience group 6: Clinic Ancillary staff of ABC Medical
Group
Target internal audience group 7: IT staff of ABC Medical Group
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2.2.
Education on ICD-10-CM and its implementation within the practice should be tailored
for each audience group to ensure that the instruction is relevant and significant to the
needs of the intended audience and that the right people receive the right training at the
right time.
Each identified target audience has a set of education objectives that have influence
in determining the lesson content, instructional design, and timing/frequency of the
education.
Internal Stakeholders
Audience Group
Objectives
Coders
Clinical Staff
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Ancillary Staff
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IT
Objectives
3.
Instructional Design
3.1.
Instructional Design
Instructional Design
Description
Frequency
Description of instructional
design 1: Staff in-service, informative meeting, executive
summary
Frequency of
deliverymonthly
Description of instructional
design 2: Face to face,
Frequency of
deliveryas
requested
Instructional design 3:
Interactive
Description of instructional
design 3: Face to face, cross
department meetings, distance
learning
Frequency of
deliveryas needed
4.
Educational Plan
4.1.
Educational Plan
The educational plan is used to provide an overall framework for defining, managing
and coordinating the wide variety of educational lessons associated with the implementation of ICD-10-CM/PCS. It helps facilitate acceptance to the implementation of this
new code set and empower participants when called upon to make critical decisions.
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Audience
Date(s)
Senior/
January 14,
Executive Staff/ 2010
Leadership
Physicians and
Non physician
Practitioners
Content
One way
Familiarity with
the final regulation
Staff
in-service
Build
February 14,
2010
Understanding
the impact of the
change to ICD-10
One Way
Staff
in-service
Build
Monthly
Staff
in-service
Build
February
2010
Familiarity with
One way
the final regulation
Staff
in-service
Build
March 2012
Understanding of
ICD-10-CM
Interactive
Face to face
meeting
Buy
October,
2012
Proficiency exam
for Certified
Coders (AAPC)
One way
On-Line
Buy
Distance
Learning
Buy
Interactive
February
2010
Familiarity with
One way
the final regulation
Staff
in-service
Build
March 2012
Understanding of
ICD-10-CM
Interactive
Face to face
meeting
Buy
October,
2012
Proficiency exam
for Certified
Coders (AAPC)
One way
On-Line
Buy
Interactive
Distance
Learning
Buy
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Instructional Delivery
Buy or
Design
Mechanism Build
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Audience
Date(s)
Management
February
Administration 2010
and Finance
March 2012
Content
Instructional Delivery
Buy or
Design
Mechanism Build
Familiarity with
One way
the final regulation
Staff
in-service
Build
General
Understanding of
ICD-10-CM
Face to face
meeting
Buy
Distance
Learning
Buy
Staff
in-service
Build
Face to face
Buy
Staff
in-service
Build
Face to face
meeting
Buy
Interactive
ClinicalNon-provider
February
2010
Audience
Ancillary Staff
February
2010
Instructional meeting
Delivery
Buy or
Design
Mechanism Build
Familiarity with
One way
the final regulation
Interactive
Interactive
February
2010
One way
Familiarity with
the final regulation
Staff
in-service
Build
March 2011
Understand both
ICD-10-CM and
PCS systems
Interactive
Face to face
meeting
Buy
One way
Staff
Training
Buy
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Objectives
Many medical practices and facilities conduct Gap Analysis quite often. They are usually defined
as the difference between the tools, processes, and resources necessary to ensure the practice runs
smoothly compared to current processes. Once your Business Process Analysis is complete, a Gap
analysis should be conducted. The Gap Analysis reflects the current state of your practice and
the gaps that must be corrected in order to achieve compliance. By now you should have a good
understanding of changes that must be made to improve both the business and clinical areas in
your practice in order to move to ICD-10-CM. Regardless of the business area involved, the Gap
Analysis is an effective solution to identify the risk area and develop an outline or plan for improvement. A Gap Analysis can be used to identify needs that cannot be supported with the current
business process.
Major areas of review include:
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Key Questions
STRENGTHS
WEAKNESSES
Goals/Opportunities
Obstacles
Figure 8.1
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Gap Analysis
Strengths, Weaknesses, Goals/Opportunities and Obstacles Analysis
Strengths
Compliance
Health plan contracts reviewed yearly Will continue to review contracts and review medical
policies as health plans publish to ensure ICD-10 compliance.
