Prepare now for the implementation of ICD-10

Look at the potential impact on case management

You may think that because you're a case manager, you don't need to be aware of the implementation of the new International Classification of Diseases (ICD-10) codes. Or you may think that since they don't take effect until Oct. 1, 2013, you don't have to worry about them yet.

Think again, advises James R. Proctor, a director with KPMG Healthcare.

"These changes in coding are going to lead to pervasive changes across the revenue cycle and will have a broad impact on the entire hospital. When ICD-10 goes into effect, it's likely to affect the ability of case managers to handle the same caseloads they are handling now. It's not too early for case management departments to start looking at the potential impact and preparing in advance for it as opposed to rushing as we near the implementation deadline," he says.

ICD-10 is a major overhaul of the codes used for inpatient diagnoses and procedures. The United States is one of the few countries not already using ICD-10 to compare its data internationally to track the spread of disease and treatment outcomes.

"This is a big deal. What complicates the adoption for the United States is that we use coding information to determine payments and to justify medical necessity. Regardless of the payment time (e.g. case rate, per diem, carve out), ICD-10 will impact the way authorization is obtained and claims are adjudicated," he says.

One huge change is that while ICD-9 uses five-digit numeric codes, ICD-10 is a seven-digit alpha-numeric coding system.

The expanded fields for coding make it possible to track much more detailed information about the patient's condition, Proctor points out.

"Payers will be able to aggregate information and perhaps adjust medical management and payment policy based on the increased level of information. They may assign different payment rates within a diagnosis group based on the additional information," he says.

With the coding reflecting a greater level of detail, coders will need more accurate and detailed information to assign the correct code to the procedure. This means that clinicians will have to provide more comprehensive documentation, Proctor says.

"Under ICD-10, much more detailed documentation is going to be required. Since case managers often are at the forefront when it comes to improving the clinical documentation, the responsibility of case managers is likely to increase," he says.

As payers start to modify their medical management policies, they will want more information for authorization. This means that case managers need to have detailed information at their fingertips and be able to communicate it to the payers.

The preparation that goes into compiling information for communication with payers regarding authorizations for treatment and continued stays is going to increase, and case managers also should prepare for an increase in the level of clinical information they are asked to produce, he says.

"If the documentation isn't complete and detailed up front, I anticipate that there will be a lot of duplicate work as case managers re-query clinicians to clarify detailed diagnoses," he says.

Many in the health care field think that because ICD-10 involves coding, it's solely the responsibility of health information management or information technology, Proctor says.

"But if you don't gather all the necessary information upfront, hospital case managers may not get authorizations, and they will have to track down physicians for clarification. The new codes will also affect discharge planning because the amount of information required to get authorization for post-acute services will increase," he says.

The changes will affect hospital technology in much the same way that Y2K did because they require that hospitals update technology to accept seven digits instead of the current five in the coding fields.

"Current hospital information technology is designed to store a five-digit field for coding. All of the programs that touch coding will have to be updated to accept the expanded field," he says.

Case management, discharge planning, registration, and clinical electronic transaction systems will have to be upgraded to accommodate the additional characters, he says.

Proctor encourages hospitals to start thinking about the impact of ICD-10 and to begin to plan for it.

"It's too early to offer detailed training for the coding staff, but it's not too early to do awareness training across the revenue cycle and other impacted processes," he says.

Case management directors should start planning for the potentially negative productivity impact the additional documentation requirements will have on their staff.

"As the hospital plans for implementation of ICD-10, case management departments should get involved and make their needs and challenges known," he says.