While working with hospitals throughout the country on improving physician documentation, a topic that consistently comes up is dual coding – coding in both ICD-9-CM and ICD-10-CM/PCS for the same record, using each code set and all of the associated coding conventions and guidelines.

Many healthcare providers are looking for ways to reduce the risks associated with the conversion to ICD-10 and prepare their organization for the impact to their systems, revenue cycle process, staffing and productivity.

Under the new ICD-10 system, there are approximately 141,000 codes, compared to the 17,000 codes being used in the existing ICD-9 structure. This is a 729 percent increase in the number of codes that may be used by coders. The number of diagnoses codes alone increases by more than five times under the new system, going from approximately 13,000 codes under ICD-9 to approximately 68,000 diagnoses codes in ICD-10.

The structure of the codes alone is going to require major changes to information systems at almost every level within the organization. Under the ICD-9 system, diagnosis codes were three to five digits, while under the new system, the codes vary from three to seven digits. And to make matters worse, there is no easy way to convert the existing ICD-9 codes to ICD-10 because there is no one-to-one relationship. For many of these codes, it is a one-to-many or many-to-many relationship.

Making the Transition

Converting from ICD-9 to ICD-10 is a massive undertaking for healthcare providers because it requires significant changes to existing data infrastructures, electronic medical records, chargemasters, and many other systems throughout the organization. Additionally, this conversion is going to reduce productivity and slow down the revenue cycle process with the potential to delay the transfer of health information between providers.

In an attempt to reduce the risk and impact of these changes when the October 1, 2015, ICD-10 transition date takes effect, many organizations have begun to implement processes for dual-coding. Dual-coding requires coders to review patient records and code them under both the current ICD-9 system, as well as under the proposed ICD-10 system. However, in order to begin the process of dual-coding the changes to the existing data infrastructures, financial systems, clearinghouses and other systems within the organization must already be complete and ready for testing.

Early adopters of dual-coding are facing the challenges of productivity and revenue cycle declines as they move to this environment; however, they are taking on these challenges prior to the official launch of ICD-10 so they may be ahead of the game when the program is fully launched. The costs associated with data infrastructures changes, revenue cycle slowdowns, physician education, claims testing and other improvements that will, ultimately, impact productivity are being incurred earlier by those facilities currently engaged in dual-coding.

A study conducted by the American Health Information Management Association (AHIMA) estimated that the time required to code an inpatient case under the new ICD-10 structure will increase by approximately 69 percent. Under the ICD-9 guideline, the average time to code an inpatient record was just over 25 minutes. The projections under the new ICD-10 system reflect an increase of almost 18 minutes to just over 43 minutes to code an inpatient case. This will have a significant impact to the productivity of healthcare providers.

Most healthcare providers have two options for implementing dual coding into their processes. They can either implement the process concurrently or retrospectively. Either of these options will help to reduce the risks associated with the transition to ICD-10. Experienced coders have been attending education sessions, national conferences and other training venues to obtain as much knowledge as possible to prepare for the transition.

However, the process of implementing dual-coding into the organization and using the cases, documentation and systems that they are already familiar with allows coders to improve their knowledge in their current environment. Additionally, as coders use the existing documentation to code patient records under the new ICD-10 system, this will allow the provider to identify potential gaps in their current processes, physician documentation, data infrastructures, staffing, productivity, budgets and training plans.

Physician Queries

In addition to the dual-coding discussion I have with hospital clients, I often talk about the physician query process and ask them if they have begun querying physicians under the new ICD-10 guidelines. Surprisingly, I have found that very few of them have started this process.

Industry experts at the annual AHIMA meeting in September 2014 estimated that CDI programs that are currently querying 25 percent to 30 percent of the records that they review could see increases to almost 100 percent of the records they are reviewing. This has the potential to significantly impact CDI programs across the country.

CDI specialists and coders are still creating physician queries (concurrent and retrospective) under the existing ICD-9 system. Therefore, organizations that are currently using paper or electronic queries that have been developed for the ICD-9 system will need to change these forms to reflect the new requirements under the new ICD-10 system. Educating physicians on how to appropriately document conditions under these two distinctly different systems will be a challenge for most providers. Physicians and providers appear to be willing to document what is necessary; however, with the ever-changing requirements, it is often frustrating for them to know which requirements are current. Therefore, educating your physicians around the new guidelines for documenting for ICD-10 will need to be a priority for hospitals and other providers.  

There are many issues that the transition to ICD-10 is going to create across the entire healthcare system. The key is how healthcare providers and employees prepare themselves. While the conversion has been on the horizon for a considerable amount of time, the constant delays have resulted in many facilities delaying the inevitable. However, make no mistake that this conversion will have significant impact throughout the healthcare industry.

Are you prepared?

About the Author

Ginny Balla is the Documentation Services, Client Services Manager at Executive Health Resources (Newtown Square, PA). She is a Health Information Management professional with more than 25 years of experience in clinical documentation improvement, hospital analytics, consulting, project management, billing and coding, core measures, quality improvement and prescription benefit management.

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