February 2014

Warning: Productivity Loss Ahead
By Lisa A. Eramo
For The Record
Vol. 26 No. 2 P. 10

Upon ICD-10’s arrival, coder output is bound to take a hit. What can health care organizations do to limit the damage?

By all indications, the coding universe is about to change. After years of dwelling in the relative comforts of ICD-9, coders are set to experience life in the double digits of disease classifications.

Productivity is bound to take a hit after ICD-10 is implemented, but exactly how much will it decrease and for how long? Is there anything hospitals can do now to mitigate these losses?

Prepare for a Slowdown
Though some estimates are lower, many industry experts have suggested that hospitals could experience a 50% to 70% drop in coder productivity—at least initially—following the implementation of ICD-10-CM/PCS. “PCS is where coders will really struggle if they don’t practice before October 1,” says Andrea Clark, RHIA, CCS, CPC-H, chairman, CEO, and founder of Health Revenue Assurance Associates (HRAA).

HRAA subject matter experts, who have been working with ICD-10-CM/PCS codes for roughly one year, say the 50% drop doesn’t seem all that far-fetched. Most recently, they’ve been coding 1.5 inpatient charts per hour, three same-day surgery charts per hour (including CM and PCS), and five emergency department charts per hour (including CM and PCS). “These standards are a lot lower than those in ICD-9,” Clark notes.

In terms of productivity, PCS will be the troublemaker, says Deborah Neville, director of revenue cycle, coding, and compliance at Elsevier. “Not only are the codes themselves different, but because they have to be built, there must be an interpretation of the documentation,” she says, adding that this more in-depth review of documentation and the requirement in some cases to assign multiple PCS codes for one procedure are what will ultimately slow down coders.

Bonnie S. Cassidy, senior director of HIM innovation at Nuance Communications, says coder productivity was a hot topic at last year’s AHIMA convention in Atlanta. Most members with whom she spoke cited a rate of one inpatient chart per hour. “If a coder goes from coding 25 [inpatient] charts a day to eight, you can do the math,” she says.

Many experts cite Canada’s transition to ICD-10-CA, which resulted in a 50% productivity loss, as a barometer for what the United States can expect. However, it’s important to note that Canada doesn’t use ICD-10-PCS, nor does the country use coding directly for reimbursement purposes.

“Our ICD-10 is a bit more complex because we use it for reimbursement. So for us, it should be at least 50%,” says Ira Shapiro, chairman and CEO of The CODESMART Group, noting that neither Canada nor Australia ever returned to pre–ICD-10 productivity levels. “I’m a big believer that history repeats itself.”

How Much of a Slowdown?
The industry isn’t quite sure what to expect come this October when ICD-10 takes affect. “There are many reports that provide information on productivity, but most are not considered authoritative or statistically valid,” Neville says.

How far productivity slips depends on several factors, including the following:

• the skill level of current coders and clinical documentation improvement (CDI) staff;

• a hospital’s specific case mix index and patient complexity; and

• the amount of time allotted for coder education and practice.

Neville says current inefficiencies also will affect productivity. “Anything that is affecting operations today will absolutely not go away under ICD-10,” she says. “I think too many people are thinking they can fix things under ICD-10.”

Marge Klasa, DC, APN Bc, medical director at Context4 Healthcare, says providers should consider the following questions when attempting to address potential productivity losses:

• What current documentation needs improvement?

• Why are denials occurring? Can denials be identified by code or provider?

• What measures can be adopted to address denials? Can coders be educated? Can software adjustments be made?

Klasa says many hospitals don’t have a denial management strategy in place to be well positioned for ICD-10-CM/PCS. Denial management—or the lack thereof—could greatly curtail coder productivity, she adds.

The hope is that as coders perform dual coding and practice with ICD-10-CM/PCS, many of these inefficiencies will surface if they haven’t done so already. Unlike industry studies and reports, hospital-specific dual coding also provides “real-time information that hospitals can work with,” Neville says.

