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ICD-10-CM/PCS News Archives

Six months later: CMS advocating detailed assessment and maintenance of ICD-10 practices

April 18, 2016:

It’s been a half year since ICD-10 took effect and the impact is still being evaluated at all levels of health care organizations. With updates coming in October, the Centers for Medicare and Medicaid Services (CMS) is advising providers to take a hard look at how they’re operating under the new classification system.

Specifically, CMS is offering ideas on how to measure performance, identify trouble spots, and maintain progress to maximize productivity and revenue. The Center released a toolkit in March that provides tips on using key performance indicators (KPIs) for detailed progress reviews, troubleshooting issues before they get out of hand, and keeping coding resources up to date.

Setting a KPI baseline

Understanding the ICD-10 impact means knowing where you’ve been and what roads you’ve traveled to get there. That means comparing data points from before the October 2015 transition date with chosen KPIs. Most organizations likely set pre-ICD-10 baselines from data practice management systems, electronic health records, or other platforms. In the case of smaller practices without access to large clearinghouses, CMS recommends they look for available data both internally and from outside sources, such as clearinghouses, system vendors, and third-party billers, to find performance baselines.

CMS provided a laundry list of possible KPIs in its latest toolkit. While it does not advocate tracking every data point, the more KPIs that are routinely assessed the greater potential to identify problems, make improvements, and improve productivity. A sample of KPIs that CMS recommends includes:

  • Days to final bill
  • Claims denial rate
  • Coder productivity
  • Payer edits
  • Incomplete or missing charges
  • Use of unspecified codes
  • Medical necessity pass rate
  • Discharged, not final billed
  • DRG volumes (by group) under ICD-9 versus ICD-10

It’s about more than data

KPIs only say so much. How providers use the data to identify issues and make improvements is what’s most important. The best information about ICD-10 impact and performance comes from staff. CMS recommends building a feedback system where staff can ask questions and make suggestions, and where leadership can collect individual insights into processes that are successful and those that need improvement. From there, organizations can create an “issues list” that tracks specific issues to show current status as well as what steps organizations have taken to resolve each issue.

CMS recommends engaging coders and clinicians in ways some provider organizations may not have done before. Troubleshooting ICD-10 issues requires regular checks on clinical documentation and code selections. Clinicians and coders also must receive continual educational opportunities to ensure they meet specific CMS guidelines for ICD-10, such as 7th character use for injuries and musculoskeletal conditions.

CMS also recommends conducting regular hospital chart audits to ensure proper reporting and accuracy of DRGs. EHR and other IT systems should be checked for technical problems and to see whether they are able to generate ICD-9 codes and qualifiers for services provided before Oct. 1, 2015, and ICD-10 codes and qualifiers for services on or after the transition date.

Ensuring forward progress

In six months, CMS will issue its next set of ICD-10 updates – some 5,000-plus new codes. Maintaining IT systems and empowering coders with the latest education is vital if HIM departments are to keep up.

Providers and other health care organizations can recommend ICD-10 code updates and changes via the ICD-10 Coordination and Maintenance (C&M) Committee. Led by CMS and the Centers for Disease Control (CDC), the ICD-10 C&M Committee reviews proposals submitted at least two months before the next scheduled meeting (in September 2016). Proposal must include:

  • Description of code change request
  • Rationale, including clinical relevancy
  • Supporting clinical references and literature

Visit Optum’s comprehensive ICD-10 resource site by clicking here.


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