Healthcare

To successfully implement ICD-10, healthcare organizations should perform thorough, enterprise-wide assessments, and develop comprehensive roadmaps that seek to achieve compliance, while taking advantage of the benefits ICD-10 has to offer. The assessments and roadmaps should incorporate the following four key factors:

• Identify and understand the codes that “move the needle.” At first glance, the number of new codes available with ICD-10 may seem overwhelming. The number of diagnosis and procedure codes combined is increasing from approximately 18,000 under ICD-9 to more than 150,000 under ICD-10.
• Start by identifying the diagnostic-related groups (DRGs) that account for the largest percentage of your organization’s revenue.
• Leverage analytics to understand how ICD-9 codes map to these DRGs today.
• Utilize predictive modeling techniques and scenario building to gain an understanding of your potential DRG mix under ICD-10.

In some markets, select providers and payers are starting to work together to abstract and code a subset of historical claims using ICD-10. By joining forces, these organizations are striving to achieve financial neutrality during the initial period when ICD-10 will take effect. Their plan is to run the data through mock end-to-end processing cycles to understand the financial impact ICD-10 may have on each of them.
Other organizations are formulating concurrent strategies in which they plan to code in both ICD-9 and ICD-10 for a period of time before and after October 1, 2013. The goal in pursuing concurrent coding strategies for these organizations is to gain a deeper understanding of how ICD-10 will impact their most critical service lines.

• Develop an effective strategy to address physician adoption and improve clinical documentation. Physician inclusion and buy-in are a must, if an organization wants to successfully implement ICD-10. In order for coders to abstract and codify records appropriately, physicians need to document in a manner that supports the granularity of ICD-10. Imprecise notes can lead to increased coder follow-up time and potential coding errors. Start by understanding documentation deficiencies that exist today, as areas that are deficient under ICD-9 will only get worse under ICD-10.

Identify physician champions who understand the importance of clear and comprehensive documentation. It is particularly important to find champions practicing in those specialties that are especially impacted. Leverage these physicians as advocates for ICD-10 in their local medical communities. Consider implementing structured documentation tools and utilizing clinical documentation specialists to help address areas in which coding deficiencies exist today.

• Implement measures to prepare coders and secure additional resources. Based on the experiences of other countries that have already moved to ICD-10 (e.g., Canada, Australia), it is likely that healthcare organizations will experience a sharp decline in coder productivity when ICD-10 initially takes effect. In order to mitigate the risks associated with lost productivity, organizations need to implement comprehensive training plans that prepare coders to work effectively with ICD-10 codes. These plans should include refresher training on anatomy and physiology. In addition, plans should explore the use of concurrent coding strategies to reinforce learning objectives. The concurrent coding approach should include a component that focuses on the codes most central to the business. Organizations should also explore the use of computer-assisted coding tools that offer robust features to increase the efficiency and accuracy of the coding process.

Along with the implementation of effective tools and processes, organizations should plan for increased staffing to fill the gaps. Budgets should include provisions for overtime, additional full-time equivalents, and/or contract coding resources for a period of time after ICD-10 first goes into effect.

• Create a reporting strategy to leverage the benefits of ICD-10. Build a long-term strategy for mining and modeling ICD-10 clinical and financial data. By designing reporting systems and processes to leverage the specificity of ICD-10, organizations will be in a stronger position to navigate changes in a landscape being shaped by healthcare reform.

Implementing an initiative as large as ICD-10 is, at best, complex. It is important not to be frozen by the size and intricacy of the task. North Highland suggests the following simple steps to take now:

• Develop a vision/plan for overall implementation
• Identify and focus on the codes that “move the needle”
• Plan a training strategy for coders

At North Highland, we work with the leading healthcare providers to address the thorny issues facing the industry today. We understand the painstaking process of compliance and the level of effort that goes into a successful implementation.  We can help you simplify the ICD-10 journey to maintain compliance and profitability.

Today, the U.S. spends $2.3 trillion on healthcare, and the U.S. Health Care Efficiency Index estimates that we could reduce this cost by $30 billion if we could eliminate the friction of phone-based and paper-based systems.(1) And while the American Recovery and Reinvestment Act includes a targeted focus on Electronic Medical Records (EMRs), conversion to EMR is likely to be a long and time-consuming process.(2)

"Low-hanging Fruit"

Meanwhile, there's a much quicker fix that is not getting much attention in the current debate, and that is the savings that could be realized by full conversion to electronic healthcare claims.

Unlike EMRs, electronic claims aren't slowed down by privacy issues and other barriers that arise with business-to-human transactions. They offer billions of dollars in savings. According to the Center for Health Transformation, 90 percent of claim payments are still made in the form of a paper check. By eliminating these paper-based checks, the U.S. could reduce the overall cost of healthcare by $11 billion.(3)

Every paper check that is eliminated and replaced with a wire transfer saves the payer $.78, according to a study from the AHIP Center for Policy & Research.(4) And given the fact that a few large payers – United, Aetna, Cigna and BlueCross BlueShield – are responsible for a majority of claims checks written in the U.S., making the switch to electronic healthcare claims may be easier than you think.

How we make the switch

Making the switch would require a standardized process that all participants would agree to follow and that would include several basic elements:

• Change would start with establishment of shared and enforced electronic standards for eligibility, authorization, and claims processing for all payers and providers.


• These eligibility standards would need to be clearly communicated to providers.


• The next step would be establishing agreements between payers and providers on "approved" processes for complex, high-cost cases.


• And, finally, there would need to be a system of third-party monitoring for adherence to the standards.

Frictionless healthcare is about removing cost from the system. If we start by eliminating paper-based claims, we could achieve a significant savings success story that could actually make it easier to achieve success in the ultimate goal of healthcare reform. And saving $11 billion in the process wouldn't be a bad way to get started.

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(1) National Automated Clearing House Association, ACH 2007 Volumes, May 19, 2008
(2) DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care - a national survey of physicians. N Engl J Med 2008;359:50-60
(3) Center for Health Transformation
(4) Hannah Yoo and Karen Harner, "An Updated Survey of Health Care Claims Receipt and Processing Times," AHIP Center for Policy and Research, May 2006