Ultimately, the best way to gauge ICD-10’s impact on coder productivity is to have staff code natively in ICD-10-CM/PCS and track how long it takes them. Neville recommends hospitals follow these four crucial steps: educate, code natively in ICD-10-CM/PCS, assess productivity, and repeat. If hospitals follow this pattern from now until October, she says they’ll have a fairly accurate sense of what coder productivity will be on day one of implementation. In the meantime, they can take steps to prepare for any anticipated productivity drop.

One big unknown is how the Affordable Care Act will affect productivity. “You’ve got 40 million new patients coming into the system,” Shapiro says. “Everyone’s volume is going to increase. I don’t think people are thinking about this.”

Cassidy agrees: “The theory is that you’re going to have more outpatients and ambulatory patients. The question I’m starting to ask is if we’re going to accountable care, population health management, and value-based purchasing, then will we need to code ICD-10 for [outpatient] procedures so we have a much richer database?” Any additional coding naturally would fall on an inpatient or outpatient coder’s plate, complicating an already slippery slope of declining productivity that must be taken into consideration, she adds.

How to Mitigate Productivity Losses
To alleviate or eliminate expected productivity losses, experts suggest coding departments adopt several strategies, including the following:

• Practice, practice, practice. There’s no doubt that practice is one of the most effective ways to ensure that coders will be ready for ICD-10-CM/PCS. However, incorporating practice time into a coder’s daily routine is no easy task. “Coders still have to work the unbilled list and do the work of today to drop bills,” Clark says. “It’s a very delicate balance that’s based on each hospital—when they started training and how much the coders can bear.”

Practice duration and timing must be based on individual coder assessments. “If you have staff members who need a lot more hours of education … you have to allocate not only enough time for that education but also a lot more practice time,” Neville says.

Focus practice time on specific diagnoses or procedures (eg, high-volume or high-risk diagnosis-related groups) that are important to the facility or that align with larger facility initiatives, such as reducing readmissions and hospital-acquired conditions. “You cannot possibly in the next eight months allow enough time to practice every kind of solitary situation,” Neville says. “Through analytics, the organization should determine what factors are most important.”

Practice sessions should not isolate coders, she adds. As they practice—ideally at least a couple of records per week—it’s a good idea to provide coders with an opportunity to talk with each other and ask questions to ensure consistent reporting.

The quality of coder training is just as important as the duration, Shapiro says. “I’ve seen organizations try to take shortcuts just because they want to save a couple of bucks. If someone says they can train your coders in 60 hours to become certified in ICD-10, you’ve got a problem,” he says, adding that providers should request a training demo and examine the curriculum’s robustness.

Shapiro says anatomy and physiology ranks near the top of training priorities. “It’s a very big subject,” he notes. “That portion of your training should be 50 to 60 hours minimum if you’re really learning it.”

• Reserve additional help. Hospitals likely will need extra help during the first six months after implementation just to stay afloat, Clark says. Several HRAA clients already have reserved outsource help, with some doubling their number of coders for the first six months and then decreasing that total over time. According to Neville, outsourcing coding also can be beneficial right now to address any backlogs and allow on-staff coders more time to learn and practice ICD-10-CM/PCS.

Shapiro says it would be wise to open a pipeline to potential new hires. “You need to begin thinking about where you’re going to get your future coders. Align yourself with a school that’s going to be producing new coders. Line yourself up with future talent sources,” he says.

To complicate matters, some coders may plan to retire before implementation, leaving vacancies that must be filled. “I think we’re going to see an exodus of between 20% to 30% of the coders who are out there,” Shapiro says. “It’s creating a huge shortage, and that is also going to affect productivity.”

Clark says coding managers must have open and honest conversations with all staff members to better understand their long-term employment plans with the hospital. A vacancy shortly after implementation surely will lead to a productivity slowdown, she says.

• Consider workflow changes. Capitalize on coder strengths to maximize efficiency. Consider routing specific specialties (eg, cardiology, interventional radiology, endocrinology) to designated coders who have a greater proficiency in those clinical areas. Ongoing ICD-10-CM/PCS assessments will help determine coders’ proficiency levels, Cassidy says.

In the interest of efficiency and accuracy, coder specialization is bound to occur, Shapiro says. “I think it makes sense, although I would recommend that all coders learn all of the body systems. That makes you more employable in the future and more versatile,” he says.

