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ICD-10

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.

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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.

Key Highlights of the ICD-10 Final Rule


ICD-10-CM and ICD-10-PCS coding systems will replace the current ICD-9-CM coding
system afer Oct. 1, 2015. This includes all inpatient and outpatient facility visits as well as
freestanding providers and ancillary services.
ICD-10-CM will replace the ICD-9-CM diagnosis codes rendered in all settings.

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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.

Comparison of ICD-9-CM and ICD-10-CM/PCS


Diagnosis Code Revisions
ICD-9-CM Diagnosis Codes

ICD-10-CM Diagnosis Codes

35 characters in length

37 characters in length

Approximately 14,000 codes

Approximately 79,000 codes

First digit may be alpha (E or V) or numeric.


Digits 25 are numeric

Digit 1 is alpha; digit 27 are alpha or numeric

Limited space for new codes

Flexible for adding new codes

Lacks detail

Very specific

Lacks laterality

Has laterality

Difficult to analyze data due to non-specific


codes

Specificity improves coding accuracy and depth


of data for analysis

Codes are non-specific and do not adequately


define diagnoses needed for medical research

Detail improves the accuracy of data used in


medical research

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

ICD-9-CM Volume 3 procedure codes

ICD-10-PCS procedure codes

34 numbers in length

Seven alpha-numeric characters in length

Approximately 3,000 codes

Approximately 87,000 available codes

Based upon outdated technology

Reflects current usage of medical terminology


and devices

Limited space for adding new codes

Flexible for adding new codes

Lacks detail

Very specific

Lacks laterality

Has laterality

Generic terms for body parts

Detailed descriptions for body parts

Lacks description of methodology and


approach for procedures

Provides detailed descriptions of methodology


and approach for procedures

Limits DRG assignment

Allows DRG definitions for recognition of new


technologies and devices

Lacks precision to adequately define


procedures

Precisely defines procedures with detail


regarding body part, approach, any device used,
and qualifying information

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

The Implementation Effort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1


Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
All About Change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Key Obstacles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Organizing the Implementation Effort. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The Strategic Steering Committee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The Educational Steering Committee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The Communication Steering Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Coordinate with Business Partners, Providers, and Vendors. . . . . . . . . . . . . . . . . 6
Educate the ICD-10 Project Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Historical Perspective of ICD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Rationale for Change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Begin the Implementation Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Conducting the Initial Impact Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Assessing Awareness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
High-level Complexity and Awareness Assessment . . . . . . . . . . . . . . . . . . . . . . . 13
High-level Complexity and Awareness Assessment Tool. . . . . . . . . . . . . . . . . . . 14
Senior Management Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
The Future. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Organizing Cross Functional Teams. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
The ICD-10-CM Cross-functional Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Organizational Structure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Transparency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Resources and Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Readiness Survey Template. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
High-level Complexity and Awareness Assessment Tool. . . . . . . . . . . . . . . . . . . 28

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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

The Impact Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63


Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
The Impact Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

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Stages of Meaningful Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67


Business Process Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
The Clinical Impact. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Information Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Crosswalks and Mapping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Tracking and Trending. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Resources and Templates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Business Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Chapter 5

Building Your ICD-10 Action Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95


Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Vendor Importance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
The Impact of Vendors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Developing a Preliminary Needs Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Discussing Key ICD-10 Implementation Issues with Vendors. . . . . . . . . . . . . . . 98
Vendor Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Deployment of Code to Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Internal Testing End to End. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Implementation Costs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Chapter 6

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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Chapter 7

Education and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119


Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
The ICD-10 Education Steering Committee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
The ICD-10 Education Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
The Education Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
ICD-10-CM Training Development Map. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Learning Styles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Resources and Templates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Chapter 8

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

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The Implementation Effort


Objectives

Understand how to begin the ICD-10-CM implementation process


Review guidance for organizing the implementation effort
Understand what briefing materials will be necessary to obtain senior management
buy-in
Obtain support from providers senior management
Understand how to conduct the preliminary impact analysis in the discovery phase of
implementation

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.

All About Change

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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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.

Organizing the Implementation Effort

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.

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Organizing the implementation effort


should include the following processes:
1. Reviewing the ICD-10 Final Rule for any pertinent areas that impact the practice.
2. Obtaining senior management support and practice buy-in.
Complete preliminary analysis of system impact.
Prepare briefing materials for providers and staff to review relating to the work and
scope of work that needs to be accomplished.
Identify the senior manager project supporter.
Establish senior managements role in completing the project.
3. Obtain support from all providers and senior management.
Talk with providers about ICD-10-CM and its impact on the practice.
4. Identify all areas that will impact the practice such as the clinical areas, systems, documentation, etc., and share this information with providers.
5. Establish a regular schedule to report progress to senior management.
6. Coordinate a briefing with the 5010 project team.
The first step of the steering committee is to complete a project plan and gain knowledge of ICD-10.

What is an ICD-10 Project Plan?


A project plan is a document outlining the purpose of the project, the way the project is structured,
and how to implement it successfully. It describes the projects:
Vision, objectives, scope, and deliverables (eg, what we have to achieve)
Stakeholders, roles, and responsibilities (eg, who will take part in it)
Resource, financial, and quality plans (eg, how to undertake it)

When Do I Use a Project Plan?


The ICD-10 project plan is usually presented by management. It is completed after the ICD-10
business case and feasibility study have been approved but before the project team is formally
appointed.
The ICD-10 project plan defines the boundaries for the project. It describes in detail the scope of
the project and when all deliverables must be produced.
The plan should include information on the following:
1. BackgroundA summary of why and how the team was selected and how it is aligned with
the practices vision for ICD-10 compliance.
2. Mission/objectiveThis should outline the what, for whom, and so that.
3. Key deliverablesWhat needs to be accomplished by whom and when.
4. Boundary conditionsIndicate what is and is not part of the teams purview.

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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

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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.

The Strategic Steering Committee

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.

The Educational Steering Committee

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 Communication Steering Committee

For large practices or facilities it is recommended to form a communication steering committee.


The communication steering committee assists and oversees the ongoing communication strategies. The committees primary responsibility is message development, dissemination planning and
oversight. To accomplish this goal, the committee should develop a communication plan for all
communication approved by the committee. Development of guidelines will ensure a consistent
message. Just as with the education steering committee, this committee will address immediate,
ongoing, and future communication needs for a number of audiences.

Coordinate with Business Partners, Providers, and Vendors

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!

Educate the ICD-10 Project Team

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.

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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.

Benefits of Replacing ICD-9-CM


Use of this new system significantly improves the capture of information for our increasingly
complex healthcare delivery system. ICD-10 contains an increased number of codes and categories
allowing for more specific and accurate representation of current and future medical diagnoses and
procedures. ICD-10 promises to provide enormous opportunity for documentation improvement
for health records. Because of this, more documentation in the medical record might be necessary
to support the specificity of ICD-10-CM reporting for diagnosis coding. This is especially true with
physician migration to EMRs. ICD-10 provides greater coding specificity for hospitals, physicians,
payers, and others within the health system to support accurate payment.
Many other countries are already using ICD-10. Studies indicate the United States needs to switch
to ICD-10 to improve the quality of their nations healthcare data and to maintain clinical data
comparability. The better data provided by ICD-10 is expected to lead to improved patient safety,
improved quality of care, and improved public health and bio-terrorism monitoring.
There is a cost and a danger when using an outdated, broken coding system. Continuing to use
ICD-9-CM will increasingly have an adverse impact on the value of healthcare data, including the
accuracy of decisions based on faulty or imprecise data.
When ICD-10 is implemented, ICD-10-CM will replace ICD-9-CM Volumes 1 and 2 for reporting
diagnoses and ICD-10-PCS will replace ICD-9-CM Volume 3. ICD-10-PCS (for inpatient procedure
coding) will not replace CPT for reporting procedures and services in outpatient setting.
Benefits of using ICD-10 are:
The alphanumeric structure provides more specific information, expands injury coding,
and provides a more descriptive clinical picture of the patient than ICD-9-CM.
ICD-10-CM contains an increased number of codes and categories allowing for a
more specific and accurate representation of current and future medical diagnoses and
procedures.

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ICD-10-CM provides more detailed and clearer clinical descriptions.


Payers require accurate diagnosis code reporting to explain why a service is provided to
the patient. ICD-10-CM allows for greater accuracy.
Figure 1.2 illustrates the United States mortality and morbidity historical tracking from 1900 to the
present.

Historical Perspective of ICD


ICD Revision
Year

Year Approved Year used


in the U.S.

ICD, Clinical Year in Use in the U.S.


Modification

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

Rationale for Change

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.

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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:




Insufficient structure for reporting new technology


Duplicate codes that overlap
Outdated terminology
Lack of sufficient specificity and detail
Lack of codes for certain types of services

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:





Identify fraudulent practices


Support medical necessity
Research and support clinical trials
Set health policy
Process claims for reimbursement
Measure quality and efficacy of care

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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healthcare professionals are facing a staggering number of technological requirements, including


multiple, overlapping federal mandates, which place significant financial and operational burdens
on practices, especially smaller practices.
For healthcare providers, ICD-10-CM will encompass more precise documentation of clinical care
and will potentially ensure more accuracy when determining medical necessity for the services
provided. Our healthcare system faces quality concerns attributed to medical errors, poor documentation, lack of support of medical necessity, and fragmented care. This new system allows
healthcare providers to code more accurately, which will contribute to the healthcare quality
improvement initiatives. The differences between ICD-9-CM and ICD-10-CM/PCS are numerous,
ranging from the number of coding categories to the structure of the codes.

The Final Rule


The ICD-10 Final Rule was published on Jan. 16, 2009, which identified the timeline for ICD-10-CM
implementation. The implementation date of Oct. 1, 2015 is fast approaching. The time is now to
begin the transition to ICD-10-CM implementation for physicians and non-physician providers. All
medical practices whether small or large will be impacted by this change and need to begin early
to assure when the Go live date occurs, the practice is ready to begin claim submission with the
new diagnosis code set. The first step in ICD-10-CM implementation is to create awareness within
the organization and planning for the transition. Many medium to large medical practices will
incorporate various teams working simultaneously on ICD-10-CM implementation, but there is a
very short amount of time to make this all important transition.

