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Wait at Your Own Risk

December 1, 2009
by Daphne Lawrence
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Relying on a vendor to manage ICD-10 conversion can mean being held accountable for lost revenue.

Wes rishel

Wes Rishel


ICD-10 coding, a CMS requirement by Oct. 1, 2013, will allow for far greater detail in classifying diseases by increasing the 17,000 codes in ICD-9 to 155,000. That increased granularity means hospitals will have greater ability to use discrete data for a variety of quality measures. But for CIOs, the transition to ICD-10 can mean much more - namely, a big headache.

“You are going to have a crisis around ICD-10,” says Wes Rishel, vice president at Gartner, a consulting firm based in Stamford, Conn. “The only variable is how well you handle it.”

Handling it, he says, means if CIOs don't already have an ICD-10 strategy in place right now, they need to make it a top priority, because the potential for losing reimbursement is high. Unfortunately, the 2013 switchover date has lulled many CIOs into pushing an ICD-10 strategy to the back burner - or worse, to wait for their vendors or payers to initiate a strategy. But playing the waiting game, experts say, is not a wise move, especially as CIOs will be held accountable by CFOs for any lost revenue.

That lost revenue, says Rishel, comes from the potential for accounts receivable (AR) days to double. As ICD-10 approaches, he adds, smart hospitals will be monitoring AR on a day-by-day manner instead of month-by-month, and keeping close track of rejections.

In order to avoid those rejections, hospitals typically implement a rule on how to edit claims before they go out. But according to Rishel, if hospitals are not set up with the ICD-10 diagnostic codes, there may be a delay. “They not only have to have the systems, but also the staff in place to jump on top of rejections and suspensions,” he says. “It's important to look at the processes that happen after you cut the bill and before you get paid, get set up both staff-wise and system-wise, and write the proper rules.”

Jim Daley, co-chair of the Workshop for Electronic Data Interchange (WEDI), agrees. “IT can get a jump by accommodating the size and format of the codes. But what are the rules you are going to follow?” Anywhere a diagnosis or procedure code is used, there will be an impact, he says. “The vendors will make the tools that allow your rule to be entered, but you have to make the rules.”

True, the vendor won't provide the rules, but waiting for them to provide a plan is risky. One CIO who is looking at the vendor situation with his eyes wide open is Bill Spooner of San Diego, Calif.-based Sharp Healthcare. “A lot of people are waiting for their vendor, and if you've only got one vendor, you're a lucky person,” he says. “At this point, we've identified all of our IT applications that utilize coding data, and there are many.” Spooner says for Sharp, an eight-hospital system, that can mean anywhere from 25 to 50 applications.

The applications come from a variety of sources - the hospital's billing system, its abstracting system, and data in its EMR. Codes also show up in quality measurement systems and admission, discharge transfer systems. Multi-hospital systems may have a different financial system in each hospital, too, so the number of systems a CIO has to consider can be high, as in Spooner's case. But Rishel says the problem is not just adapting each of those systems to ICD-10 - it's being ready and able to change the mapping once hospitals learn how their payers are dealing with ICD-10. “It's the agility issue,” he says.

Spooner agrees that staying agile at the time of changeover is going to be key. “The real kicker is going to be that not everybody is going to be ready at the same time,” he says. “We're going to have to figure out how to put the pieces together.”

Another problem is that the hospital can't perform testing until the software vendor makes its own upgrades and rolls them out. “The whole timeframe needs to be sequenced out,” says Daley. “And there is a risk that if you get in late in the game, you may not be at the front of the line to get the upgrades to the applications.” Daley recommends bird-dogging the vendors to know when they'll have something ready that accommodates ICD-10 - and when CIOs can bring it into their shop.

Spooner doesn't think the wait will be short. “I expect if I wait for them to come to me, all of my hair will be gray,” he says.

“The real kicker is going to be that not everybody is going to be ready at the same time.”

Many say that keeping an eye on new vendor products will be important, too. Rishel says he expects 3M and Ingenix to offer new products to assist coders.

One IT product that will be in demand, most agree, is intelligent crosswalks that can map from ICD-9 to ICD-10. Spooner expects crosswalks to be part of his strategy.

If there's a magic bullet in the ICD-10 conversion, many say it will be the use of SNOMED (systemized nomenclature of medicine). SNOMED was designed to allow a consistent way to index, store, retrieve, and aggregate clinical data across specialties and sites of care. It also helps organize medical record content, and reduces the variability in data capture, encoding and use. It's more specific than ICD-10, according to the Wikipedia definition.


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