Adapting to a Changing Environment with ICD-10

Benjamin Franklin coined the phrase, “nothing is certain but death and taxes.” Anyone in the healthcare industry would quickly update that phrase to “nothing is certain but death, taxes, and change.” We have not yet recovered from the implementation of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and the calendar year 2017 changes are almost on our doorstep.

Each of the 3 primary code sets is updated annually, and payer policies seem to be “revised” any day that ends in “y.” It can be overwhelming. Providers are also frustrated with the frequent “updates,” and the intrusion on clinical care time to stay ahead of changes that impact their documentation.

Here are a few key reminders to assist you with efficiently managing the never-ending stream of updated information related to ICD-10. First, accept that change is constant. Next, recognize that your individual plan to customize, quantify, and leverage resources must be sustained over the long haul; this is not a one-and-done project. Finally, start small so that you can be consistent in your efforts, and build as your time or resources allow.

Customize the Content

Calendar year 2017 will usher in close to 3000 ICD-10 changes; less than 300 may be specifically within the neoplasm (C/D) or hematology (D) chapters of the code set. Your practice may not need even half of those changes, but it may need to explore revisions within other sections of the code set.

The most direct path to determine what you need to know is to routinely run a frequency report of the diagnosis codes from your billing system. Once every quarter, quickly scan the top 25 or 30 diagnosis codes used in your practice. The goal is to identify the codes that will represent 75% or 80% of the conditions treated. There will always be exceptions and queries for additional information, but if you can manage the lion’s share of the volume, you will have a manageable process. If possible, run this report by provider and location, because knowing which providers primarily treat what conditions, comorbidities, and in which settings (ie, clinic or hospital) will allow you to customize the changes—not only for your practice but also for specific providers.

The overall ICD-10 changes can be presented annually at a “coding update” breakfast meeting, or in a recorded webinar for viewing at the staff’s convenience. Ongoing changes need to be provider-specific; for example, “Dr Smith—beginning Monday, these additional data elements will need to be included in your clinical history (or past medical history, or impression as appropriate) for your patients with—[insert condition].”

Once every quarter, identify the most common diagnosis codes related to the “medical necessity” denials, and keep a pulse on the payer’s changes related to their edits and/or coverage guidelines.

Balance the data that are expected by the code set with the data that are reasonably available to the provider at the time of the encounter. This is part of the customization task: filter the information to what can be applied to your practice at this time. For example, during this transition period, it may not be reasonable for the documentation to include the specific site of all Hodg­kin lymphoma cases for patients who received treatment in the past decade. However, if the data allow for “multiple sites” or other appropriate reporting, customize the content for your practice.

If your practice includes dozens of providers, start where it matters most. Which providers are most affected by the changes? Which providers are currently generating the highest volume of “medical necessity” denials? Which providers may be the most receptive to your new communication or training strategy? The practice typically has a physician champion, or a physician who is willing to hear the message and share it with colleagues. Consider your options, and develop a solid foundation.

Customizing the content is the first step in a forward direction, but it is also important to keep those changes in perspective. You know that you have selected the conditions used most frequently, but be sure that you can quantify that to the providers.

Quantify What You Communicate, Demonstrating the Message Affects the Majority of Cases

Training providers will usually generate a handful of comments with a similar theme: “We don’t have time for this,” or “I will have to see half the patients I see now.” Patient care is the primary objective of any practice, and everyone agrees that administrative tasks are reducing the face-to-face time that providers have with patients.

Be sure to share the hard numbers with the providers, and keep the coding changes in perspective for specific providers. For example, identify the condition that now requires additional data, and convey to the providers that they reported that condition a certain number of times in the past 90 days; share the top 10 conditions that require changes in their documentation.

If the change does not affect the provider, perhaps because it is a sequencing change, and it will be managed by coding staff after the charges are generated (but before claim submission), then do not bother the providers with those details on a daily basis; save such overall, big-picture changes for an annual update.

Avoid phrasing messages that can be interpreted as “every” visit will require this additional information or “every” payer is requiring this level of detail. Similarly, use caution when reacting to messages that “all” claims are denied because of a lack of information such as smoking history. Do the homework first to find answers to questions such as, which payers are starting to deny claims because of a lack of social history or underlying infection? How often in an average day will this denial affect this specific provider?

Over time, quantifying the changes will send a clear message to the providers that you will only “bother” them with information that is mission-critical to them. If you can provide specific solutions for capturing the additional data, then you are 2 steps ahead of the process.

Leverage the Template: Capturing the Data within the EMR System

It is common to react when someone proposes a change, and usually to react defensively. Listening is quickly replaced by thoughts of how to make it happen, why it will not happen, and how long it will take to make it happen, and, before long, the minor change has revamped the entire charge-capture process. If the upcoming ICD-10-CM changes affect a specific provider for a specific group of patients, then do your homework.

Anyone would be frustrated when told to start documenting something without a mechanism with which to accomplish the task. You can move the process along by printing a recent progress note and highlighting the data elements that are available and needed. Try these steps:

1. First, determine which field within the electronic medical record (EMR) system will best capture that additional information, and whether it is recurring information (think “stage of the tumor” or “history of radiation therapy”) that can be appropriately pulled forward into each progress note.
2. Next, determine what information is available to the providers at that specific step in the documentation process. For example, if they are expected to select the diagnosis code, how is the dictionary set up, and can it be modified to be more clinical, without changing the intent of the code?
3. Finally, review the type of data, and determine if the data must be entered by the reporting provider (think “history of present illness”).

By the end of this exercise, you will have a clear grasp of what specific content will need to be captured for your providers within your EMR.

The data stream will continue to rush through our practices. If we can get into the habit of customizing the content based on what will impact the majority of our business, and leverage the electronic resources, then we can stay abreast of this constantly evolving landscape.