Begin the Implementation Process

The steering committee should begin with the key areas of focus in:












10

Current areas for documentation improvement


Budget planning
Adoption and implementation timeline
Identify the systems that will be affected (practice management system, EMR, etc.)
Training practitioners, coders, billing staff, and other identified staff
Development of a crosswalk to ICD-10-CM specific to the practice specialty
Orient information systems or vendors related to coding specifications (eg, sixth and
seventh digit character extensions, alpha numeric, etc.)
Orient the physicians and clinical staff on how the system can be used by the practice
Review the impact and expectations on documentation
Review and update coding support tools (eg, superbills)
Discuss with vendors as to when to expect software updates and what the estimated
costs will be
Operational transition
Assess coding personnels skill to identify knowledge gaps in the areas of medical
terminology, anatomy and physiology, pathophysiology, and pharmacology to ensure
expanded clinical knowledge meets ICD-10-CM requirements

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Identify weaknesses where additional education would be beneficial


Identify communication methods for staff not involved in the committee and develop a
communication plan to keep others informed of the ongoing work
As stated earlier, the team must be proactive and instrumental in its preparation for ICD-10-CM.
Other staff members should be involved in the transition. It is important to understand that
the transition effort will not succeed without input and cooperation from all practice members.
Personnel involved in the transition process should begin planning early to avert problems in the
process. When a person is in training or learning a new skill, productivity slows down short term.
These slowdowns result in loss of productivity, including charge capture and reimbursement, and
can affect the financial health of the practice. The practice should anticipate a decrease in productivity by measuring and analyzing the impact prior to beginning the training process.

Conducting the Initial Impact Analysis

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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1. Where do you work?

Readiness Survey

a. Include division, department, and unit


2. Do you have staff who reports to you?
__ Yes. If so, how many? _______
__ No
3. How did you hear about ICD-10? Check as many as apply.
a. My manager
b. My coworkers
c. Staff meetings
d. E-mail
e. Outside of this organization, news, internet, etc.
f. Otherplease specify
4. What do you know about ICD-10? Why are we changing from ICD-9 to ICD-10?
5. Do you have any knowledge of what the company is doing to address the change from
ICD-9-CM to ICD-10-CM?
6. What projects are your department/area initiating and/or supporting in the next 15 years?
7. Are your business areas policies, procedures, and standard operation procedures documented and who is responsible for maintenance of these?
8. How much do you think ICD-10 implementation will affect your business area?
a. A lot
b. Somewhat
c. Not at all
d. Not sure
Please explain.
9. Does anything concern you about the ICD-10 implementation?
10. What specific questions would you like answered in the future on ICD-10?
11. Where do you go for information? Check as many as apply.
a. My manager
b. My co-workers
c. Staff meetings
d. Email
e. The internet
f. Other __________
Figure 1.3

12

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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

High-level Complexity and Awareness Assessment

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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High-level Complexity and Awareness Assessment Tool


Assessing Complexity and Awareness

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.

How many of the core processes* are affected in each department?


Explain:
[ ] 1 or 2 core processes

Indicate which core processes

[ ] 3 or more core process

Indicate 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.

Indicate experience level with technology and supporting processes related


to this effort?
Explain:

[ ] 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

How much training for employees or providers is required to support this


effort?
Explain:
[ ] No training

[ ] Minor training

[ ] Formal training

[ ] Extensive training

Figure 1.5

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Senior Management Support

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:






Goal of the presentation


Outline of the key concepts
What ICD is
Why ICD-10-CM implementation is necessary
Areas of the organization impacted by implementation
High-level financial impact
Timeline with key projects for Oct. 1, 2015 compliance

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.

Organizing Cross Functional Teams

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.

The ICD-10-CM Cross-functional Team

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:




Developing of training programs


Choosing and implementing new technologies for the practice
Controlling training costs
Improving the communication process
Coordinating with the 5010 implementation team

Synergy

According to Wikipedia, synergy is derived from the Greek syn-ergos, meaning


working together and is when different entities cooperate advantageously for a final outcome.
Simply defined, it means the whole is greater than the sum of its parts. Although the whole is
greater than each individual part, this is not the concept of synergy. If used in a business application, it means teamwork produces an overall better result than if each person is working toward the
same goal individually. Wikipedia further describes synergy as:
A dynamic state in which combined action is favored over the sum of individual
component actions.
Behavior of whole systems unpredicted by the behavior of their parts taken separately.
More accurately known as emergent behavior.
The cooperative action of two or more stimuli or drugs.

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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.

The Team Leader


In cross-functional teams, the leaders role is more of a coach rather than a traditional manager.
Team leaders do not distribute assignments or give out orders; rather, they rely on other team
members to help and to assist in decision-making responsibilities. They are not above the group;
rather they are more of a contributing group member.
Team leaders do not manage all of the teams activities; they promote performance and make sure
team efforts are in line with the practices goals. The leaders responsibility is to be the liaison for
upper management, suppliers, and other outside entities. He or she is the teams leading spokesperson and keeps a clear vision of the teams goals and promotes activities to obtain those goals. A
team with an effective leader, regardless of their functional background, will have better performance results.

Subject Matter Experts


A subject matter expert (SME) is an expert in their department or subject and not necessarily an
expert in all areas. Dont confuse SMEs with training experts. A training expert is an expert in all
affected areas and conducts training across the practice or facility divides.

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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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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

Rick Jameson All

workgroup

TBD

TBD

Cross-functional Analysis

Martin Short, All


MD

TBD

TBD

TBD

spreadsheets

TBD

TBD

Estimate Budget Kevin Picolla Finance/


Administration

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

ABC Medical Group

President & CEO


Brentt McQuail, MD

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

Christy Masura, CPC

Jim Clover
Physician

Otis Brown, CPC, CPC-H


Roberta Cooper, CPC,
CEMC

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

Christy Masura, CPC


Otis Brown, CPC, CPC-H

Nurse/MA

Physician Assistant

Roberta Cooper, CPC,


CEMC

Cynthia Soringer, LPN

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

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ABC Medical Group


ICD-10-CM Steering Committee
Susan Parkins

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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The Implementation Effort

Chapter 1

Transparency

To achieve exceptional results transparency is necessary in the cross-functional team. Successful


ICD-10-CM implementation relies on good communication and follow-throughthis project will
consume more resources than ever required in a practice and facility. Openly share information
and details to facilitate implementation. If transparency is not evident, the project will struggle.
Selecting the right cross-functional team from the start is essential. Once your team is assembled,
look from within for that inspirational leader to keep the group focused and motivated to move
forward. Make this person responsible for the group and for tracking progress. This person needs
to be flexible, motivated, and willing to let others shine for the good of the group. They need to be a
cheerleader for change and to stay positive during the transition.
To form an effective cross-functional team, evaluate the ICD-10-CM implementation project by
asking three questions:
1. Do potential members have expertise in the groups problem?
2. Do they have expertise and credibility that can help the team fulfill their charter?
3. Can they all get along and work together to achieve the common goal?
Expertise is a sticky issue. If all team members have substantial expertise in the problem area, they
may not see the forest for the trees, yet a group of novices can make fundamental mistakes. Based
on experience, the amount of expertise required for a group to be effective depends on the purpose
of the group.
If the purpose is to make incremental, small-scale change, weight the group with experts. If the
purpose is fundamental, large-scale change (re-engineering), such as with ICD-10 implementation,
weight the group with less-than experts.
A clear project plan and purpose is fundamental. Being on a team without a clear direction or
purpose is frustrating. People meander and waiver around and after a few overly long meetings,
members stop showing up. Team members, their management, and other stakeholders should agree
on the plan before the team starts on its task.
Not only should members have some expertise on the subject, they should have access to administration, and should be credible within the practice.
Well-established departments tend to have well-established measures of success, even though what
is measured is questionable. Cross-functional teams, however, should decide what results they
expect to achieve. What they want to achieve may have no current measure of success.
Establish normal ground rules for the group (how conflict and consensus is handled, who writes
the minutes, who facilitates the group, etc.). Just as important, ground rules are:
1. Time, money, people, and other resources the department is willing to give to this project.
2. Who the group can turn to when in trouble.
3. If management doesnt follow through, how the group will motivate others.
Build the team up front. So often teams come together with good purpose, but through misunderstanding things come apart. Consultants are called in after the damage is done. It is better to

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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

The Implementation Effort

Resources
and
Templates

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The Implementation Effort

Chapter 1

Templates

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Readiness Survey Template


1. Where do you work?

Readiness Survey

a. Include division, department, and unit


2. Do you have direct reports?
__ Yes. If so, how many? _______
__ No
3. How did you hear about ICD-10? Check as many as apply.
a. My manager
b. My coworkers
c. Staff meetings
d. E-mail
e. Outside of this organization, news, internet, etc.
f. Otherplease specify
4. What do you know about ICD-10? Why are we changing from ICD-9 to ICD-10?
5. Do you have any knowledge of what the company is doing to address the change from
ICD-9-CM to ICD-10-CM?
6. What projects are your department/area initiating and/or supporting in the next 15 years?
7. Are your business areas policies, procedures, and standard operation procedures documented?
8. Who is responsible for maintenance of these?
9. How much do you think ICD-10 implementation will affect your business area?
a. A lot
b. Somewhat
c. Not at all
d. Not sure
Please explain.
10. Does anything concern you about the ICD-10 implementation?
11. What specific questions would you like answered in the future on ICD-10?
12. Where do you go for information? Check as many as apply.
a. My manager
b. My co-workers
c. Staff meetings
d. Email
e. The internet
f. Other __________
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Chapter 1

High-level Complexity and Awareness Assessment Tool


Assessing Complexity and Awareness

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.

How many of the core processes* are affected in each department?


Explain:
[ ] 1 or 2 core processes

Indicate which core processes

[ ] 3 or more core process

Indicate 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.

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ICD-10 Implementation Training

[ ] Little confidence

[ ] Low confidence

[ ] High confidence

[ ] N/A

[ ] Moderate confidence

How much training for employees or providers is required to support this


effort?
Explain:
[ ] No training

[ ] Minor training

[ ] Formal training

[ ] Extensive training

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Chapter

Communication
Objectives:





Discuss the communication plan


Define a communication plan.
Identify how to develop a communication plan
Execute the communication effort
Determine when and how to disseminate information
Discuss using communication templates

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:





Methods used to gather and store information


Limits, if any, on who may give direction and to whom
Reporting relationships
List of contact information of all key group members
Schedule for distribution of information
A method to update the communications management plan as the project progresses

Responsibilities of the communication lead include:


Ownership of the project status reporting
Set-up and management of the processes required for the communication aspect of this
project
Ownership of communication and responsibility for updating status reports, setting up
meeting schedule details, communication planning, and registering actions and meeting
notes
Ensures meeting invites are sent in advance to relevant stakeholders and acceptance of
attendees

Roles and Responsibilities

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

Title and Role

Mary Smythe

Coding managerDevelop monthly ICD-10 update newsletter

Mark Rodgers

Practice administratorConduct weekly department staff meetings


Figure 2.1 Roles and Responsibilities

The Communication Plan

A communication plan is a written document that describes the following elements:







Objectivewhat needs to be accomplished


Goal(s)what your end result needs to be
Flowwith whom communication is established
Toolswhat methods of communication will you use
Timetablewhen communications are necessary to meet the final goal
Evaluationhow will your results be measured

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

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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.