Weaknesses
Documentation
IT Systems
Staffing
Finance
Goals/Opportunities
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Improve Documentation
Finance
Will expand budget to include addition of system hardware which was not previously budget for.
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Obstacles
Medical Policies
Finance
Documentation
Physicians are reluctant to change documentation practice relative to ICD-10. They feel the way they document
now is sufficient. Need to continue to educate.
Government regulation
While it is important to identify impacts and interdependencies during this phase of the analysis,
it is also important to identify and address risks and opportunities that present themselves through
ICD-10. Risks are relatively easy to assess and prioritize; however, opportunities for change and
improvement may not be as readily evident. Ask the question, How can each of our business
areas leverage their use of the ICD-10 codes to improve the effectiveness and efficiency of our
operations?
By analyzing your ICD-10 implementation processes you will be able to determine and identify key
players and solutions to your implementation hurdles. Remember to review your process ongoing
to stay on top of any issues arising.
Now is the perfect time to review reporting requirements and health plan contracts to identify
ways to increase reimbursement or insure reimbursement is not lost during the transition to
ICD-10-CM. Take an in-depth look on how future payments may be effected and formulate a
plan for smooth transition. Review any current carrier policies, national carrier, or local carrier
determinations for Medicare, or any other health plan guidance and meet with key stakeholders
as well as the project team to discuss how changes must be made, and how it will affect future
reporting requirements and revenue streams. Work closely during this time with other vendors as
well, especially practice management systems, and EHRs as covered in previous chapters.
Outcomes Measurement
Outcomes measurement enables a practice to define and use specific indicators to continually
determine and to measure how well services or programs are doing compared to the desired results.
With this quantified information, managers can better develop budgets, allocate their resources,
challenge and motivate employees, and improve their services.
A successful outcome measurement program includes a process to measure outcomes plus the use
of that information to help manage and improve services and organizational outcomes. A practice
2015 AAPC. All rights reserved.
032415
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should have certain characteristics to successfully develop and implement an outcome measurement process. They include the following:
Leadership support. There must be visible support from top management in the
organization.
Commitment of time and staff resources. Initial development and introduction of the
process often requires the time and effort of many staff members.
Once the process is in place, the effort required typically decreases, as outcomes measurement
becomes part of basic program management.
If a practice has more than one group providing the same service, managers can use a common
measurement approach for both. For example, if two offices provide primary care services, each
with its own supervisor, then primary care services can be treated as one programand use the
same outcome measurement process.
A good process is to establish an outcome management-work group for each department. The work
group members work out the details of the outcome management process and oversee its initial
implementation.
Work groups that include representatives from the program and also other parts of the practice
can provide a rich variety of perspectives on what outcomes should be measured, how outcome
information can be collected, and the ways the outcome information can be used. The work group
approach can also reduce the likelihood that program staff will feel that outsiders imposed the
outcome process on them. It is important to allow enough time to work through the many issues
that will arise in the outcome management process. This approach works well for a large practice,
but would not work well for a medium to small group.
The work group will almost certainly need many sessions to work through the issues and questions
that inevitably arise. Work by one or more of the work group members may also be needed between
formal meetings to help resolve specific issues. After the outcome management work group has
selected programs to measure, the detailed work begins.
Goals and objectives should be identified such as:
Describe the service
Discuss goal or objective
Outline final result
Productivity
Productivity refers to the measurement between input and output. It reflects the amount of time
required for the trained/qualified individual working at a normal rate to accomplish a given task.
This standard level of productivity is expected regardless of the workload. In instances of reduced
workload, the manager/administrator should assign other duties and that variance time should be
logged accordingly. When developing productivity standards within the practice related to coding
patient encounters, the practice should take into consideration routine interruptions encountered
in the normal course of business.
A coding productivity quality review standard should be developed as part of the practices compliance
policy. Within that policy certain criteria should be addressed. Review the sample policy in figure 8.3
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Productivity/Quality will be monitored on a quarterly basis. Three month s results will be averaged
into one productivity and one quality score. If assigned to different OP coding jobs, coder must meet
productivity on 2 out of 3 months. If productivity/quality is not met quarterly, the employee will be
subject to disciplinary action.