• Keep tabs on your discharged not final billed (DNFB). A huge DNFB is the last problem coders will want to deal with as they’re shifting their focus to ICD-10-CM/PCS. According to Clark, some hospitals are relying on coders who intend to retire before ICD-10 is implemented to specifically focus on the DNFB. “They’re capitalizing on those veterans to clean up that ICD-9 backlog so [newer] coders can concentrate on ICD-10,” she says.

Staggering ICD-10-CM/PCS training times allows certain coders to work on the DNFB while others are trained. Neville says this strategy can help keep operations running smoothly as the ICD-10 deadline approaches.

• Consider computer-assisted coding (CAC). CAC can increase coder efficiency but only if coders are thoroughly trained in ICD-10-CM/PCS and have had time to practice, Cassidy says. “You have to know how to code in ICD-10 before you become an ICD-10 coding validator with a CAC solution,” she notes.

CAC is only as effective as the documentation on which it’s based. “If the clinical documentation has gaps, CAC will not make that go away,” Cassidy says. “What will help is if you have a CDI program in place with [ongoing interactions] with physicians. You have to have a CDI program that is built for ICD-10 readiness.” CDI programs should broaden their scope to include quality measures as well as payers other than Medicare, she adds.

The good news is that if a hospital has strong CDI and coder training programs, CAC can mitigate productivity losses. If CAC is applied to a robust ICD-10–ready medical record with good clinical documentation, coders may experience only a slight productivity drop that will likely improve over time, Cassidy says.

• Spread the word. Coders and HIM professionals know that productivity will decrease, but are the board of directors and the C-suite aware of ICD-10’s impact? Working to gain buy-in from organizational leaders helps obtain additional funding for training and hiring new employees, Clark says.

• Talk with your payers. Initiate communication with your top five to 10 payers. Inquire about when testing can begin and whether unspecified or not otherwise specified codes will be accepted. Although these codes are valid, many payers are setting their claims systems either not to accept them or to accept them only during a specific grace period. “Having a denials strategy beginning October 2, 2014, and beyond will assist with potential bottlenecks that will slow the revenue stream,” Clark says.

“Now that the Centers for Medicare & Medicaid Services will be conducting end-to-end testing, you have the opportunity to take advantage of the momentum and reach out to all of your business associates, trading partners, vendors, payers, and clearinghouses as soon as possible,” Cassidy says. “From a pure revenue cycle and reimbursement perspective … you have to focus on the efficiencies that you’re building into your IT infrastructure and ensure that the ICD-10 coded data is appropriately being sent and received as intended.”

Anything coders can do to identify claim submission errors or snags in advance will be helpful, Neville says. “Otherwise, if you don’t have the more specific codes or the right number of codes, you’re going to find out about it in real time,” she says. “Then when that happens, the inaccurate coding will have a downstream effect on productivity.”

Plan for the Future
Experts agree that coder productivity probably won’t return to pre–ICD-10-CM/PCS levels anytime soon—if at all. Clark says it’s not realistic to impose current-day productivity standards on coders working with ICD-10-CM/PCS, noting that the best strategy is to audit coders frequently during the first few months after implementation to get a read on how much time each record type requires.

At some point, experts say productivity will at least stabilize; however, the question is when. Some anticipate that it may occur six months or one year following implementation as coders become more skilled and comfortable with the codes.

Don’t Forget Quality
Quality audits should begin immediately after implementation and occur at regular intervals. “It can’t just be about productivity; it has to be compliant and accurate,” Cassidy says. “The clinical documentation integrity drives the integrity of your coding. You want that claim going out correctly. That takes quality monitoring of the documentation as well as the coding.”

To ensure accuracy, consider the following questions:

• Which cases will be evaluated? Will it be those involving certain diagnosis-related groups, procedures, or physicians?

• When and how often will accuracy be evaluated?

Don’t expect 95% accuracy on day one. Monitor coders closely, provide remedial education, and strive to improve accuracy going forward. Preparing and executing an ICD-10 strategy to maintain acceptable productivity is a difficult, complicated task but one that every health care organization must prioritize.

— Lisa A. Eramo is a freelance writer and editor in Cranston, Rhode Island, who specializes in HIM, medical coding, and health care regulatory topics.