Developing Your Communication Plan


Evaluate Current Communication Methods
Determine what each department in your practice is currently doing to get the message to the
providers and staff. Evaluate the communication capacity, and the cost to the practice when evaluating future ICD-10 communication needs. Also evaluate the necessity of communication efforts to
outside vendors.

Define ObjectivesDetermine Anticipated Results


Make sure the objective includes ICD-10 code awareness, what necessary implementation steps
have been initiated, how progress milestones will be communicated, the business areas that might
need improvement and problems, barriers, and challenges in the implementation process.

Define the Audience


Determine who you might contact, attempt to influence or serve. This list may include:









ICD-10 steering committee or project team


Administrators
Board of directors
Accounting
Human resources
Nursing
Billing/coding
Providers
Health plans
Vendors

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Communication

Chapter 2

Define the Goals


With stated objectives, define your ICD-10 goals as a work program for each objective. Identify how
information will be gathered, and who is affected. Keep in mind one of the important elements of
successful implementation is to build awareness for ICD-10 at the beginning of the project.

Identify Effective Communication Tools


Decide what tools will be used to accomplish your ICD-10 goals. Be creative in identifying tools.
Dont overlook the obvious and the easiest. Keep tools simple and easy for the team to use and
comprehend. Some communication tools might include:







Project status reports


Email updates
Updates posted on the facilities intranet site
Staff or departmental meetings
Regular conference calls
Newsletters
Audio or videoconference updates
Webinars

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.

Establish the Timetable


Once the objectives, goals, audiences, and tools have been identified, quantify the results in a
communication template that outlines roughly what communication projects will be delivered and
when. Separate objectives into logical time periods such as monthly, weekly, etc. This will help you
stay on track and be organized.

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Figure 2.2 is an example of a communication schedule:

Communications Calendar
Tasks, Activities

Who is Responsible for Delivery

JAN

Develop monthly newsletter to update physicians


and staff on ICD-10 implementation issues

Mary Smythe

FEB

Conduct staff meetings with physicians and other


department managers regarding progress

Mark Rodgers

MAR

Send email updates to the CFO and CEO of organization identifying progress

Mark Rodgers

APR

Conduct a system-wide webcast regarding ICD-10 Julian Marriway


updates

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

Conduct a system-wide webcast regarding ICD-10 Julian Marriway


updates

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

Conduct a system-wide webcast regarding ICD-10 Julian Marriway


updates

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

Figure 2.2 Communication Schedule

Evaluate Results
Build into your ICD-10-CM implementation communication plan a method for measuring results.
Tools to evaluate can include:



A periodic report on work completed and work in progress


Formalized departmental reports for presentation at business area staff meetings
Periodic senior management briefings
Year-end summary reports

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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 budget Communicate


update ICD-10 costs and
implementation
progress

Email and report


briefing

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

Significance of a Communication Plan


Communication is the key to a smooth transition to ICD-10-CM. Developing a written communication plan will take effort but will make your implementation much smoother. Remember to
be creative and that the communication effort must continue for the duration of the ICD-10-CM
implementation project. Once in place, you will reap the benefits of the written plan as it will help
set priorities, gain the respect of senior management and the ICD-10 implementation team, protect
you from last minute information demands, and bring order to your chaotic job.

The Communication Effort

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.

Ask the Right Questions

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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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.

ICD-10 Communication Strategy Template

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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Communication

Resources
and
Templates

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Communication

Chapter 2

Roles and Responsibilities


Name

Title and Role

Figure 2.1 Roles and Responsibilities

Communication Calendar
Communications Calendar
Tasks, Activities

Events

JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
Figure 2.2 Communication Schedule

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Results Analysis
Stakeholder

Objective

Key Messages

Communication
Vehicles

Feedback
Mechanisms

Internal Stakeholders

External Stakeholders

Figure 2.3

Communication Plan Development Tool


Overview
[Provide an overview of the process you plan to employ to manage issues, what roles will be
involved, what the procedures will be, and how you will measure the impact of issues.]

Goals and Objectives of Communications Strategy


Goal: [The communications goal is a direction-setter and future-end related; toward which
planning and implementation activities are directed. A goal is generally not quantifiable,
time-dependent, or suggestive of specific actions for its achievement.]

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.]

Critical Success Factors


[Describe those items that must be achieved at the end of the communications program.
These factors will basically determine whether the communications program is a success.]

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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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.

Key Messages/Themes Worksheet


Audience

Phase

Objectives Key Messages Media

Content, Materials Frequency

Figure 2.4

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Communication

Chapter 2

Communication Plan No. 1


Audience

Communication Content
Method

Administration/
Board Members/
Providers

Presentation

ICD-10 awareness including:


Regulation overview

Dates Responsible
Party
Core ICD-10
strategy team

Business area impact;


Implementation process
and timeline budgetary
considerations

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

ICD-10 code set awareness


High-level understanding of
ICD-10-CM and ICD-10-PCS
Differences between ICD-9 and
ICD-10
Impact on organizational
operations (people, processes
and technology)
Budget implications
In-depth ICD-10 training
communication
Budget implications

Health Plans

Overview of contracts
Coverage determinations
Implementation delays

Vendors

Implementation issues
5010 readiness
Acceptance of code testing
Security
Figure 2.5

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Other

Vendors

Subcontractors

Employees

Project team
members

Physicians

Senior management

CEO/CFO

Key Stakeholders
(distribution
schedule)

ICD-10-CM
Issues

Key
Messages to
Communicate

Project Name: ICD-10-CM Implementation


Prepared by:
Date:
Communication Methods
to be Used
(written, one-on-one,
electronic, meetings, etc.)
Description of Specific
Communications
(content, format, level of
detail, etc.)

Communication Plan Template No. 2

Timing Issues
(project
schedule)

Other

Chapter 2
Communication

Figure 2.6

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Communication

Chapter 2

Communications Matrix for Project Team


The following table identifies the communications requirements for this project

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

Project Team Meetings

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

Discuss and develop


technical design
solutions for the
project.

Face-to
Face

Project
Technical
Staff

Technical
Lead

Monthly Project
Status Meetings

Report on the status


of the project to
management.

Face-to
Monthly
Face
Confer
ence Call

PMO

Project
Manager

Project Status
Reports

Report the status of Email


the project including
activities, progress,
costs, and issues.

Project
Sponsor
Project
Team
Stakeholders
PMO

Project
Project
Manager
Status
Report

ICD-10 Implementation Training

Once

As Needed

Monthly

Agenda
Meeting
Minutes

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Communications Management Plan


Internal Stakeholders

Stakeholder What Information?


Project
Sponsors/
Directors

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

Email

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

Email

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

As per project team


Daily
(above)
Cross communication
between project team
and volunteers

Email CC

Project Team
/Volunteers

Employees

Current work
assigned, time due

Task Outline

Functional Manager

Project
Manager

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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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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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Chapter

Information Technology
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

Electronic Data Interchange (EDI)/


5010 Accommodates ICD-10s Size

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

837-I, 837-P, 837-1 COB, 837-P COB, NCPDP

Remittance

835

Claim Status Inquiry/Response

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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Chaptere 3

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.

Interface, Tables, Programs, Extract, Report, and Changes


An initial task will be to identify all possible systems, tables, databases, reports, and algorithms
that currently have ICD-9-CM information or references. Dont forget to look for hard coding of
diagnoses and procedures in a myriad of places throughout systems, programs, and applications. A
complete assessment of systems, applications, interfaces, programs, and reports needs to be done to
ensure reporting continuity. With vastly expanded code sets, take into consideration character and
field length modifications and the new long code descriptions.
Those responsible for the review of existing programs, extracts, and reports for ICD-10 dependencies may want to think strategically and assess the existing programs, extracts, and reports not only
for diagnosis and procedure codes but assess the value of the programs, extracts, and reports to the
practice. Ask the following questions:





50

What is the purpose of the program, extract, or report?


Will it be affected by ICD-10-CM/PCS?
If so, what modifications will be required to produce the same or better information?
Who will be responsible for the changes and by when?
How much programming effort will be needed to make the required modifications?
Who will be responsible for testing?

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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.

ICD-10 Implementation in Healthcare Services


Code Change Log
Project Manager:

J. Taylor

Publish Date:

01/05/10

Project Scope Description:

Diabetes and Osteoarthritis Reports for Healthcare


Services

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.

Information Technology Issues

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

ICD-10-CM/PCS implementation information technology solutions will be faced with budgetary


limitations. Some solutions will not be fiscally realistic compared to other options that may be
available to the practice. Hardware and software changes may become required if existing hardware and software becomes obsolete with ICD-10-CM/PCS implementation. Consulting costs to

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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)

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.

How the GEMs Files Work


GEMs can be thought of being like two-way translation dictionaries where diagnoses and procedure
codes can be translated to and from ICD-9-CM and ICD-10-CM/PCS. The translations go in both
directions so that it is possible to look up a code to find out what it means according to the concept
and structure use by the other coding system. Neither of the GEMs are mirror images of each other
because the translation alternatives are based on the meaning of the code being looked up.
For ease of use, the diagnoses and procedure mapping use the same format and method. The
GEMs consist of two mappings for diagnosis; ICD-9-CM to ICD-10-CM (forward mapping) and
ICD-10-CM to ICD-9-CM (backward mapping). Similarly, the GEMs consist of two mappings
for procedures; ICD-9-CM to ICD-10-PCS (forward mapping) and ICD-10-PCS to ICD-9-CM
(backward mapping).

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Table one shows the four GEM files that are available for use by the physician and others.

Table One: 2 Code Sets x 2 Directions = 4 GEMs


Diagnosis Code Set

Procedure Code Set

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

Diagnosis Code Mapping


There are quite a few ICD-9-CM and ICD-10-CM codes whose translation between them is very
straightforward and easy to match one with another. These are referred to as one-to-one (1:1)
match. The one-to-one match does not necessarily mean the two codes are identical, it simply
means there is only one alternative.

ICD-9-CM Source

ICD-10-CM Target

783.21 Loss of weight

R63.4 Abnormal weight loss

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

784.2 Swelling in head and neck

ICD-10-CM Target
R22.0 Localized swelling, mass or lump head

R22.1 Localized swelling, mass or lump neck


Figure 3.3

ICD-10-CM Source

ICD-9-CM Target
995.92 Severe sepsis

R65.21 Severe sepsis with septic


shock

AND

785.52 Septic shock


Figure 3.4

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There are instances of 1:3 mappings and below are examples.


ICD-9-CM Source

ICD-10-CM Target
L56.0 Drug phototoxic response

692.72 Acute dermatitis due to solar


radiation

L56.1 Drug photoallergic response

L56.2 Photocontact dermatitis


Figure 3.5

ICD-10-CM Source

ICD-9-CM Target

E08.52 Diabetes mellitus due to


underlying condition with diabetic
peripheral angiopathy with gangrene

251.8 Other specified disorder of the


pancreatic internal secretion
443.89 Other specified peripheral vascular
disease

785.4 Gangrene
Figur 3.6

Procedure Code Mapping

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

51.23 Laparoscopic cholecystecomy

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

96.04 Insertion of endotracheal tube

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

There are instances of 1:2 mappings and below is an example.