A coder will not be eligible to train on a new coding job until productivity and quality standards have
been consistently met on the current coding job. The established productivity standards will be re-evaluated at least semi-annually and revised appropriately in accordance with the above-described process.
Figure 8.3
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Measure Productivity
There is usually a learning curve and productivity might be compromised for a short period of
time. With diligence, the coders and providers will become comfortable with ICD-10-CM and
gradually productivity will increase. Did training accomplish your objective? Have the coders and
providers developed a level of proficiency?
Keep in mind with the transition to ICD-10-CM coding productivity can be reduced by as much as
3040 percent until the learning curve has been realized.
Outcomes Measurement
Three to six months prior to implementation measure the coders and providers understanding of
ICD-10-CM, and then provide customized learning to fill knowledge gaps. This is a good time to
formulate new policies and procedures as part of your compliance plan. Communication is the best
way to make sure everyone in your practice is comfortable with ICD-10-CM. This is also a good
time to perform a coding audit focusing on documentation to support ICD-10-CM.
Next, the goal/objective should be translated into specific ICD-10-CM results. These should be as
specific as possible, as they become the basis for identifying specific outcome indicators.
After the outcomes are defined in general terms, the next step is to translate the statements into
specific indicators that will be measured. For each outcome, the working group needs to identify
one or more outcome indicator that could be measured to track progress toward the outcomes. Key
criteria are the feasibility and cost of measurement.
Outcome indicators should almost always begin with words such as The number of or The
percent of
While the working group should be responsible for selecting indicators, or at least providing
specific recommendations, management should review them to ensure that the indicators chosen
are comprehensive and do not neglect important outcomes.
Data collection procedures need to be selected carefully so that the program obtains quality
information.
Basic data sources include the following:
Training
Implementation efforts
Policies and procedures
Compliance
Conclusion
Top Tips for Developing Your Outcome Measurement Strategy
Measure what you can, and measure what you should: Consider your projects objectives to ensure
they are actually measurable. When assessing the progress of your sub-awardees, measure that
which is most vital to the intended results of your program.
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Plan the evaluation and the programs together: If possible, flush out your evaluation plan and your
program design concurrently, rather than waiting to devise an outcome measurement strategy as
an afterthought when your program activities have already begun.
Consult the standards: If there is no expert on your staff to competently identify measures and
indicators, consult the generally accepted tools, models, and standards to define your own.
Get the know-how: You may wish to acquire the expertise in measuring outcomes that your staff
may lack through partnerships, not just through hiring or contracting.
Flush-out the details of the baseline: Many facilities find it helpful to augment self-administered
surveys with staff-conducted interviews, site visits, etc.
Full service or self-serve? Self-administered baseline surveys are fine for collecting quantitative
data. But staff administered baseline surveys, which are more time and resource consuming, can
yield more forthright, accurate and qualitative data.
The cycle of refinement: Assessment shapes programs; programs shape assessment, and so on. Periodically revise your ICD-10 implementation to meet goals and objectives.
Outcomes measurement is important to the overall success and compliance of your transition into
ICD-10.
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Resources
and
Tools
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Templates
Operational Impact Worksheet
Practice Name:
Impact: (1-10) None (0), Low (2), Med (5), (High 10)
Date:
Clinical/
Business
Function
Process
Description
Impact
Status
Internal/
External
Disruption
to Staff
Violations of
Policies/
Laws/
Regulations
Issue resolution:
Part of assessment
recommendation
Gap Analysis
Strengths, Weaknesses, Goals/Opportunities and Obstacles Analysis
Strengths
Compliance
Continuous auditing and monitoring
IT on staff to customize systems
Health plan contracts reviewed yearly
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Goals/Opportunities
Improve Documentation
Replace current hardware with
updated system
Finance
Education and Training
Obstacles
Medical Policies
Finance
Documentation
Negative economic conditions
Government regulation
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Chapter
Go Live
Objectives
Introduction
Although healthcare practices and facilities will still maintain their historical records in
ICD-9-CM, they will need to address the challenge of accessing this data for future case mix
analysis and comparative studies.
