The transition to ICD-10: Where to begin?

If you are a healthcare provider—physician, administrator, or some other leader at a healthcare site—then you know that you face many challenges.  Some seem overwhelming and you may be thinking that you may not be able to handle some of them well.  Perhaps the transition to ICD-10 coding is your main concern right now.

The solution to difficult challenges begins with the first step.  I am taking the liberty of adapting the legendary quotation of Lao Tzu to our present situation—“The journey of a thousand miles begins with one step.”

What, then, is the first step that I would take?  Before I answer that, let me illustrate with a common household problem.  I want to hang a new painting that I have purchased; I want it in my office.  What tool should I use?  A hammer?  A screwdriver?  The answer to this is whether I am going to use a nail or screw to hang the painting from.  The answer to which of these I am going to use depends upon the placement in the office.  If the painting is going to hang where there is a stud in the wall behind the picture, then I will surely use a nail with a hammer.  If the painting is going to hang in a place where there is only wallboard, then I will use an anchor screw with a screwdriver.

Taking the illustration as a starting point, I will start finding a solution to the challenge at my work site by defining the problem—what is the wall like where I will be hanging the picture—and then proceed to getting the right tool—collect baseline data.  Finding a solution to a problem or at least starting on the path to overcome the challenge requires that one first have a very good understanding of the problem.  If you do not have a good understating and are not able to state the problem explicitly, then much of the effort in solving the problem will result in wasted effort.

For example, suppose that you want to set up a patient portal for patients to electronically communicate with you?  You spend time and effort creating such a portal through a practice management system.  Once it is up and running you find that very few patients are using it.  Why?  Perhaps most of your patients do not use email or have access to a computer.  Perhaps you have failed to inform your patients about this new means of communication.  Whatever the reason may be, you have failed to understand the problem fully.  You did not know which was best to use to hang the painting, the screw or the nail.

Let’s examine some examples of this strategy with some current challenges of healthcare providers or other businesses.  I mentioned transition to ICD-10 above, so let’s start there.

The transition to ICD-10 is complex but must be done well if a provider expects to be reimbursed when its use takes effect in October.  There are many things to do to get ready for this transition.  Among them are seeing if your billing and coding department staff have the necessary training and understanding to use ICD-10, seeing if your clearinghouse is ICD-10 ready and if your clinicians provide enough detail on patient visit documentation to support the coding.  A leader at the site should have a team meeting of representatives from affected departments and staff (a representative from most departments other than physical plant will probably need to have a representative) and create of list of tasks that need to be done, such as those listed above, before October.  Then, some data should be collected about the current state of affairs.  For instance, you may want to review a random sample of physician patient visit documentation from each physician and check with a coder who is very familiar with ICD-10 to see if enough information is provided; you could use an outside agency to check the documentation if you feel you need to.

The ICD-10 example covers challenges that come from outside your site.  There are challenges that come from inside your site too.  For instance, any group that uses Lean or Lean Six Sigma are familiar with eliminating waste to save time and monies. How can one find projects to apply Lean to at your site?  I suggest that a few leaders at a site be identified who can receive suggestions from staff for projects to consider as well as submit their own.  These projects can be then prioritized and teams selected to begin the work of leaning the process.

For instance, the patient-centered medical home at its highest level of implementation will use a patient coordinator to make sure that a patient receives all necessary services from outside providers and that the information generated at other sites flows back to the primary care giver.  The patient coordinator may want to examine the processes used to collect data from outside sources and make sure it is fed back to her in a timely manner.  Once the project is clearly identified and the team decides what data to collect, it can begin its work to redesign the process to improve it and eliminate waste.

There are many other sources of problems or challenges for healthcare providers.  For instance, your group may need to have a better understanding of population level outcomes and services so as to meet the requirements of payer contracts, such as with an accountable care organization.  Your group may want to become more patient-centered or improve the bottom line.  If you look carefully there will always be room for significant improvement at your care site.

No matter what the source of the challenges or projects, the beginning of any effort to address them is to begin with the first step—define your problem as completely as possible and then collect some baseline data so that you can tell later on if your solutions have led to improvements.

Donald Tex Bryant is a consultant who helps healthcare providers meet their challenges. He can be reached at Bryant’s Healthcare Solutions.

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  • Guest

    God help us.

  • Guest

    I think I’d rather abolish this whole nonsensical ICD system and take back the medical decision making process from the pencil pushers. Thanks, consultant with no medical background for your input.

    • Bob

      We can’t, as this is how the World keeps health care statistics, you know the ones we always sore poor in. Of course we alone use it for billing unlike the rest of the socialized medicine World, which has nothing to do with medical decisions, unless the coders “game” the system by “up-coding”.
      How, with 10 times more codes in ICD-11, this makes “up-coding”, the most common cause of fraud and abuse, less rather than more likely who could tell. It could be fraud or simple mistakes in coding of physicians verbal descriptions of treatment.
      Yes we now are Globally socialized but the only ones using ICD’s for billing causing costs to be twice those of the others while our insured population will soon rise with tens of millions more entitlement recipients.

  • Noni

    If I was an independent in primary care this right here would make me switch to cash only. There’s barely a word or two about actual patient care in this article, which is not surprising as it’s written by a consultant who likely has no real medical experience and certainly isn’t on the front lines. But that’s who makes policy and that’s how we’ve found ourselves in this situation in healthcare.

    Actually, as a patient I might start seeking out concierge care now. I don’t know that I’d want a physician who has to prioritize this crap over actual medicine.

    • azmd

      Ditto, I am aghast at the level of complexity that ICD-10 is introducing into the process of diagnosing a patient. Doctors who take this crap seriously will find themselves with no time to think critically about treatment decisions for patients, they will be far too busy trying to figure out which of five minutely different ICD-10 codes should be used in the diagnosis box.

      As a physician this doesn’t affect me (I use DSM-V coding in my work). As a patient I am alarmed.

      • Noni

        Spoke to a cardiologist at a social function recently. He’s in independent solo practice, and he is terrified of the changes coming with ICD10. He keeps his overhead low but still struggles as reimbursements have been consistently dropping and bureaucracy is going to increase substantially. He advised me “Keep you expenses low. Over the next 5 years you will be in the red if you continue spending the way you do now because your income is seriously going to tank.” I guess that’s what happened when HMOs came on the scene with capitation.

        Scary stuff

        • buzzkillerjsmith

          Or he could go to work for CorpMed and be miserable in that particular way.

          • Noni

            I think he’s doing everything he can to avoid that scenario.

      • buzzkillerjsmith

        Are you a shrink? I had no idea. Damn good comments for a psychiatrist. :)

        • azmd

          Gee…thanks! I think. :-)

          • Bob

            You won’t have to think long as ICD-11′s are only a couple of years away and add mental and more computer standards to the mix. So if you think jumping from 16,000 codes to 160,000 in ICD-10 is hard you’ll get your turn too!

  • buzzkillerjsmith

    Solution to the challenge. We hear that word challenge a lot in HC, mostly from people who intend to challenge us with clinically meaningless soul-crushing administrative and business juggernauts . To wit: EHRs and meaninful use, ACOs, the PCMH, the ICD-10 debacle, CorpMed buying up practices and enserfing us.

    Nothing will change unless or until there is such a primary care doc shortage that the NYT and LA Times and WA Post are screaming from the rafters about it. Nothing will happen unless or until great numbers of the upper middle class find it impossible to find a PCP. Nothing will happen until HC inflation continues to gallop, finally making society call uncle. And even if these things come to pass, perhaps not much will be done. Patch jobs, half- measures.

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