ICD-9-CM Source

ICD-10-PCS Target
0VTT0ZZ Resection of prepuce, open
approach

64.0 Circumcision

0VTTXZZ Resection of prepuce, external


approach
Figure 3.9

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

Limitations of the GEMS

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

Creation of the Reimbursement Files


CMS used the GEMs as a starting point by selecting the best ICD-9-CM code that maps to each
ICD-10 code. Selection of a single ICD-9 code for both diagnosis and procedures made use of data
available to CMS. This included 11 million Medicare records and 4 million inpatient records available from the California Office of Statewide Health Planning and Development (for newborn and
obstetrical data). The data used to create the files may reflect more characteristics of what occurs in
the inpatient setting than outpatient data.
More than 95 percent of the ICD-10-CM diagnosis codes translated to a single ICD-9-CM code
in the diagnosis GEM. Similarly, the same pattern (95 percent) was found with ICD-10-PCS
procedures codes translated to a single ICD-9-CM code in the procedure GEM. When the GEM
offered more than one translation, the reference data was queried to find the most frequently
coded alternative.

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

Project Scope Description:

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Objectives




Understand ICD-10 impact based on results of the readiness survey


Understand how to conduct an impact analysis
Review key areas of impact
Understand how to use flow sheets
Review the development of the business plan

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 Impact Analysis

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.

Conducting the Impact Analysis


In the impact analysis phase, staff should work closely with all departments and vendors to fully
explore relevant factors, which could improve project results. It is important for the practice to begin to
identify and mitigate risks. In most cases, the impact analysis is a series of interviews using pre-developed survey tools. These survey tools will capture information on each business area in the practice.





Infrastructure (systems and how they interface)


Systems (core systems and key business area applications)
Processes (workflows)
Information management uses (data, extracts, reports, etc.)
Linkages to other business area(s) in the practice
Linkages to external entities

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Information Technology (IT)


When assessing information systems, a comprehensive audit of all data systems that currently
use ICD-9-CM must be assessed. Your information system analysis should answer the following
questions:
1. How are ICD-9-CM codes used in each information system?
2. Which vendor software applicationsversus internally developed system interfaces, customizations, and other affected software (like Charge Description Masters, practice management
software, financial software, etc.)are being used?
3. How are codes entered? Are they manually entered or imported from another system or
software?
4. What is the current character length specification in the system? Does the code format include
a decimal?
5. Can the system handle alpha-numeric structure?
6. Can the codes, code descriptions, and support documentation be obtained in a machine-readable format?
7. Can the current system house both ICD-9-CM and ICD-10-CM codes simultaneously?
8. Will the vendor or internal IT personnel be able to map forward from ICD-9-CM to
ICD-10-CM and backward from ICD-10-CM to ICD-9-CM if you need to keep historical data
in your practice?
9. How do the systems interface (if applicable)?
Once you have performed a comprehensive audit of the IT systems, map the electronic data flow to
inventory all practice reports that contain ICD-9-CM codes. After that, perform a detailed analysis
of necessary changes to be implemented for the transition to ICD-10-CM. You will need to contact
software and hardware vendors during the analysis phase to identify potential costs that will
impact your budget. Typical expenses will include the following:




Hardware
Software
Upgrading systems
Customization
Staffing and overtime

Software Changes
Software modifications will include the following:




64

Change to alphanumeric structure


Longer code descriptors
Field size expansion
Edit and logic changes
Table structure modification

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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:













The electronic medical record/electronic health record (EMR/EHR)


Billing systems
Clinical systems
Code look-up software
Encoding software
Computer-assisted coding applications
Medical record abstraction systems
Scheduling and registration systems
Accounting systems
Quality management and utilization systems
Clinical protocols
Test ordering systems
Script writing systems
Clinical reminder systems

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.

Meaningful EHR Adoption


Under the health IT provisions of the American Recovery and Reinvestment Act of 2009 (ARRA),
a medical practice wont receive stimulus money if it simply buys an EHR; the practice needs to
demonstrate it is using the EHR in a meaningful way. Except for a small loan program, the
federal government is not providing money upfront. The practice needs to purchase or lease a
system. In 2011, Medicare or Medicaid started reimbursing the medical practice for part of the cost
if it can demonstrate meaningful use of a qualified EHR.
The federal government is offering stimulus money to assist with EHR implementation. A provider
can receive up to $18,000 in 2011 (assuming that you can show meaningful use on a certified
EHR). The question remains; how many doctors will be eligible for the full $18,000 in stimulus
money and how many would only be eligible for $10k or $5k in stimulus money and how much
allowable Medicare charges are necessary to receive the full reimbursement.
Heres how the program works: Non-hospital-based physicians who participate in Medicare or
derive 30 percent or more of their business from Medicaid (20 percent for pediatricians) are eligible
to receive subsidies. The maximum amount for which you are eligible ranges from Medicare
payments of $44,000 to nearly $64,000 from Medicaid over a five-year period. A medical practice
may apply for either of these programs, but not both, and physicians practicing in underserved
areas are eligible for an extra 10 percent from Medicare.
Under the Medicare provisions, if the practice applies for the stimulus money in 2011 or 2012, you
can receive $18,000 in reimbursements that year, followed by annual payments of $12,000, $8,000,
$4,000, and $2,000. Those who apply in 2013 receive $15,000 in the initial year, followed by three
years of diminishing payments. The first-year payment in 2014 is $12,000, with lower incentives the
following two years. No incentives are available to anyone who applies after that, and no payouts
will occur after 2016.
Physicians who are not using qualified EHRs meaningfully by 2015 lose 1 percent of their Medicare reimbursement; in 2016, they forfeit 2 percent, and in 2017 and each year thereafter, 3 percent.
If less than 75 percent of physicians have met the EHR requirements by 2018, the Secretary of the
U.S. Department of Health and Human Services (HHS) is empowered to cut Medicare payments to
those who have not adopted EHRs by up to 5 percent.
Some have interpreted meaningful use as including the use of electronic prescribing, the
exchange of clinical information with other providers, and the reporting of quality data to the
Centers for Medicare & Medicaid Services (CMS).

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What Qualified Means


The Secretary also must define what constitutes a qualified EHR for practices to qualify for
subsidies. Under the HITECH Act, the Office of the National Coordinator for Health Information
Technology (ONC) is responsible for developing standards, implementation specifications, and
certification criteria for EHR technology. ONC has developed an interim final rule on those topics
and also is drafting a notice of proposed rulemaking on the process for recognizing organizations
to conduct the certification of health information technology (HIT). Under the HITECH Act, CMS
administers the EHR incentive programs under Medicare and Medicaid. CMS also prepared a
proposed rule on the EHR incentive programs for public comment. This proposed rule includes the
definition of meaningful use and other requirements for qualifying for incentive payments. CMS
worked closely with the ONC in developing the proposed rule.

Stages of Meaningful Use

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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For 2014 only

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.

Business Process Analysis

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

Process Flow Diagram


The entry and exit points of the process define the process boundaries.
Once the boundaries are defined, the process flow diagram (or process flowchart) is a valuable tool
for understanding the process using graphic elements to represent tasks, flows, etc.
In a process flow diagram, tasks are drawn one after the other in series is performed sequentially.
Tasks drawn in parallel are performed simultaneously.
When constructing a flow diagram, care should be taken to avoid pitfalls that might cause the
flow diagram not to represent reality. For example, if the diagram is constructed using information obtained from employees, the employees may be reluctant to disclose rework loops and other
potentially embarrassing aspects of the process. Similarly, if there are illogical aspects of the
process flow, employees may tend to portray it as it should be and not as it is. Even if they portray
the process, as they perceive it, their perception may differ from the actual process. They may leave
out important activities that they deem to be insignificant.
The flow diagram offers the following benefits:




Shows everyone how what they do impacts other departments


Enables quick fixes that work the first time
Focuses on interaction between departments, clinical, or business areas
Makes the impact of proposed changes visible to all involved parties
Generates ownership of the business processes

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Establishes a baseline of how things work today


Develops a snapshot of how things should work in the future
Business processes are the day-to-day drivers for practices. They are often a key connection between
the practice and the patient. They are a combination of business operating procedures, business rules,
and supporting computer systems. Yet, many business processes are often undocumented, misunderstood, not optimized, error-prone, and inefficient. This is true in many practices as many focus on the
day-to-day frustrations and not the overall picture. To improve your process for ICD-10-CM:
Choose the right business process to analyze focusing on ICD-10 implementation efforts.
Your practice likely has numerous processeslarge and smallvital to your practice
functioning as a cohesive unit.
Map the relevant process steps.
Follow the ICD-10 implementation process from its initiation through the successful
(or unsuccessful) completion with the target date being after October 1, 2015. Note how
long each step in the implementation takes, how many steps are required to successfully
implement and what documentation is necessary to complete each task. Pay particular
attention to bottlenecks in the process that slow the process and create frustration for
employees.
Identify the key personnel. Make note of those employees that play key roles in the
ICD-10 implementation process and record their specific functions. Evaluate their
strengths and weaknesses and note how they affect the overall implementation efforts.
Be prepared to eliminate or reassign personnel where they do not directly contribute to
the successful completion of the process.
Record the important implementation steps. Assess them for timeliness, efficiency, and
effectiveness. Identify redundant and unnecessary steps that can be eliminated or folded
into other steps.
Create a business process map that targets ICD-10 implementation. Diagram each step
and its relationship to the steps that precede and follow it. Make the map easy to follow
and communicate it throughout the practice. Include all steps, players, equipment and
materials that are intricately involved in the process.
Follow the map through the live business process and check how accurately it represents
both the process itself and each step along the way.
Revise the process both immediately after testing the process for accuracy and on an
on-going basis. Alter the process to accommodate changes in personnel, products, and
services, and changing healthcare conditions. Ensure that the process is dynamic and
can accommodate change without adversely affecting efficiencies, productivity, and
personnel for successful implementation of ICD-10. Review frequently for optimal
results.

Business Processes Impacted


It is recommended that the practice use a tool to assist with the analysis. Review an example of a
business process analysis worksheet (figure 4.2).
If you are using a worksheet, use this tool to determine the operational impact and to prioritize
each business process. Write down each of your primary business processes and rate each one as
its impact to the listed categories as if it were to cease functioning. Add each category. The process
with the highest impacts should be your critical functions.

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Practice Name: ABC


Medical Group

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

Violations of Issue resolution:


Policies/Laws Part of
/Regulations assessment
recommendation
Review medical
policy; change
internal policies
for compliance

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 Impact

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.