The most important benefit of ICD-10 implementation is quite obviousin order to continue
operating in the healthcare industry, it will be imperative to make the transition to ICD-10-CM by
the compliance deadline in 2015. All claims payment operations will be handled using these code
sets, and it will be important for the practice to become compliant to meet deadline.
Vendors should begin internal testing on ICD-10-CM no later than November, 2012. That
means they should test their software, crosswalks and mapping, and other issues relative to
implementation within the practice. Partner testing should begin no later than September 2013.
However, it is recommended that the vendor install the new software and test the system end to
end at least six months prior to implementation in case there are errors or problems to resolve. To
ensure that codes are ready to be deployed the system should be re-tested end-to-end at least three
months prior to implementation.
If the electronic health record is not integrated with the practice management system, the EHR
vendor will also need to install the upgraded software and test the system for compliance. This
upgrade and testing should occur within six months of implementation.
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Go Live
Chapter 9
Go-live
The Go-live date is Oct. 1, 2013. On this date, only ICD-10-CM codes can be submitted. ICD-9-CM
codes will no longer be accepted. Also ICD-10-CM codes will be frozen with no new updates for a
period of time prior to and after implementation beginning October 1, 2012.
The ICD-9-CM Coordination and Maintenance Committee will implement a partial freeze of
the ICD-9-CM and ICD-10 (ICD-10-CM and ICD-10-PCS) codes prior to the implementation of
ICD-10 on October 1, 2015. There was considerable support for this partial freeze. The partial freeze
will be implemented as follows:
The last regular annual updates to both ICD-9-CM and ICD-10 code sets will be made
on October 1, 2011.
On October 1, 2012, there will be only limited code updates to both the ICD-9-CM and
ICD-10 code sets to capture new technologies and diseases as required by section 503(a)
of Pub. L. 108-173.
On October 1, 2013, there will be only limited code updates to ICD-10 code sets to
capture new technologies and diagnoses as required by section 503(a) of Pub. L. 108-173.
There will be no updates to ICD-9-CM, as it will no longer be used for reporting.
On October 1, 2015, regular updates to ICD-10 will begin.
This code set freeze will allow for a stable learning environment.
If previous claims are outstanding and need to be resubmitted, ICD-9-CM code(s) will be reported.
Example: A patient is seen on Oct. 1, 2015.
The service is reported with an ICD-10-CM code.
Example: A patient is seen on Sept. 30, 2013. The claim is submitted the next day. The claim is
outstanding after 30 days. The coder inquires with the insurance carrier as to why the claim has not
been paid. The carrier informs the coder the claim was not received and would need to be resubmitted. The coder would code the claim using ICD-9-CM since the date of service is the date that
determines whether ICD-9-CM or ICD-10-CM is reported.
Keep in mind when transmitting or submitting claims, some health plans may not be ready to
accept ICD-10-CM codes. As a preventive measure every practice should contact every health plan
they contract with at least three months prior to implementation to question readiness. Be prepared
to have someone in the organization available to troubleshoot problem whether they be system,
coding, documentation, or other implementation compliance problems. Having several people
from the ICD-10- CM project team available the first few weeks post implementation will benefit
the organization.
Implementation Compliance
Claim Error and Denial Resolution
During the transition period, which could range from the first six to 12 months, increased levels of
errors both from a coding and claims submission standpoint to the claim adjudication process may
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be problematic. In addition, within the practice it is likely that there will be increased queries from
coders regarding code selection, and increased billing inquires from the health plans.
Resolution may require hiring additional temporary staff to assist with pended, denied, and delayed
claims.
Conclusion
There will be problems associated with implementation that will need immediate resolution. The
most troublesome issue is claim denials, claim delays and payment disruption. In order for any
practice to stay healthy, it must have a healthy cash flow. However this is one of the most extensive
transitions that healthcare has seen in decades, and involves all business areas of medicine.
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Many of the benefits of ICD-10 implementation will be a direct result of ICD-10s increased
specificity and greater degree of clinical knowledge. Provider reimbursement will have a level of
precision never before seen in this country this is also a direct result of increased specificity in ICD10-CM. As a result health plans will be able to reimburse claims in an improved, more accurate
manner with less documentation scrutiny. Despite the time, and investment, and the vast amount
of work, there are significant benefits to be had as a result of successful ICD-10-CM implementation
even though most practices will not realize the benefits for many years.
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