Version 5010 and ICD-10 Update

By Anita Johnson Archer, Doug Nixdorf and Robyn O’Connell

Hayes is gearing up to help organizations convert to version 5010 and the ICD-10 code sets. As we talk to people, the main concerns we hear are:

• Will vendors be ready?
• How do we staff this and keep on top of day-to-day operations?
• How am I going to minimize reimbursement delays?

Although we are currently receiving requests for impact assessments, many organizations are not taking any action at this time. We often hear people joking that “the feds will delay the deadlines anyway.”  This may be true, but there is so much preparation work to do, it will make life a lot easier to start some of it now. The mere process of taking an inventory of affected systems and processes is a huge task.

Impact on provider operations

It’s clear that version 5010 and ICD-10 changes will have an enterprise-wide effect on provider practice and hospital operations. From front-end to back-end, the following list summarizes the areas and specific activities that will be affected by the changes:

• Appointments/Scheduling:  Transaction format changes - Diagnosis Codes / Reason for Visit/ DX Present on Admission
• Referrals and Authorizations: Diagnosis Codes/Claim requirements/ Utilization Review/Compliance
• Pending Orders: Clinical systems’ use of diagnosis and procedure codes
• Eligibility: Confirmation of coverage transaction files
• Services Rendered: EMR - clinical systems’ use of diagnosis and procedure codes
• Medical Information Systems:  Abstracting system - diagnosis and procedure codes / Present upon Admission
• Claims:  Transaction files- Professional and Institutional, electronic billing vendor
• Payment Processing: Remittance
• Follow up: Claim status and remittance
• Interfaces: Transactions sent between integrated systems
• Data Mapping: Integrated systems, concurrent/cross mapping coding ICD-9 and ICD-10 based on payer.
• Internal HMOs:  Multiple transaction files (Eligibility/Enrollment/Claims/Remits)

What you should do in 2010

We think that now is the time to set up the project infrastructure by planning and executing the following activities:

Understand the final rules and implementation timelines.  Look at the final rules for ICD-10-CM and ICD-10-PCS and the electronic transaction standards (Version 5010). Learn the benefits and value of ICD-10 and fits within the overall electronic health record (EHR) and data quality initiatives.

Establish a steering committee. The committee should be interdisciplinary and include senior staff, a health information systems manager, compliance and coding professionals, financial management staff, medical staff and information services staff. This committee will develop the organization’s 5010 and ICD-10 implementation strategy and will identify the actions, people responsible, and deadlines for required tasks.  The committee should discuss strategies and tactical plans for specific provider types, such as small physician practices, or for healthcare vendors, health plans, etc.  It should engage stakeholders and motivate key players, leveraging ICD-10 as an opportunity to take a fresh look at operations and timelines to accomplish the organizational strategy. A compliance professional will be in an excellent position to serve as a subject matter expert with regard to the regulations. A project manager should be assigned exclusively to help manage the entire process.

Create awareness. This is a crucial task.  One of the main ingredients for a successful transition is clear, concise and regular communication.  Educate key members of your organization on the ICD-10 final rule, basic structure, organization, and key unique features of v5010, ICD-10-CM and ICD-10-PCS.

Assess readiness for 5010 transaction standards.  The transition to 5010 is a dependency of ICD-10-CM/PCS. January 1, 2012 is the deadline for all organizations that exchange coding and billing information to update electronic data transaction standards (Version 5010). Assess organizational readiness for this milestone, including the readiness of affected staff, information systems (affected systems, applications, and databases), documentation process and workflow, data availability and use, and organizational capacity (including budget). Also, determine whether there are other key projects that will occur during this timeframe.  Address challenges related to system development, testing, communication and collaborative efforts between trading partners.

Perform an inventory of all processes and systems that will be affected by ICD-10.   The impact of ICD-10 will be seen in systems that contain ICD-9-CM codes.  Those include clinical ordering systems, DRG groupers, encoding software, abstracting systems, and compliance software.  The impact to billing systems will need to be considered, such as the size of the data fields.  The current payment system will need to be converted to ICD-10 codes.

Start tactical planning.  List out the operational aspects of the transition to v5010 and ICD-10-CM/PCS including, for example, internal governance structure, project management techniques and tools, reports on dual coding projects or demonstration projects, collaboration with key trading partners, accommodating dual code sets and compliance based on date of service.

Employ change management strategies.  Minimize the “fear of change” factor. As with any major change, communication is the key.  Coding professionals and staff who have worked with ICD-9-CM for years, even decades, may need support during this transition.

Plan training. Conduct a detailed assessment of ICD-10 educational needs for your coding professionals, physicians, and others within the organization that currently use ICD-9 codes, such as billing, accounting, data quality and data security.  Identify training needs, priorities, and staffing. The final rule recommends 50 hours of training for hospital inpatient coding professionals and 8 to 16 hours for other coding professionals.  Coding professionals in the hospital inpatient setting will require education on ICD-10-CM and ICD-10-PCS, while all others will only require training on ICD-10-CM.

Conduct a gap analysis of coding knowledge. Measure your coding professionals’ baseline knowledge of anatomy, physiology, pharmacology and medical terminology.  Doing so now will shorten the learning curve, improve coding accuracy and productivity, and accelerate the realization of benefits.

Conduct a gap analysis of documentation practices. Optimal documentation is a requirement for successful application of ICD-10-CM/PCS. Learn the language of the ICD-10-CM/PCS systems, and determine how to use existing ICD-9-CM guidance with ICD-10-CM/PCS. Use this lead time to work on documentation improvement strategies as necessary.

Perform data trending and identify mapping challenges. Conduct data analysis with data spanning  ICD-9-CM and ICD-10-CM/PCS, longitudinal data use and trending plans for data warehouses during or after implementation, quality reporting in both code sets, and other issues related to secondary uses or use of the general equivalence maps (GEMS).  Identify technical limitations and opportunities of the GEMs, application of the reimbursement crosswalks, mapping tools and techniques, appropriate use of maps and their limitations.

Develop a budget.  Identify the specific departmental budgets that will be responsible for the cost of system changes, hardware and software upgrades and education.

Prepare for impact on reimbursement.  Access and anticipate the impact of ICD-10-CM/PCS on prospective payment systems and payer coverage policies.  Determine tools, strategies and tactics to employ to achieve a revenue-neutral transition.

Perform a documentation audit.  It is essential to perform a documentation audit to compare current code assignments to future code assignments.

Engage vendors. Identify vendor systems and contracts early. If vendors are going to charge more for this regulatory update, or if there are any additional fees, organizations need to know sooner rather than later. In addition, if vendors are still saying that they do not have a plan in place, or seem to be stalling, a vendor change may be necessary.

Go-live Dates

For more information

We have found AHIMA  and AAPC to be the best resources for ICD-10 information. WEDI is the best resource for version 5010 information, but you must be a member. The CMS has information about both.  If you need planning and hands-on help with these initiatives, read about Hayes’ version 5010 and ICD-10 transition services, email us at info@hayesmanagement.com or call us at 617-559-0404.

	Anita Johnson Archer, CPC is Hayes’ Director of Business Services West. She is also a certified professional coder, an AHIMA-approved ICD-10-CM/PCS Trainer, and specializes in revenue cycle improvement. Anita is leading the v5010/ICD-10 services initiative for Hayes.
	Doug Nixdorf is one of Hayes’ EDI experts and a point person for information and assistance with version 5010. A former business systems manager, he is familiar with all aspects of claims production.
	Robyn O’Connell has more than twenty years of healthcare IT experience, including implementation and user support for EDI. She is one of our resident experts on version 5010 and ICD-10.