Compliance and Clinical Documentation


In the clinical area, documentation will have the largest impact on ICD-10-CM implementation
success. Since ICD-10-CM is more robust and has up to seven characters of specificity, you should
verify that your current documentation in the medical record can support ICD-10-CM on the
go-live date. Conducting an ICD-10-CM Documentation Readiness Audit can help the practice
assess risk and identify future training needs.
Your practice should utilize an experienced auditor(s) to conduct the audits either internally or
externally. Evaluate random samples and review various types of medical records during these

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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:









Outpatient office visits


Consultations
Medications and prescriptions
Immunization records
Laboratory tests and results
X-rays, imaging, and diagnostic studies
Surgical services and operative reports
Hospital records
Pathology services
Other ancillary services

Organization and maintenance of medical records is an important factor in providing quality


of care. A well-organized and well-maintained medical record provides a user-friendly source of
information for internal staff, physicians, auditors, and insurance carriers.
Many providers have staff who already conduct audits in their medical practice or have a consultant
who routinely audits for appropriate documentation and coding. This is a very important element
of compliance and many practitioners usually undergo this process from a comprehensive coding
perspective. For ICD-10 though, take a different approach: Review the patient chart note to make sure
the physician or non-physician practitioner is documenting a complete diagnosis and that the current
documentation is complete enough to accommodate the higher level of specificity in ICD-10.
Auditing in this manner is somewhat different than the typical medical record documentation and
coding audit. The auditor will assess the documentation and determine:
1) Does the documentation support the current diagnosis reported, and
2) Will the documentation support an ICD-10-CM code(s)?

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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.

Comparison between ICD-9-CM and ICD-10-CM


ICD-9-CM
931 Foreign body in ear

ICD-10-CM
T16.1XXA
T16.1XXD
T16.1XXS
T16.2XXA
T16.2XXD
T16.2XXS
T16.9XXA
T16.9XXD
T16.9XXS

Foreign body in right ear, initial encounter


Foreign body in right ear, subsequent encounter
Foreign body in right ear, sequela
Foreign body in left ear, initial encounter
Foreign body in left ear, subsequent encounter
Foreign body in left ear, sequela
Foreign body in ear, unspecified ear, initial encounter
Foreign body in ear, unspecified ear, subsequent
encounter
Foreign body in ear, unspecified ear, sequela
Figure 4.3

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.

Comparison between ICD-9-CM and ICD-10-CM


ICD-9-CM
850.9 Concussion
723.1 Cervicalgia
739.2 Somatic dysfunction cervical region

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

The encounter is coded as:


ICD-9-CM
ICD-10-CM
850.9 S06.0X0A
723.1 M54.2
739.2 M99.01
W20.8XXA
Note: More documentation is required in ICD-10-CM. In this instance the provider should be
trained regarding the specificity required to meet coding requirements such as if there was or was
not loss of consciousness and if so for how long, and that documentation must include stage of
encounter as well. An activity code would also need to be assigned to indicate what the patient was
doing at the time of the injury as well if one is available. We would also need to know where she was
when the injury occurred to report the place of occurrence.

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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.

Jonathan Friedland Diaper rash

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
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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

Date of Audit: 10/20/20xx

Reviewer (Auditor): Mary Ellen Ellis, CPC, CPC-H


Number of medical records reviewed month of October, 200x:

10

Number of medical records documented the appropriate ICD-9-CM code:

100%

Number of medical records support documentation for ICD-10-CM:

20%

Number of medical records lacking documentation specificity to support ICD-10-CM:

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.

Medical Contracts and Policies


Another large hurdle facing the clinical area is the impact of ICD-10-CM to health plan contracts
and medical policies. Health plans will most likely modify contracts when moving to ICD-10-CM.

Steps when analyzing this impact, include:

Identify contracts where reimbursement is tied to particular diagnoses


Contact payers and discuss potential changes to existing contracts

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Determine timing of contract negotiations


Modify agreements as needed
Communicate contract changes to appropriate staff
In general, current medical policy is based upon the ICD-9-CM code set and corresponding
nomenclature. Each and every medical policy will need to be reviewed and updated for the new
ICD-10 code sets and nomenclature. Many of the services and procedures performed in a medical
practice are tied to a health plan medical policy. Should contracts or policies change significantly to
include more specific diagnosis requirements, substantial adjustments might be necessary.
Because of the greater specificity of the new code set and the opportunity to report the severity of
a patients condition in more detail, it is anticipated most health plans will require a more detailed
level of specificity in reporting. Using an unspecified ICD-10 code will, in most cases, cause further
review by the carrier.
While procedure coding will not change for outpatient and professional services, it is still not clear
what impact the change in the diagnosis code sets will have on payment rates in relation to medical
review, auditing and coverage. Practices would need to do some projections to determine the scope
of this. It is time to begin a review of current medical policies in relation to the most common ICD9-CM codes used in the medical practice. The time spent on this will depend entirely on how many
insurance companies the organization contracts with, and what the changes in the contract may be.

Insurance Plan Contracts


Participation in health plans should be reviewed as with the medical policy changes the organization may end the association with a particular plan and may participate in other health plans not
yet contracted with. A complete and thorough review of individual health plan contract changes
should be undertaken as part of the analysis to determine what health plans the organization will
contract with after ICD-10-CM is implemented. Extra time will be necessary to review current
contracts, discuss changes with health plans, investigate new plans, and decide what with what
plans to contract.

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.

Laboratory and Radiology Procedures


Laboratories and radiology services rely on the ordering physician to provide a diagnosis code. The
biggest problem in the billing process for clinical laboratories is a missing or invalid diagnosis code
on orders from physicians. When this happens contact with the ordering provider occurs. When an
ordering provider submits a narrative diagnosis rather than a diagnosis code, the narrative diagnosis may be translated into the appropriate code by trained laboratory staff without direct contact
with the ordering practice. Given the expected change in coverage policies, and the increased
specificity and complexity of ICD-10-CM codes, it is expected that the rate of missing or invalid
diagnosis codes on test orders will increase significantly, while the level of expertise needed for
translation of narrative diagnoses will exceed the capabilities of current translators, who typically
have multiple responsibilities in addition to narrative diagnosis translation.
As claims are returned to the laboratory for an invalid diagnosis, they must be individually handled
with the ordering practitioner, which impacts productivity of the provider and/or staff. This will
have a significant impact on both the ordering providers and laboratories.

The Advance Beneficiary Notification


When billing Medicare services that may not be covered based on medical necessity or the condition treated, and Advanced Beneficiary Notification (ABN) is required to inform the patient that
the service or supply may not be covered. The patient (or, in some cases, a patients authorized
representative) must sign a waiver of liability (ie, advance beneficiary notice, or ABN) when a physician or healthcare provider has good reason to believe that Medicare certainly or probably will not
pay for certain services because they fail to meet the programs requirements relating to reasonable and necessary care. The most common scenario occurs when a diagnosis code is not listed
under a local coverage determination as an appropriate reason for a procedure, and the carrier
denies the service as not medically necessary. Waivers also are required for procedures or services
performed more frequently than listed in the Medicare exclusions from coverage guidelines. Two
procedures that fall into this category are screening mammograms and colorectal cancer screens
performed more frequently than allowed.
Prior to performing the service, the patient must be notified in writing that Medicare likely will
deny payment. The ABN must indicate the reason for probable denial. To be acceptable, an ABN
cannot state simply medically unnecessary or its equivalent as the expected reason for denial.
The ABN is intended to give a Medicare beneficiary a reasonable idea of why a Medicare denial is
expected so the beneficiary can make an informed decision about whether to receive the service
and pay for it personally. If the patient is not notified prior to the procedure and does not sign the
waiver, the patient cannot be held financially responsible for the service performed (see figure 4.7).
When analyzing the business process ask the following questions:
1. Who currently gets the ABN signed?

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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?

Excerpt from Form CMS-131

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)

(E) Reason Medicare May Not Pay:

(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.

Other Physicians and Providers


Another issue that will need to be addressed is how to get a diagnosis code from another provider
or referring physician when required by the insurance carrier. Any lack of information not supplied
by another practice or healthcare entity might result in claim delay or denial, which will require
additional staff time to resolve.

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.

Billing and Coding


Billing and coding will undergo a significant impact with ICD-10-CM implementation. Every
process in this area must undergo review. Who selects the codes? If the provider is determining the
diagnosis code selection, comprehensive education and training will be necessary. If the provider
is using a superbill and writing the diagnosis on the charge ticket, specific detail will need to be
documented on the superbill creating the need for extensive review of the process as to how the
organization communicates coding to the coding and/or billing staff.
Unless the practice uses an electronic health record, the most common basis for recording procedures, services, and diagnoses is realized using a superbill or charge ticket. Typically, a provider

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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.

Crosswalks and Mapping

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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Tracking and Trending

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.

Using a Business Plan to Finalize the Impact Analysis


A business plan is a formal document describing the business reason (beyond mandated compliance) for ICD-10-CM/PCS implementation. A well-written business plan provides a wealth of
information by explaining what systems or processes will be impacted and describing high-level
recommendations for the best possible solution.
A typical ICD-10 business plan describes the business problem, the possible solutions, the risks and
benefits of each course of action, and the solution recommended for compliance assurance. The
scope of this document is proportional to the size and risk of the project. Larger, riskier, and more
expensive projects typically warrant a more formal and quantitative assessment of the business
rationale.

Why is a Business Plan Useful?


The business plan helps communicate the objectives of the project, and provides necessary information to create business requirements. Establishing the business plan helps pinpoint the specific
obstacles and costs of a proposed solution (necessary information for administration as the implementation of ICD-10-CM proceeds). By describing the risks, the business plan also allows decision
makers to determine their risk tolerance level, and establishes a realistic expectation of the risk
associated with the approved project.
Contingency planning should be part of the business plan. By including information on all reasonable alternatives, the business plan serves as a valuable document in the implementation effort for
the practice. If a contingency plan is needed, administration can review the relative merits of all
available options, instead of making decisions in a vacuum. The results should dismiss any contingency alternatives that do not demonstrate value.

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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.

How to Use a Business Plan


Begin developing the business plan in the discovery phase. Each business area in the
practice should complete a business plan. The specific business area project teams will
take on the task of completing the business area specific business plan.
Share the initial draft of the business plan with the strategic steering committee and
solicit feedback. Incorporate the strategic steering committees feedback into the document to complete the business case.
The strategic steering committee should share a summary of the completed business
plan with the administrative staff.
Once the business plan is reviewed, use the business cases to establish the success
criteria for the project. The business area project teams will have a clear understanding
of the key factors involved in ICD-10-CM/PCS implementation.
Review the business plan throughout the project to verify the initial justification is still
valid, and to verify the project will deliver the solution needed. If a review reveals issues
jeopardizing the implementation effort, address these immediately.
A change concept is a general notion or approach to change that has been found to be useful in
developing specific ideas for changes that lead to improvement. Creatively combining these change
concepts with knowledge about specific subjects can help generate ideas for tests of change. After
generating ideas, run a Plan-Do-Study-Act (PDSA) cycle to test a change or group of changes
on a small scale to see if they result in improvement. If they do, expand the tests and gradually
incorporate larger and larger samples until you are confident that the changes should be adopted
more widely.

