Although a recent American Hospital Association survey shows that most hospitals are in a readiness assessment phase, most are finding it a momentous task as they work to make code sets more operational and gear up physicians, staff and equipment.
Making the mandated implementation is not just a matter of swapping out your coding manuals and modifying a super bill. Meeting the International Classification of Diseases, Tenth Revision (ICD-10) as implemented by the Centers for Medicare & Medicaid Services (CMS) requires strategic preparation that will affect every area of your practice or institution.
This includes policies, procedures, contracts, as well advance beneficiary notices and super bills (an itemized form reflecting services rendered.) Some of the necessary steps to transition to ICD-10 include readying information technology, budget, software, and of course, staff. Your technology and finance leaders need to have a thorough understanding of ICD-10 and share it with all departments.
In addition, careful planning with vendors, clearly laying out timelines for any needed software or hardware updates – and their costs – helps anticipate work flow. Of course, the biggest expenses for IT and training, depending on who needs training and the amount of education needed. Certified coders need to take proficiency assessments, which measure understanding of coding concepts; code categories and grouping; ICD-10 official guidelines, and other important rules.
Start now with improving your clinical documentation to ensure that you’re meeting the closer level of clinical specificity required by ICD-10. Most physicians document patient care, but this may not fit coding requirements, which require precise anatomy and pathophysiology coding as well as honing in on disease processes. Properly documented in this way, a medical record allows for proper reimbursement of services as well as protection from malpractice claims and audits. Keeping up-to-date as CMS sends out policy updates and procedures will also ensure accurate documentation.
What’s the point of moving to ICD-10? This is a question that’s bound to be asked by a staffer in the midst of struggling with finding the right code. The new ICD-10 code set will allow greater specificity, thus helping with quality measurements, assist in meeting patient safety goals and quality standards, as well as tracking public health dangers and raising technology standards in medicine. It might be a challenge, but ICD-10 will prove its worth.
