Review of Responses to Reader Survey: ICD-10-CM Lessons Learned

In our most recent Reader Report, we examine responses to Part 1 of our ICD-10 series of surveys.

As a follow-up to the launch of ICD-10-CM on Oct. 1, 2015, Today’s Wound Clinic (TWC) invited our readers to participate in a three-part survey. (Thanks to all who took time to answer the detailed questions on the survey, which, in turn, required detailed answers.) As promised, we’ve compiled responses for this edition of the journal, which is completely dedicated to reporting on the state of the industry’s ICD-10 absorption. (Note: This report covers Part 1 of the survey. Part 2 and Part 3 results will publish in March and April, respectively.) Our survey responses have produced fascinating stories from those in the business who have successfully implemented ICD-10 without much disruption. However, there are those who have struggled and are still struggling with the implementation. We hope that those among the latter will benefit from the success tips we’ve received from your peers and that they bring answers to some of your ICD-10-related difficulties. For those who’ve rated their own implementation process with high scores, we hope to guide you toward that “perfect 10” score as you consider some of the success tips among your peers in the ensuing pages. Without further ado, let’s review the responses to Part 1.

(Note: For responses placed in quotations, paraphrasing was used in many instances.)

Survey Part 1: Processes That You Put in Place to Implement ICD-10.

Responses to Part 1 of our survey came from qualified healthcare professionals (QHPs - physicians, nurse practitioners, podiatrists, physician assistants, and clinical nurse specialists) working in private offices, wound care hospital-based outpatient departments (HOPDs) managed by the hospital, and HOPDs managed by wound management companies. Therefore, we’re reviewing surveys here from these three perspectives. In addition, we divided each group of surveys into those respondents who rated their ICD-10 conversion-process experience in ranges of 1-5 (low) and 6-10 (high).

Private QHPs

All respondents (excluding one) gave high scores to their experience with the ICD-10 conversion process. Let’s take a look at the major reasons given:

• “QHPs took advantage of using the many ICD-9-to-ICD-10 conversion tools and the ICD-10 tools made available.”

• “Electronic health record (EHR) companies made the conversion seamless. Some included a word-search function, which helped guide QHPs to the correct family of ICD-10 codes.”

• “The hospital provided many ICD-10 in-service education programs prior to and after Oct. 1, 2015.”

• “The information technology (IT) department played a superior role in facilitating the conversion.”

• “QHPs committed to ICD-10 self-learning, including reading medical journal articles such as TWC and attending wound care-focused ICD-10 seminars.” 

• “QHPs created wound care-specific ICD-10 coding tools and loaded those tools into each examination room’s computer. In addition, QHPs used several Internet-based ICD-10 resources.”

• “Beginning in August 2015, QHPs dual-coded (with both ICD-9 and ICD-10) every patient encounter.”

• “QHPs participated in workplace-scenario practice sessions.” 

The QHP who gave the conversion process a low rating stated that he/she had a one-page ICD-9 “cheat sheet” and knew ICD-9 very well: The QHP could no longer use a one-page cheat sheet. This same QHP stated that understanding the ICD-10 naming convention was problematic, and that he/she is still having difficulty with “initial,” “subsequent,” and “sequela” when reporting wound-related ICD-10 codes. Other problems reported by QHPs include:

• “The drug/biologic order forms and the procedure charge sheets were not updated with the new ICD-10 codes.”

• “The payers and drug plans did not always load all possible ICD-10 codes into their medical policies and into their claims-payment software.” 

• “When the ICD-10 codes were not specific enough, QHPs received general queries that identified a problem rather than specifically describing the issue: QHPs reported they wasted a lot of time trying to figure out the problem.”

• “The EHR did not consistently convert from ICD-9 to ICD-10 for every progress note; QHPs had to use a separate Internet-based conversion tool. They found this process cumbersome.”

Hospital-Managed HOPDs

The majority of respondents from HOPDs managed by the hospital gave high scores to their ICD-10 conversion process. However, a sizeable number of respondents rated the conversion process experience with a low score.  The major reasons given for a positive conversion experience:

• “The hospital system and EHR were ready and provided a lot of support.”

• “Extensive education specific (in-person and webinars) to wound care conversion charts from ICD-9 to ICD-10 and incorporation of ICD-10 education into staff meetings.”

• “Turned on ICD-10 crosswalk prior to Oct. 1, 2015, so that staff gained a comfort level with new codes.”

• “Began double-coding ICD-9 and ICD-10 codes four months prior to Oct. 1, 2015.”

• “Wound care-specific EHR prepared one year in advance; multiple templates made for each QHP.”

• “Education and resources supplied by billing and coding departments and by the Centers for Medicare & Medicaid Services.”

• “Assistance of IT department.”

• “Tested submission of claims with ICD-10 to various clearinghouses.”

• “Everyone’s commitment to improving documentation.”

These respondents reported a few “bumps” in their conversion experience, specifically: “The need to encourage QHPs to pay attention to details in their documentation, the seventh digit required by some diagnosis codes were missed, the lack of attention to the wound care department during the conversion, the amount of time that it takes to read the medical record and determine the appropriate ICD-10 diagnosis code (especially the ones that do not easily translate from ICD-9), insurance benefit verification takes longer, updating forms, interface issues between EHR and billing software, and lack of attention to local coverage determinations and medical policies that list specific covered ICD-10 codes.” The major reasons given by respondents who rated their conversion-process experience as low:

• “No formal ICD-10 training.”

• “Ordered ICD-10 coding books too late and they were still on back order on Oct.1, 2015.”

• “Too many ICD-10 codes to choose from.”

• “Wound care nurses should not need to understand diagnosis codes and find it difficult to make it a priority.”

• “Takes too much time to verify you are using most-specific diagnosis code.”

These respondents reported that their lack of preparation made insurance benefit verification extremely difficult.

Wound Management Company HOPDs

Most respondents from HOPDs managed by wound management companies gave high scores to their ICD-10 conversion experience.  The major reasons given for the positive experience:

• “Extensive education of QHPs, wound care nurses, and therapists.”

• “Creation of multiple templates in the EHR for each QHP.”

• “EHR crosswalk from ICD-9 to ICD-10.”

• “Excellent cooperation between HOPD, QHPs, coding, and billing departments.”

• “Attendance at Wound Clinic Business seminars.”

• “Preparation and prework completed.”

These respondents reported their largest difficulties were with QHPs’ documentation, implementation of new documentation forms, volume of available diagnosis codes, lack of training about wound care-specific diagnoses, interface between EHR and billing software, referral forms that were not updated, and obtaining insurance benefit verification with new ICD-10 codes. Some of the HOPD coders reported that some wound care diagnoses are not easily transitioned to ICD-10 and often cause delays in submitting claims to payers.  The few respondents from wound management company HOPDs who gave low scores to their ICD-10 conversion process contributed their reasons to:

• “Lack of downstream communication.”

• “Little to no support from EHR vendor and wound management company.”

Additionally, these respondents did not establish any of the conversion-process steps except for identifying the major ICD-9 codes used in their wound care businesses. Therefore, they reported problems with their EHR, lack of preparedness, lack of understanding ICD-10 codes that pertain to their patients, and mental roadblocks by clinical staff members who did not embrace the value of the new diagnosis codes and did not learn about the documentation that was required to select the most specific ICD-10 diagnosis code(s) that defined their patients’ diagnoses. Table 1 provides a profile of the processes/procedures/programs implemented by the respondents who submitted “high” survey ratings. 

Kathleen D. Schaum, MS, is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL; and director, medical products, reimbursement, biotherapeutics at Smith & Nephew.