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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:

Strategic Steering Committee Member 1


[Name]

[Email]

Signature

[Telephone]
Date

Strategic Steering Committee Member 2


[Name]

[Email]

Signature

[Telephone]
Date

Business Area Project Team Member 1


[Name]

[Email]

Signature

[Telephone]
Date

Business Area Project Team Member 2


[Name]
Signature

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[Telephone]
Date

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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.

Governance and Business Plan Analysis Team

2.1 Governance

Describe the ICD-10 governance processes and structures within the practice or business area.

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2.2

Business Plan Analysis Team Members

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.

Identify and briefly describe each employees relation to the project.

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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3.3

Current Technology Environment

3.3.1

Current Software

Describe the business areas existing software that will be modified or replaced with ICD-10
implementation.

Software Items

Description

3.3.2 Current Hardware

Describe the business areas existing hardware that will be modified or replaced with ICD-10
implementation.

Hardware Items

Description

3.3.3 Current Applications

Describe the business areas existing applications that will be modified or replaced with
ICD-10 implementation.

Applications

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3.3.4 Current Vendors

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

Goals and Objectives

Describe the business goals and objectives of this project. Ensure the goals and objectives
support business needs.

Business Goal/Objective

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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

Proposed Technology Environment

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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The Impact Analysis

Application Analysis

Describe the application changes that will have to occur with ICD-10 implementation.

Applications

4.8

Description

Major Project Milestones

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

Total Project Costs


(to implement ICD-10)

Equipment/Hardware
Application/ Software
Labor Costs (new staff and OT)
Consulting Costs
Vendor Costs
Training Costs

Other Costs

TOTAL

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Objectives



Understand the importance of working with vendors


Develop a preliminary needs assessment
Review health plan contracts
Develop policy changes

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.

The Impact of Vendors

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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Expansion of flat files containing diagnosis codes


Both coding systems ICD-9-CM and ICD-10-CM will need to be supported for a
period of time which will add to user expense with more storage required
Systems interfaces
Review the typical flow of patient information in figure 5.1. Patients are registered for services by
ancillary staff and demographic and insurance information is gathered. All information is keyed
into a database that houses all the information for patient services. Charges are entered into the
system as services are performed and codes are captured and entered or validated into the system.
The services are priced typically via a fee schedule that is updated and maintained in the system.
Claims are processed either electronically, or a CMS-1500 is generated for each patient. Once the
information is sent to the insurance carrier, the claim is paid, suspended for further information, or
denied for payment. The patient financial services department will either post applicable payments
to each line of service or the billing department will review the claim and resolve any conflicting
information so the claim can be resubmitted to the insurance carrier. All of these functions are tied
into the database, which stores all the information on each patient in the practice.

Figure 5.1

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Developing a Preliminary Needs Assessment

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:







Upgrade hardware to accommodate additional space requirements


Upgrade practice management software
Upgrade financial software (if tied to coding)
Upgrade electronic medical record (if applicable)
Conversion to 5010
Electronic transactions
Statistical reporting
Internal reports such as the accounts receivable report

Types of software and functions that might be impacted by ICD-10-CM include:












Decision support systems


Billing systems (code length will require changes to electronic/paper formats)
Systems containing medical necessity edits
Systems that support the correct coding initiative (bundling edits)
Clinical systems for documentation such as the electronic health record or electronic
medical record that includes clinical guidelines, protocols etc. (support diagnosis coding)
Managed care systems that allow HEDIS reporting
Other quality reporting measures such as Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Pharmacy or lab systems depending on diagnoses
Mapping from ICD-9-CM to ICD-10-CM
Electronic data interface (EDI)
Clinical and financial reports

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.

Discussing Key ICD-10 Implementation Issues with Vendors


Most medical practices rely more heavily on vendors than large hospital systems do. Vendors
provide hardware and software for the practice management system, EMR, and other software
programs used. A practice must begin work early with the vendors to determine:








What implementation plans vendors have in place for the conversion


What software changes are needed
What products and services will be available
What changes are required to accommodate all applications within the organization
that uses coding data
How long software development will take
How do we increase system storage capacity to support both ICD-9-CM and
ICD-10-CM simultaneously
When vendors will be ready to begin testing and implementing their products and
services in the practice
When vendors will schedule installation
What guidance and assistance vendors will provide during the rollout

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:



Who will pay for systems upgrades?


Are the upgrades included in an annual maintenance contract?
Will hardware upgrades be needed to ensure optimal system performance?
If costs will be incurred by the practice, what are those projected costs and when will
they be incurred?
Will the vendor provide training on the new software?
When will the software be available for internal and testing in the facility?

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 to Practice

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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Internal Testing End to End

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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Budgeting
Objectives



Understand how to assess project costs


Develop and draft project budgets
Review the estimated implementation costs
Understand how to develop a budget for ICD-10-CM implementation

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:



Hardware and software


Implementation and deployment
Potential transition to an electronic medical record (EMR)
Version 5010 electronic data interchange (EDI) implementation

2. Auditing and monitoring documentation related to ICD-10 implementation


3. Education and training
4. Staffing and overtime costs
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ICD-10-CM Project Costs

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.

Estimate Project Costs


Budget development begins with cost estimation. The cost estimation process involves developing
an approximation of the resource and task costs necessary to complete a project. Some project costs
are not defined monetarily but can be translated into a dollar figure. For instance, an IT developer
effort costs in hours, not dollars. To translate the hours into dollars, multiply the time involved by a
price per hour. This will provide a cost estimate for the developer effort and for the project cost (see
Figure 6.1).
Cost is critically important to account for expenditures. Document and account for high-priced
implementation items. For example, consider equipment, hardware, software, and any other item or
service necessary to ensure meeting the compliance date. You also may need to account for items or
services that are part of contingency planning. With the items or services, the project team should
capture information about dates and responsibilities to ensure the equipment or services are available on schedule.
Refine cost as more information is gathered and made available to project staff. Cost estimate accuracy will increase as project implementation progresses.
After ICD-10-CM implementation effort costs are determined, identify the risks and assign a
percentage reflecting how much each risk factor may affect implementation. Risk management
allows for better management of events occurring beyond the control of the project team. Assign a
risk value to each of the practices business areas to cover reasonable costs such as hiring an occasional contractor, overtime, etc. and to ensure adherence to the timeline.

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.

Planning the ICD-10-CM Budget

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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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.

Vendor and Information Systems Costs


When preparing the ICD-10-CM budget, immediately contact practice management software
vendors to obtain the estimated cost. Practices using an EMR should contact vendors to find out
what update costs will be. Consider many things when budgeting for ICD-10 to foresee any cash
flow issues that may influence your practice moving forward. In the budget include other costs that
will affect your IT systems, such as code-look up programs or encoders.
If the vendor does not include implementation and deployment of the code sets in the upgrade,
additional costs may be incurred. Get the information from the vendor when developing the
budget. Not only will the vendor need to upgrade the software and test for consistency, but it will
need to test the software end-to-end internally with practice and external vendors such as clearinghouses and health plans.
Hardware might be an issue for the practice. Will the current hardware support both ICD-9-CM
and ICD-10-CM codes sets simultaneously? Make sure there is enough space to accommodate
ICD-10-CM. Because ICD-10-CM is much larger than ICD-9-CM, hardware upgrades might
be necessary and should be included in the budget. There may be limitations with the current
data warehouse or business intelligence solution. Check for necessary hardware changes. In the
budget, consider consulting costs to perform necessary tasks and the internal downtime the
changes might create.
Holding preliminary meetings with vendors is beneficial in development of a realistic budget. In
addition to vendor costs, also consider overtime and staffing if the practice utilizes IT staff and if
the software has been customized for the organization. Many practices customize vendor software
internally to meet specific needs in the organization. The budget needs to reflect changes the IT
staff will need to make.

Documentation Review Costs


Also consider documentation deficiencies and the cost to review your practices documentation. Every ICD-10-CM implementation budget should include ongoing auditing and monitoring costs to ensure the documentation in the medical record supports the diagnosis code
transition. For example, in a practice of 20 physicians, the cost averages approximately $6,000
$8,000 for one audit with a probability that more than one audit will take place in the two-year
implementation period.
This step in implementation should be conducted quarterly for the first year, and every six months
during the year of implementation. If that is too costly for the practice, an audit twice a year should
be beneficial. If ongoing physician education and training is required to ensure the medical records
compliance with diagnosis documentation, costs could escalate higher.

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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.

Education and Training Costs


Before the training plan development can begin, the budget must reflect the training costs.
The practice must first identify who needs training, how many hours of training will be required,
and the most beneficial training method. Questions to ask when determining training needs are:
Who requires training? First and foremost, the physicians, nurse practitioners (NPs),
physician assistants (PAs), etc. need to be trained. Nurses and medical assistants (MAs)
also sometimes use diagnosis codes, and then, the coders, billers, managers, front office,
and ancillary staff.
How much training on ICD-10-CM will be necessary?
How many training days will be required?
Will there be lost revenue if the physicians and non-physician practitioners (NPPs) need
to be out of the office for training?
How will productivity be affected?
How much training does each department need?
What extent does each staff person need?
Physicians, NPPs, coders, and billing staff will need more extensive training than ancillary staff,
(eg, nurses, MAs, managers, etc.).
Training will be a large expenditure and should be analyzed carefully. Everyone in the medical
practice will need training:



Providers will need approximately 816 hours of training.


Nurses will need an introduction to ICD-10-CM with 610 hours of training.
Coders will need 4060 hours of training, depending on specialty.
Ancillary staff will need 610 hours of training.

Training depends on each individuals understanding of anatomy, terminology, and ICD-9-CM.


A person who is experienced in ICD-9-CM coding and has a good understanding of anatomy and
terminology in their specialty may take less time to train than the person with limited knowledge.
You may want to include the cost of medical terminology and anatomy training for the non-clinician as ICD-10-CM is more complex in meaning and coders or other ancillary staff might benefit
from training as those who need more extensive knowledge.

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Staffing and Overtime Costs


Overtime will be another issue to consider. Physicians and managers are most likely compensated based on revenue or salary, so overtime will not be a consideration for this group. Coders
and ancillary staff, on the other hand, typically are paid hourly rates. The recommended overtime
budget is at a minimum 1520 hours pre-implementation and 2040 hours post implementation.
After implementation, work will increase due to system problems, denials, etc. Address these issues
along with the daily business that occurs in a typical medical practice.
Consider the time staff will be out of the office to train. When budgeting, consider staff issues and
allow for temporary staff prior to implementation and to assist with claims issues post-implementation. Post implementation workflow processes such as claim denials and delays could impact
staffing and workflow within the organization and may incur additional overtime or temporary
staffing needs.

