ICD-10: Senior care makes the transition

Genice Hornberger, RN
Genice Hornberger, RN

After years of delays, the United States remained on track with transitioning over to ICD-10 on October 1, 2015. While transitioning from ICD-9 and its 13,000 diagnostic codes to the 70,000 ICD-10 codes was been underway in the years leading up to this fall, we will learn how the change will impact healthcare providers as well as payers.

All United States healthcare providers covered under HIPAA – even if the entity is not currently submitting electronic transactions – were required to make the change. Providers who cannot generate ICD-10-compliant claims by October 1, 2015, will see those claims returned for correction, which will mean delayed reimbursement for services provided, ultimately affecting that organization's bottom line.

PointClickCare added a configuration allowing providers to activate the ICD-10 library on their own timelines. Like most EHR vendors, PointClickCare diligently worked with vendors, integration teams and clients to ensure the completion of end-to-end testing.

What senior care organizations can expect

If you did a lot of last-minute prep for ICD-10, you're not alone. A Porter Research survey funded by billing vendor Navicure found that as of August 2015, fewer than half (43%) of U.S. providers felt they were ready for ICD-10, which actually more than doubled the number (21%) of respondents in the same survey earlier in 2015.  The silver lining? Some 85% of respondents felt optimistic they would be ready October 1.

Although the October 1 deadline has passed, you can still check your billing processes to address these not-so-obvious items:

  • Key in on code specificity. All codes on outgoing claims need to be reviewed. Note that payers may require the code with the highest specificity reported, and be aware that payers may alter payment schedules and reimburse differently for different levels of specificity.

  • Watch claims for documentation problems and adjust existing workflows to ensure clinical documentation captures enough information to determine the highest level of specificity. This may require additional documentation on sidedness (left or right) and determination of extent (i.e. mild, moderate or severe asthma).

  • Double check payer contracts and make sure there are no contractual changes required with payers related to the implementation of ICD-10.

  • Build in extra time for coders. Studies suggest that it will take 15 percent longer on average to code in ICD-10 vs. ICD-9. Some specialties, orthopedics for example, may need even more time to code due to the volume of related codes.

  • Budget for training and implementation. Account for resources such as additional coders during the transition phase and new coding books. Not sure how to calculate that? This spreadsheet, developed by the Health Information Management Systems Society, can help providers estimate it

  • Improve your denials management process. In the above mentioned survey, 94% of respondents indicate that they expected increased denials, but only 30% did any work toward solving the problem. Those who did focused on improving patient cost estimates and patient collections. Most are simply bracing for the revenue cycle disruption and hoping for the best; about half (46%) believed problems, such as payer readiness and new documentation processes, would impact their bottom lines at less than 20%.

The good news is that long-term and other post-acute care organizations may have it easier than their acute care siblings, at least one of our customers believes. Once the acute care provider – and its certified coding team – sets a patient's ICD-10 diagnosis code properly, that should trickle down to the post-acute provider after discharge and handoff.

I recently discussed this specific issue and ICD-10 prep in general with Jean McGill, clinical services director at American Baptist Homes of the West (ABHOW), a senior housing and healthcare provider based in Pleasanton, CA. She manages 33 affordable housing communities, 10 continuing care retirement communities and one residential living building.

The ICD-10 prep at ABHOW, which focused on the CCRCs, included a three-day class for all MDS (minimum data set) coordinators and interdisciplinary team members, coders and admissions staff – those who are primarily the users of ICD-9 and ICD-10 information – to get them all on the same ICD-10 information sources. Trainings explained, primarily to medical directors of each facility, the difference between ICD-9 and ICD-10 and how to set up a schedule for converting.

The rollout began with train-the-trainer staff working with long-term care residents who will be in the building after October 1. Training at rehab facilities followed. The ICD-10 trainees returned to their respective facilities, and in turn, trained the rest of their teams and their doctors, with about half her communities offering one-on-one training with the doctors.

McGill said she was confident ICD-10 prep would effectively guide ABHOW's transition. Moreover, “while ICD-10 will challenge people for a while,” she said she's sanguine about ICD-10 improving senior care. The specificity of the codes should improve communications between the different levels of care and help create smoother transitions of care. By this clearer, more concise data set, ICD-10 will help senior caregivers to get more accurate picture of diagnosis and see exactly what someone is being treated for – and better help them to heal.

Her No. 1 piece of advice for senior care providers weathering the transition from ICD-9 to ICD-10? As it is with any major change, it is important to have on-site champions who understand why they are making this transition and can explain that to others. This shortens the learning curve.

Genice Hornberger, RN, RAC-CT, is the manager of Care Delivery Products at PointClickCare. In her 20-year career in long-term care, she has held a variety of positions, including MDS coordinator and director of nursing. 

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