Productivity losses: Lessons learned from the Canadian ICD-10 experience

Most certainly, says Cindy Grant, CHIM, ICD-10 Practice Lead at TELUS Health Solutions in Toronto, Ontario. Productivity levels may increase as coders become more familiar with the new classification system, but it’s unlikely that they will ever return to pre-ICD-10 numbers, she says. Grant, who is currently leading various U.S.-based ICD-10 implementations on behalf of TELUS, says this fact should be evident to those familiar with ICD-10, given the additional amount of information that coders will need to locate in the medical record to assign codes correctly.

 

What are some of the lessons learned from the Canadian experience in terms of mitigating coder productivity losses?

 

Lesson #1: An accurate gauge of current coder productivity is paramount. Coding managers and HIM directors must understand the volumes of records that coders can code per hour today to prepare for any future changes with ICD-10-CM/PCS, says Kerry Johnson, MAEd, CHIM, senior lecturer and HIM instructional coordinator at the University of Ontario Institute of Technology in Oshawa, Ontario. Some questions that might be asked are:

Features and functions such as drop-down lists, structured data fields, and Natural Language Processing, may have a positive indirect effect on coders workflow and resultant productivity, says Grant.

 

Lesson #2: Don’t underestimate the amount of education that coders need. ICD-10-CM/PCS implementation requires a significant investment in coder education as well as an ongoing assessment of coder skills, says Grant. In Canada, coders underwent a five-day self-learning course combined with a two-day in-person training. However, this training wasn’t sufficient for acute care coders. Grant urges U.S.-based coders to err on the side of caution in estimating and planning for  the amount of training necessary to code effectively using ICD-10-CM/PCS.

 

“Coding staff will need to completely unlearn what they know now and re-learn almost a complete new skill set,” she says. “If you think you’ve estimated the right amount [of training time], probably increase it by another third.”

 

Johnson agrees, adding that hospitals should at least double—if not triple—the amount of training time they anticipate for coders. He says AHIMA’s recommendation for 50 hours of training (i.e., 16 hours for ICD-10-CM, 24 hours for ICD-10-PCS, and 10 hours for hands-on practice) may not be enough.

 

The amount of coder training should depend on an individual coder’s skills and knowledge in basic biomedical sciences and anatomy and physiology, says Johnson. Coders in Canada struggled most with anatomy and physiology—not the coding logic itself.

“It wasn’t so much the coding system and how the codes work,” he says. “We found them struggling with anatomy and physiology and understanding what exactly the intervention was, including determining the root operation.”

 

The depth of coder training will also depend on the types of records that coders code most frequently. Coders who code same-day surgeries may require less training than those who code acute inpatient care that tends to vary in terms of diagnoses and severity, says Johnson.

 

Lesson #3: Optimal efficiency may require workflow redesign. Identify chronic inefficiencies and take steps to fix them, says Johnson. Also identify any unnecessary tasks or data collection that coders may be performing that you can eliminate, he adds. Johnson, who helped implement ICD-10 in a large, urban multi-site acute care facility in Ontario, says eliminating unnecessary tasks was particularly helpful during and after the transition.

 

Hospitals may also want to consider using predefined pick lists (superbills) for common procedures performed as same-day surgeries, he says. Physicians can help create these lists in conjunction with the coders who frequently code these procedures.

 

A concurrent coding workflow at or near the point of care can also help capture the details necessary for ICD-10-CM/PCS, says Johnson.

 

“You can start to collect the data as soon as possible. This will support some of the other issues you may encounter with documentation … to understand where documentation gaps are and what might need to be improved,” he says.

 

Grant added that a detailed review of all report or other outputs will be required since the logic of the reports and the data/information that is reported will significantly change with ICD-10. This is also a good time to conduct a full inventory of all reports that include an ICD-19 code to ensure that they all continue to be required and are useful to the end user or report requestor.

 

The results in Canadian organizations were surprising in that these inventories resulted in significant efficiencies and process improvements by reducing or eliminating reports that were no longer required.    

Lesson #4: Decide now how you’ll hire additional staff. Contacting a contract company or hiring additional staff members now will help prevent a scramble for limited resources later as other hospitals make similar decisions and begin to vie for those same resources, says Johnson. Hospitals even want to consider contacting coders who have previously retired, he says. In Canada, coders who had previously retired decided to start working again to assist with the transition.

 

If you don’t already have a HIM professional resource  to monitor coding quality, consider hiring one. Concurrent quality audits will be important during the transition, says Johnson.

 

“There are going to be many, many questions that are going to arise as you’re coding … You’ll need to come up with agreed upon interpretations of the coding guidelines that you can put into practice at your facility,” he says.

 

In addition to these four lessons learned based on the Canadian experience, both Grant and Johnson strongly recommended that audits of clinical documentation be conducted as a first key step in an organizations’ readiness assessment.

 

A sample of current clinical health records should be re-coded using ICD-10; the results of this audit will be very revealing and informative in terms of areas for clinical documentation improvement initiatives necessary to support the increased granularity of ICD-10; in addition, the necessary workflow and process re-design efforts may be informed by this initiative and physician education efforts can be aligned with specific documentation improvement requirements.     

 

Editor’s note: The content in this article was originally presented during HCPro’s audio conference An Insider’s Perspective of ICD-10 Implementation. For more information, visit http://tinyurl.com/cn7ykv5. This article originally published in Briefings on Coding Compliance Strategies.