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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4. Costs associated with running dual systems:


a. Are multiple servers necessary?
b. What is the staff time required to maintain both systems?
5. Delays in payers payments:
a. What kinds of delays may occur? Ask payers.
b. How long will they allow dual reporting?
c. Will timely filing deadlines apply to implementation dates?
When creating the budget, estimate high as there will always be unexpected costs occurring with
implementation. (See Figures 6.16.4).
Budget planning will take research and discussion with all vendors. In this early implementation
stage, the budget is a projection or estimate of potential costs. It can be as simple as creating a
spreadsheet with items and services necessary for implementation.
Once you have a good handle on the estimated costs, the committee should develop a timeline for
ICD-10-CM implementation.
Implementation Advice: Create the budget for the two-year transition and break it down per year,
so expenditures can be spread over a two-year period.

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Cost Estimate 2012-2015 ICD-10-CM Implementation


The cost estimate is a two-year period estimated cost for ICD-10-CM implementation for a five,
25, 50, and 100 physician practice. The estimate will help you develop a budget over the two-year
period. Figure 6.1 is a cost estimate for a five physician group.

ICD-10-CM Implementation Cost Estimate


Two YearFive Physician Practice
Information Systems
Practice Management System Upgrade
EMR Upgrade (if applicable)
IT and Consulting
Totals
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
$5,000
$5,000
$5,000
$15,000
Estimated Time

30 hours
15 hours

Education and Training


Physicians 5
Coder/Biller 1
Management 1
Nurses/MA 2
Ancillary 2
Totals

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

Staffing and Overtime


Coders
Ancillary Staff
Productivity Loss
Totals

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

Figure 6.1 (cost estimate five physician group practice)

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ICD-10-CM Implementation Cost Estimate


Two Year25 Physician Practice
Information Systems
Practice Management System Upgrade
EMR Upgrade
Coding Software
IT and Consulting
Totals

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

Education and Training


Physicians 25

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

Staffing and Overtime


Coders
Ancillary Staff
Productivity Loss
Totals

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

Figure 6.2 (cost estimate 25 physician group practice)

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ICD-10-CM Implementation Cost Estimate


Two Year50 Physician Practice
Information Systems
Practice Management System Upgrade
EMR Upgrade
Coding Software
IT and Consulting
Totals

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

Education and Training


Physicians 50
Coders/Billers 8
Management 2
Nurses/MA 25
Ancillary 7

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

Staffing and Overtime


Coders
Ancillary Staff
Productivity Loss
Totals

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

Figure 6.3 (cost estimate 50 physician group practice)

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ICD-10-CM Implementation Cost Estimate


Two Year100 Physician Practice
Information Systems
Practice Management System Upgrade
EMR Upgrade
Coding Software
IT and Consulting
Totals

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

Education and Training


Physicians 100
Coders/Billers 16
Management 4
Nurses/MA 50
Ancillary 15

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

Staffing and Overtime


Coders
Ancillary Staff
Productivity Loss
Totals

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

Figure 6.4 (cost estimate 100 physician group practice)

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ICD-10 Steering Committee

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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Resources
and
Templates

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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

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ICD-10-CM Implementation Physician Practice Budget


Information Systems

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

Practice Management System Upgrade


EMR Upgrade
Coding Software
IT and Consulting
Totals
Auditing/Review/Crosswalking
General Consulting/Audit @
500 Per Provider 2 x Year
General Consulting/Training
Review of System Process
Crosswalking and Mapping
Totals
Education and Training
Physicians
Coders
Management
Nurses
Ancillary
Totals
Staffing and Overtime
Coders
Ancillary Staff
Productivity Loss
Totals
Totals
Information Systems
Consulting/Auditing/Crosswalking
Training
Staffing/Overtime
Total Budgeted Expenses

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Chapter

Education and Training


Objectives

Gain understanding of the education and training components by putting definition


around:
ICD-10 Education Steering Committee
ICD-10 Education Strategy
ICD-10 Education Plan
Understand the importance of an education and training plan
Identify resources for education
Review available training mechanisms
Understand importance of coordinating training into phases
Develop a training schedule
Develop tools for on-going support
Develop a communication mechanism for training
Suggest instructional design approaches for ICD-10 training
Provide an education strategy template and instruction on how to use the tool
Discuss the different types of learners
Determine what types of trainings are best
Review the types of trainings available

Introduction

Education is a critical success factor in successful implementation of ICD-10-CM. A comprehensive


ICD-10-CM/PCS education and training program is necessary to meet the needs of the practice in
its effort to implement the new code set. This chapter will assist your practice in putting into place
the educational and training tools that will be helpful in understanding the new codes sets and the
implementation effort.
ICD-10-CM education and training planning efforts can be accomplished through establishing the
following in a larger practice or facility:
Education Steering Committee
Education Strategy
Education Plan

The ICD-10 Education Steering Committee

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.

The ICD-10 Education Strategy

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 Plan

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:



Assessment of education and training needs


Development of programs that are effective in meeting those needs
Implementation strategies that match programs with those that need them
Evaluation of the education programs to ensure stated learning outcomes are achieved

Keeping the mission in mind, the education plan should be a written document with the following
elements addressed:





Objectivewhat will be accomplished


Goal(s)the methods in which those objectives can be accomplished
Audience-to whom will the education be addressed
Toolswhat methods of education will be used
Timetablewhen will the education be delivered
Evaluationhow results are measured

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)

ICD-10-CM Training Development Map

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.

Identify Training Source


How will you accomplish the training if you decide to undertake a classroom model or seminar?
Will you conduct the training internally? Is there someone in your practice that is ICD-10-CM
coding savvy? If you do not have the time to prepare and deliver training consider external sources.
Contract with an instructor, consultant, or other organization that can deliver the training over a
specified period of time. Seminars are good adjunctive training options, but based on the ICD-10
implementation challenges Australia had and the recommendations that coders and providers need
a minimum of seventy (70) hours of training, it would be impossible to learn everything you need
to know about coding with ICD-10-CM in one day.

Develop a Training Budget


As discussed, it will be important to develop your training budget once you determine the
method(s) of learning that will be required for ICD-10-CM. Make sure you budget for training
managers, clinical staff, non-physician providers, managers, front office staff, ancillary staff, and
physicians. Keep in mind everyone will need training on some level.

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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Find something to watch if they are bored


Like to see what they are learning
Benefit from illustrations and presentations that use color
Are attracted to written or spoken language rich in imagery
Prefer stimuli to be isolated from auditory and kinesthetic distraction
Find passive surroundings ideal

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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Need to be active and take frequent breaks


Speak with their hands and with gestures
Remember what was done, but have difficulty recalling what was said or seen
Find reasons to tinker or move when bored
Enjoy field trips and tasks that involve manipulating materials
Sit near the door or someplace else where they can easily get up and move around
Feel uncomfortable in classrooms where they lack opportunities for hands-on
experience
Communicate by touching and appreciate physically expressed encouragement, such as
a pat on the back
Youll also see the kinesthetic types following along as you demonstratemoving their arms and
legs in imitation of what youre doing. Moving is so fundamental to kinesthetic learners that they
often just fidget if nothing else. It helps them concentrate better.

Four Education Objectives


Remember that ICD-10 education should target four strategic education objectives:
Build diagnosis and procedure coding awareness across the organization
Maximize educational opportunities
Engage the organizations staff and sustain their interest in ICD-10-CM coding and its
significance in the implementation effort
Promote collaboration with others (internally and externally) to continue to enhance
knowledge of ICD-10-CM and code change implication to the implementation project
Take another look at the training media available; and, after doing an assessment of your employees
needs, determine which ones are best suited.

Conclusion

It is recommended that learning ICD-10 should be accomplished in phases. For example, it is


important to learn the general guidelines in ICD-10-CM as it was in ICD-9-CM. The guidelines are
a roadmap to successful and accurate diagnosis coding. This could be accomplished in a two-day
seminar, distance learning mechanism, or a webinar. Once the user understands the general
guidelines, specialty specific code set training should be employed. Not every specialty will need
to learn all sections of codes during initial ICD-10 training. Once the training has been completed
it is important to continue to work with the ICD-10 code set. One way to accomplish this prior to
implementation is to select an ICD-9-CM code and simultaneously select an ICD-10-CM code. This
will help build skill and also identify any weaknesses in the providers documentation.

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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 is a critical success factor in successful implementation of ICD-10-CM/


PCS. A clear education strategy that is recognized and supported by the practice that
identifies all key elements of ICD-10 education is the prerequisite to empowering staff
to participate in this key endeavor. An effective education strategy will build confidence in the organizations ability to make informed decisions and recommendations
for the rollout of this new code set and meet the October 1, 2015 compliance date.

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.

ICD-10 education will target four strategic education objectives:


Build diagnosis and procedure coding awareness across the practice
Maximize educational opportunities
Engage staff and sustain their interest in ICD-10 coding and its significance in the
implementation effort
Collaborate with others (internally and externally) to continue to enhance knowledge of ICD-10-CM/PCS and coding change implication to the implementation
project

2.

Target Audience Group

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.

Objectives and Target Audience

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

Target Audience Group 1: Executive Staff Leadership

Objective 1: Familiarity with the final regulation


Objective 2: Understanding the impact of the change to
ICD-10
Objective 3: Update on status of implementation

Target Audience Group 2:

Objective 1: Familiarity with the final regulation

Physician and non-physician


practitioners

Objective 2: Understanding ICD-10-CM

Target Audience Group 3:

Objective 1: Familiarity with the final regulation

Coders

Objective 2: Understanding of ICD-10-CM

Objective 3: Maintenance of code set skills

Objective 3: Maintenance of code set skills


Target Audience Group 4:

Objective 1: Familiarity with the final regulation

Management, administration, and Objective 2: General understanding of ICD-10-CM


finance
Objective 3: Update on status of implementation
Objective 4: Application of ICD-10-CM within the
Organization
Target Audience Group 5:

Objective 1: Familiarity with the final regulation

Clinical Staff

Objective 2: General understanding of ICD-10-CM


Objective 3: Maintenance of code set skills

132

Target Audience Group 6:

Objective 1: Familiarity with the final regulation

Ancillary Staff

Objective 2: General understanding of ICD-10-CM

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Target Audience Group 7:

Objective 1: Familiarity with the final regulation

IT

Objective 2: Understanding of ICD-10-CM


Objective 3: A
 pplication of ICD-10 to systems and
applications
Figure 7.2

External Stakeholders (if applicable or desired)


Audience Group

Objectives

Target Audience Group 1:


Vendors

Objective 1: Maintenance of code sets and software

3.

