Global Lessons: Planning and Preparation are Keys to ICD-10 Success

The American Recovery and Reinvestment Act (ARRA) provides incentives to modernize health care via the HITECH Act, which in turn created stimulus dollars for Meaningful Use of Electronic Health Records.  What most don’t know is that the upgrade to a new medical coding standard, ICD-10 was mandated in August 2008 before President Barak Obama was elected.  It is a Health and Human Services (HHS) mandate promulgated by the Centers for Medicare and Medicaid (CMS).

For more than a decade, AHIMA has warned of the problems that exist with the ICD-9-CM system, while artfully promoting the value proposition of ICD-10. The AHIMA site offers a wealth of information from which CIOs and other senior executives can benefit.

We need first to understand some of the baseline deficiencies inherent as we continue to use the ICD-9-CM system. ICD-9-CM is obsolescent. The system is quickly running out of space for new codes, thereby limiting the inclusion of new procedures and diagnoses. Further, it is not sufficiently precise to fully enable an EHR, conform to pay-for-performance reporting requirements, it adversely affects DRGs by grouping different procedures into a single code, and decreases our already considerable investment in SNOMED-CT.

Whether you work for a provider or payer, keep this in mind as we move to the October 1, 2014 compliance date.

HIPAA X12 5010, the EDI standard required for implementing ICD-10 has an earlier date.

We can learn from ICD-10 implementations that have already taken place in other countries. Thailand *yes Thailand* implemented ICD-10 in 1994. The U.S. is implementing a version of ICD-10 which the W.H.O. granted permission for it to modify, ICD-10-CM.

Key points where the U.S. and international experiences differ:

  1. The “WHO” version of ICD-10 from the World Health Organization is actually smaller and less complex than the version of ICD-10 that the United States is switching to, which is ICD-10 CM
  2. In the U.S., ICD-10 will be used to collect money for services.  It will drive the DRG (diagnosis related group) based reimbursement system for a multi-$trillion industry.  Consequently for the US, ICD-10 represents a new payment paradigm, not just a new coding system

Here is a summary of lessons learned from the Canadian experience with ICD-10 implementations:

The International Classification of Disease (ICD) is used for classifying diseases and other health problems recorded on many types of vital records including death certificates and hospital records. The International Statistical Classification of Diseases and Related Health Problems is maintained by the World Health Organization and was endorsed by the World Health Assembly in May 1990. Many countries around the world began implementing ICD-10 for mortality statistics in 1994. In the natural progression of coding medical records, various countries around the world began to contemplate the idea of using ICD-10 for morbidity data. the World Health Organization (WHO) holds the copyright to ICD-10, those countries seeking to modify the system had to request permission to do so. All modifications must be approved by WHO to keep certain standards and conventions in place.

By imposing standards and restrictions the coding integrity is maintained, allowing for comparative analysis between counties on global conditions and diseases. The countries that sought and gained approval to create their own ICD-10 include Australia (ICD-10-AM), Thailand (ICD-10-TM), Germany (ICD-10-GM), Canada (ICD-10-CA) and the United States (ICD-10-CM).

Of particular interest to the United States is the experience Canada had in the implementation of ICD-10. Our neighboring country, Canada sought approval to modify ICD 10 from WHO in 1995, began work to modify the codes in 1999 and commenced adoption in April 2001.  But not too fast, there are important differences between the U.S. and Canada.

The rollout of the new code set in Canada was different in some respects from the anticipated rollout in the United States.

  • Canada’s universal, single-payer system is funded and regulated at the federal level but coordinated at the provincial level.
  • In the Canadian ICD-10 rollout, each province had the ability to determine the date for their specific implementation. As a result, provincial implementation of ICD-10-CA was staggered beginning in 2001 with completion by April 2005.
  • We do not have a single-payer system nor do our states have the same control as the Canadian provinces; as such, our implementation effort will not be staggered.
  • The somewhat interesting challenge that Canada had was that when they rolled out the ICD 10 system, Windows-based computer software was just making the scene. Not only were Canadian coders faced with a new code set, but they were also faced with the challenge of changing from using hardbound books to desktop Windows-based applications for their reference materials.  The Canadian government provided free code selection software and provided it to hospitals to aid in training and accurate code selection.
  • Canadians concluded that there is limited benefit in doing ICD-10 codes on the ambulatory side.  Unfortunately in the U.S., it is a given that we must implement on the outpatient side, but we should be mindful of where the benefits will come from and where they will not.

A coding set doesn’t always mean more accuracy.  For example, Blue Cross Blue Shield of Arkansas did a study of diagnosis and coding, and found that of the approximate six codes for ICD-9 the most common sinusitis detail diagnosis was “unspecified” by 82 percent.  In ICD-10, there are about 14 codes.  This does not guarantee that they will be used.   Payors will pay a claim with ‘unspecified’ therefore behavior will not change based on monetary outcome.

Canadian experience suggests key points to remember:

Planning and preparation are keys to success

Auditing business and IT 5010 and ICD-10 requirements using experts before health plans go live can save costly mistakes and reduce risks in meeting implementation timelines.

A careful look at the “as is” and “to be” of process is important, and use them as an opportunity to re-engineer for quality improvements and increased CMS Medicare Advantage ratings for payors and providers, where applicable.

Trading and partner testing is a big hamstring to health plans, so allow time for it.  HIPAA 5010 will demand more testing work that compliance checking as plans and providers struggle to have new systems integrate end to end.

Security is key – in the U.S. by February 2010 organizations are required to have a HIPAA security officer. Blend security requirements into the plan early.

Consider whether you are adequately staffed to do the ICD-10 Clinical Documentation and Physician Engagement work – don’t leave it to inexperienced coder – trainers alone when you deal with clinicians.

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Michael F. Arrigo

Michael Arrigo, an expert witness, and healthcare executive, brings four decades of experience in the software, financial services, and healthcare industries. In 2000, Mr. Arrigo founded No World Borders, a healthcare data, regulations, and economics firm with clients in the pharmaceutical, medical device, hospital, surgical center, physician group, diagnostic imaging, genetic testing, health I.T., and health insurance markets. His expertise spans the federal health programs Medicare and Medicaid and private insurance. He advises Medicare Advantage Organizations that provide health insurance under Part C of the Medicare Act. Mr. Arrigo serves as an expert witness regarding medical coding and billing, fraud damages, and electronic health record software for the U.S. Department of Justice. He has valued well over $1 billion in medical billings in personal injury liens, malpractice, and insurance fraud cases. The U.S. Court of Appeals considered Mr. Arrigo's opinion regarding loss amounts, vacating, and remanding sentencing in a fraud case. Mr. Arrigo provides expertise in the Medicare Secondary Payer Act, Medicare LCDs, anti-trust litigation, medical intellectual property and trade secrets, HIPAA privacy, health care electronic claim data Standards, physician compensation, Anti-Kickback Statute, Stark law, the Affordable Care Act, False Claims Act, and the ARRA HITECH Act. Arrigo advises investors on merger and acquisition (M&A) diligence in the healthcare industry on transactions cumulatively valued at over $1 billion. Mr. Arrigo spent over ten years in Silicon Valley software firms in roles from Product Manager to CEO. He was product manager for a leading-edge database technology joint venture that became commercialized as Microsoft SQL Server, Vice President of Marketing for a software company when it grew from under $2 million in revenue to a $50 million acquisition by a company now merged into Cincom Systems, hired by private equity investors to serve as Vice President of Marketing for a secure email software company until its acquisition and multi $million investor exit by a company now merged into Axway Software S.A. (Euronext: AXW.PA), and CEO of one of the first cloud-based billing software companies, licensing its technology to Citrix Systems (NASDAQ: CTXS). Later, before entering the healthcare industry, he joined Fortune 500 company Fidelity National Financial (NYSE: FNF) as a Vice President, overseeing eCommerce solutions for the mortgage banking industry. While serving as a Vice President at Fortune 500 company First American Financial (NYSE: FAF), he oversaw eCommerce and regulatory compliance technology initiatives for the top ten mortgage banks and led the Sarbanes Oxley Act Section 302 internal controls I.T. audit for the company, supporting Section 404 of the Sarbanes Oxley Act. Mr. Arrigo earned his Bachelor of Science in Business Administration from the University of Southern California. Before that, he studied computer science, statistics, and economics at the University of California, Irvine. His post-graduate studies include biomedical ethics at Harvard Medical School, biomedical informatics at Stanford Medical School, blockchain and crypto-economics at the Massachusetts Institute of Technology, and training as a Certified Professional Medical Auditor (CPMA). Mr. Arrigo is qualified to serve as a director due to his experience in healthcare data, regulations, and economics, his leadership roles in software and financial services public companies, and his healthcare M&A diligence and public company regulatory experience. Mr. Arrigo is quoted in The Wall Street Journal, Fortune Magazine, Kaiser Health News, Consumer Affairs, National Public Radio (NPR), NBC News Houston, USA Today / Milwaukee Journal Sentinel, Medical Economics, Capitol ForumThe Daily Beast, the Lund Report, Inside Higher Ed, New England Psychologist, and other press and media outlets. He authored a peer-reviewed article regarding clinical documentation quality to support accurate medical coding, billing, and good patient care, published by Healthcare Financial Management Association (HFMA) and published in Healthcare I.T. News. Mr. Arrigo serves as a member of the board of directors of a publicly traded company in the healthcare and data analytics industry, where his duties include: member, audit committee; chair, compensation committee; member, special committee.

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