Instructional Design

3.1.

Instructional Design

Instructional design is the practice of maximizing the effectiveness, efficiency and


appeal of instruction. It is the method used to channel the delivery of the lesson (eg,
audio conferences, e-learning, instructor based etc.). The vehicle varies depending audience, urgency in providing education and the frequency of the delivery.

Instructional Design

Description

Frequency

Instructional design 1: One Way

Description of instructional
design 1: Staff in-service, informative meeting, executive
summary

Frequency of
deliverymonthly

Instructional design 2: Hands on

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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ICD-10 Training Delivery Template for ABC Medical Group


Purpose: Identify key audiences, content and method of ICD-10 training with each audience,
timing and acquisition of the training

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

Update on status of One way


implementation

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

January 2014 Maintenance of


code set skills
Coders

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

January 2014 Maintenance of


code set skills

134

Instructional Delivery
Buy or
Design
Mechanism Build

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Audience

Education and Training

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

January 2014 Application of


Interactive
ICD-10-CM within
the organization
Familiarity with
One way
the final regulation

ClinicalNon-provider

February
2010

Audience

January 2014 General


Date(s)
Content
Understanding
of
ICD-10-CM

Ancillary Staff

February
2010

Instructional meeting
Delivery
Buy or
Design
Mechanism Build

Familiarity with
One way
the final regulation

January 2014 General


Understanding of
ICD-10-CM
IT Staff

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

January 2014 Application of


ICD-10 in systems
and applications
Figure 7.3

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Chapter

Assessments
Objectives



Understand a GAP analysis


Utilize tools to accomplish the analysis
Provide a mechanism to measure ICD-10-CM productivity and compliance
Re-evaluate medical record documentation to ensure ICD-10-CM coding can be
achieved after implementation
Determine when to perform an outcomes measurement
Perform internal testing of the coding, billing, physicians, and other staff in ICD-10-CM
proficiency
Understand what additional education and training might be beneficial if deficiencies
are identified

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:



Understanding and compliance with HIPAA and impact of ICD-10


Understanding the current level of documentation and coding capability
Developing an inventory and evaluation of all information systemsthe as-is state
Classifying information systems as legacy, proprietary, commercial vendor-supported,
and outsourced
Developing the to-be state
Evaluating system remediation, replacement, and outsourcing options
Determining information system vendor understanding of ICD-10 and the plan and
timeline for ICD-10 compliance
Gap Analysis is the first step to compliance. The deliverable from the Gap Analysis is the implementation plan and road map. It is a method by which the road map is developed from As Is to
To Be. Determining the direction the practice needs to take requires a starting pointwhere the
practice is now, and an ending pointwhat the practice will look like when processes are changed.

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A business process as reviewed earlier is a collection of related, structured activities, or chain of


business functions, activities, and tasks that produce each specific service or product that a medical
practicewhether large or smallmust perform. Each service consists of one or more business
processes working independently and in tandem to execute that service. Each business process
consists of inputs, method, and outputs. The inputs are required before the method can be put into
practice to achieve the outcome. When the method is applied to the inputs then certain outputs will
be created. The collective output of the combined business processes required is the service itself.
For most, the first step is to prepare a detailed assessment of what needs to be done. A gap analysis
identifies the practices strengths, weaknesses, and opportunities to make improvements.
For this reason the perspective of the Gap Analysis identifies the changes that are required at each
point along the route. By viewing the business model from the perspective of Gap Analysis, these
relationships are identified and applied objectively to the processes of the new model.
Gap Analysis creates a map of the required changes that can be used to identify the required
changes in process, organization and resources to move the business to the next phase ensuring
smooth transition to ICD-10-CM/PCS. Review figure 8.1 and 8.2.

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Key Questions
STRENGTHS

What do we do exceptionally well?


What advantages do we have?
What valuable assets and resources do we have?
What do others identify as our strengths?

WEAKNESSES

What could we do better?


What are we criticized for or receive complaints about?
Where are we vulnerable?

Goals/Opportunities

What opportunities do we know about, but have not addressed?


Are there emerging trends on which we can capitalize?
What opportunities do we have to improve processes

Obstacles

Are weaknesses likely to make us critically vulnerable?


What external roadblocks exist that block our progress?
Is there significant change coming for our organization?
Are economic conditions affecting our financial viability?
With the implementation to ICD-10-CM affect the organization
financially?

Figure 8.1

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Gap Analysis
Strengths, Weaknesses, Goals/Opportunities and Obstacles Analysis
Strengths

ABC Medical Group

Compliance

All coders and physicians receive training based on


compliance in the organization and are up to date on
coding issues.

Continuous auditing and monitoring Based on compliance current documentation compliance


is at 95 percent based on ICD-9-CM codes.
IT on staff to customize systems

IT staff is working with vendors on converting to 5010


and ICD-10-CM testing.

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

Documentation appears to be an issue whereas when


reviewing documentation based on the ICD-10-CM code
set only 5 percent could be coded.

IT Systems

Need to replace existing hardware to accommodate ICD10-CM.

Staffing

Currently short-staffed; will need to budget for 2


additional coders/billers to assist with pre- and post
implementation for at least 2 years; may need to hire
consultant.

Finance

Funding of training and new IT systems and software


upgrades.

What needs improvement?

Documentation, improve and expand education and


training for providers and coders.

Goals/Opportunities

140

Improve Documentation

Will begin quarterly auditing and monitoring using


ICD-10-CM codes and review provider documentation
to ensure compliance.

Replace current hardware with


updated system

IT will begin researching system needs and work with


software vendor to ensure an appropriate timeline for
delivery.

Finance

Will expand budget to include addition of system hardware which was not previously budget for.

Education and Training

Will schedule all staff for education on ICD-10 code sets.


Will work with project team and key stakeholders to
ensure readiness.

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Obstacles
Medical Policies

Finding time and resources to review all carrier medical


policies for ICD-10.

Finance

Finding the additional funds to pay for training and new


system upgrades including software.

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.

Negative economic conditions

Economy has slowed considerably and a 20 percent


reduction in revenue has been realized the past six
months.

Government regulation

Unknown as to what new regulations will be enacted and


with healthcare reform, not certain how this will affect
medical practice.
Figure 8.2

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.

The Importance of Performing an Outcome Measurement

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
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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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Coding Productivity Policy 4248-103


(A) The ABC Medical Group Coding Department follows the Official Coding Guidelines and Definitions, as well as any insurance carrier regulatory requirements for the selection and sequencing of
codes, In addition, the coding is based on physician documentation in the medical record. The standard level of quality is expected on all patient types at all times.
(B) Purpose of Policy
In order to maintain the coding workflow at acceptable and adequate levels, each member of the
coding team is expected to meet the established patient type hourly medical record productivity standard on a monthly basis. The standards represent the projected time frames in which specific tasks
are to be accomplished. Productivity standards have been developed using data collection through
employee reporting, management observation and computer generated data. Productivity is generally
perceived as the quantity of work performed.
The Coding Quality Review Plan is designed to measure the accuracy and consistent assignment of
ICD-10-CM, CPT codes and HCPCS coding on all coding cases (outpatient). Quality is generally
perceived as the degree or grade of excellence of work performed.
(C) Procedure
Employee performance, both quantitatively and qualitatively, will be monitored monthly or on a
more frequent basis when deemed appropriate by the supervisor. The coding staff; which consists
of outpatient coders, is expected to meet a monthly minimum of 95 percent coding accuracy on
inpatient and outpatient coding. Outpatient coding consists of all coding performed for an outpatient
encounter (inpatient and outpatient surgery, physician services, ancillary, and hospital coding).
Productivity figures will be calculated by dividing the output by the amount of time taken to complete
the Task. Coding staff will be responsible to report their weekly productivity totals (amount of records
coded and the amount of coding time) on a spreadsheet saved on the F drive. Based on these evaluations, employee performance will be assigned one of the following ratings:
E = Exceeding Standards
M = Meeting Standards
U = Unacceptable; falling below standards
The coding team will be expected to meet the following established productivity standards:




Outpatient coding includes patient types: surgery (8/per hour)


Outpatient testing: (xx/per hour)
E/M services: (xx/per hour)
Ancillary services: (xx/per hour)
Hospital admissions and daily visits (xx/per hour)

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

ABC Medical Group

Compliance
Continuous auditing and monitoring
IT on staff to customize systems
Health plan contracts reviewed yearly

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Strengths, Weaknesses, Goals/Opportunities and Obstacles Analysis


Weaknesses
Documentation
IT Systems
Staffing
Finance
What needs improvement?

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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Objectives

Understanding the testing and deployments of codes


Learn how to maintain compliance after October 1, 2015
Review how to measure productivity

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.

Testing and Deployment of Code

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.

Clearinghouses and Billing Services


If the practice uses a clearinghouse or billing company to submit and process claims, considerations include business versus technical services that could be offered and testing versus production
services. Practices will need to make their internal business decisions before determining what
services they would look for from their software vendors and clearinghouse. All may have a role in
supporting end-to-end testing.

Internal Customization After Deployment of Code


If your practice customizes software obtained by a vendor, the IT staff will need to have ample time
to make customization and test the changes at least one to two months prior to implementation.

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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.

Medical Record Documentation Re-assessment


Another area of concern will be the increase of reviewing/auditing charges for compliance in order
to comply with the more extensive documentation that ICD-10-CM requires. Reviewing the documentation post implementation might involve retraining if compliance has not been achieved prior
to implementation. It is a good idea to continue to monitor not only procedures and services on an
ongoing basis but continue to pay special attention to documentation in relation to ICD-10-CM
coding as well.

Medical Policy Review


The practice must review health plan medical policies and contracts on a regular basis as changes
are likely during the transition. These changes will reach well beyond the October 1, 2015 deadline.

Monitoring Training and Productivity Outcomes


It is important post implementation to monitor coding productivity to ensure productivity
increases over time. It may take approximately a year to see productivity to return to the pre-implementation status. Making sure the providers, coders, and other staff have the appropriate training
and periodic refreshers on the new code set will ensure that claims are submitted correctly, and
that documentation supports medical necessity for the services reported.

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.

Several overall risks can be identified as follows:

1. Payment disruptionThis is a real risk; payment must be continued no matter what.


2. Provider ability to submit electronically may be dependent on their business partner readiness.
a. Dropping to paperAny small increase in percent of paper claims could have serious
implications to payers and could result in processing and payment delays.
3. If the practice is not ready to Go-live it could place a severe financial burden on the practice
overall.
4. Documentation does not contain the specificity to code with ICD-10-CM.
5. Lack of ICD-10-CM training in the organization.
No one doubts that implementing ICD-10 will be an arduous and laborious process. Well-prepared
practices are those who recognize the obstacles and begin their preparation early.
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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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