Monday, July 30, 2012

6 Considerations for Choosing Your ICD-10 Services Partner

If you’re a healthcare organization faced with the ICD-10 mandate and haven’t already engaged outside assistance with your assessment and remediation project, you must certainly be in the process of doing so.  Here are six considerations for choosing a partner to assist with your ICD-10 project.

1.       Payer Expertise vs. Provider Expertise?
There’s little overlap between the applications and business processes used by a healthcare payer vs. those used by a healthcare provider. Likewise there’s a gap between the apps and processes used by an institutional/hospital provider vs. those a professional practice. These differences should influence the partner you select.
2.       Does Size Matter?
While some firms mandate preferred consulting partners of the Big 4 genre, ICD-10 services are specialized, the pool of qualified resources is rather limited and quality resources are not easily grown. While there is no doubt Big 4 firms can perform, some niche firms or even a group of affiliated consultants could offer quality and value equal to or even better than the Big 4 types. Remember that bigger is not always better – but almost always the most expensive.
3.       Partner vs. Senior vs. Junior?
Which consultants are actually going to be assigned to your project? While you can’t expect, or even need, your effort to be staffed solely with senior-level resources, your contract should specify the exact resource types and time commitments assigned to your project.  Resumes for each would not be an unreasonable request. The last thing you want to be doing is paying a healthy rate to train your partner’s junior resources only to risk them bolting before your project is completed.
4.       Ours, All Ours!  Or Sure, We Can Share!
Often there’s a clear chain of command requirement, financial or functional benefit to engage a single consulting firm to provide all services needed. Other times there could be some benefit to parceling out certain aspects to different firms – especially aspects of testing, training and validation. I suggest you explore this option early on.
5.       On-site, Remote or a Healthy Mix of Both?
It may not be in your firms best interest to have all work performed by your consultants on-site. Consider the type of work being done, the potential negative impact to your staff having consultants around your office and travel expenses; chances are you may get a better quality outcome at a lesser cost by considering a mix of on-site and remote working arrangements.
6.       Tools & Templates or Time & Expense?
An often overlooked aspect of engaging a consulting firm is having a clear understanding of the tools, templates and frameworks they’ll bring to the table and use to expedite your project.  You probably want to avoid having consultants build tools at your expense – unless there is some clear benefit of re-use, ownership, etc. Be sure to understand any additional costs that may apply.
So What’s the Best Approach?
All of the above considerations are inter-related and each firm has its own unique needs for ICD-10 services. Moreover, ICD-10 can be considered a Vujà dé event: You’ve never been through this before and neither has anyone else.
But what would I think is an ideal situation if I was an institutional provider looking to engage outside services?
A consulting firm specializing in hospital systems that's not too big or too small charging a reasonable hourly rate and who’s assigned a partner to oversee a reasonable ratio of senior to junior staff using a hard drive full of templates and tools working in harmony with your staff and other external specialty vendors. 
Good luck with that! (And who cares what I think?) 

Saturday, July 28, 2012

And the Survey Asks: “What do you mean by ‘prepared for ICD-11?’”

Healthcare IT News recently asked its readers if they would be prepared to head straight for ICD-11, bypassing ICD-10. Of the 200 respondents, about half said “Yes! We’d be prepared to skip ICD-10 and go straight to ICD-11.”

Go straight to ICD-11? Do not stop for ICD-10? No hard labor on the way?

Supposedly these were industry groups, hospitals, “organizations” and individuals voting in this poll. What do these respondents think it means to “be prepared for ICD-11?” When do they think ICD-11’s Clinical Modification will be ready for use in the United States? I’d like to see a poll on that latter question.

So in my opinion, without an answer to the two questions I posit above and more details as to the knowledge level, authority and actual organization/title of these respondents, I call bullshit! I’d say these respondents just want more delay; they’d probably vote for going straight to “code assignment by telepathy” where the diagnosis code assigned to the patient encounter is “automagically” defined based on whatever the creator wants it to be; and whenever they want it to be assigned.

Surveys results can be funny; and also reflective of ignorance.

ICD-10 Tools: Beyond Simple Mapping and Translation

A number of companies are touting ICD-10 tools to help payers and providers with their ICD-10 assessment and remediation efforts. The range of functionality and features offered by these tools is growing by the day. Some are very purpose-specific and others appear to be taking the Swiss Army knife approach by offering dozens of capabilities; few of which appear to provide any real depth and value.

Whether planning to use a 3rd party tool or creating one of your own, there are a few functions and features to consider beyond the common mapping and translation functionalities offered by most 3rd parties:

1. Analyzing Your Data, Software and System Configuration Tables

As part of your ICD-10 assessment, you’ll have to answer a number of questions:

a. How should we plan for changes to contracts and medical policy?

b. How can we identify areas where additional training and / or provider outreach is necessary?

c. How can we predict the financial implications of the ICD-10 implementation?

d. How do we create an ICD-9 to ICD-10 and an ICD-10 to ICD-9 translation that can be utilized by all departments or specialized versions for specific departments?

Scanning, analytics and reporting capabilities are critical to help answer these questions. A good ICD code scanning and analyzer tool will identify how ICD-9 codes will translate to ICD-10 codes by code occurrence, dollar amount, unspecified codes, etc.

For instance, an unspecified codes report contains a count of the occurrences of all ICD-9 codes defined as unspecified can be used to identify the codes where you might wish to create an outreach and education plan to those providers submitting them; in order to encourage use of the enhanced granularity found in the ICD-10 code set.

2. Handling Groups, Lists and Ranges of Codes

Many business processes and software applications use groups of ICD codes for medical review determination, fraud and abuse detection, reporting quality measures, coding benefits, coverage determination, medical policy editing, and provider contract assignment. These groups, lists and ranges of codes must be updated to include their ICD-10 code equivalents.

Your tool or process should be able to identify and maintain ICD-9 and ICD-10 group and range equivalencies; with the ability to define master and purpose-specific variations.

3. Normalizing Diagnoses Codes for Testing and Production Purposes

Part of your remediation effort will involve conversion of historical data containing ICD-9 codes. You’ll also need to create ICD-10 test data from ICD-9 coded records. Depending on how your systems are remediated, you may need to convert back and forth between ICD-9 and ICD-10 codes as part of your normal business processes – especially during the period before and after the cutover.

For instance, when processing a claim requiring a prior authorization and the incoming claim has an ICD-10 code but the prior authorization was approved with an ICD-9 code, a crosswalk of the ICD-10 code that comes in on a claim to its equivalent ICD-9 code is required. A similar need presents itself when conducting medical reviews across the transition period, when creating reports for quality measures, HEDIS, fraud and abuse, etc - you’ll need to be able to review and analyze a normalized set of diagnoses data.

4. Incorporate Reference Information and Allow for Annotations

When reviewing the I-9 to I-10 and I-10 to I-9 diagnosis and procedure code mappings to determine the their accuracy, as well as any possible additions you may want to make to add specificity to the mappings, it will be necessary to easily access ICD-10’s tabular Indexes, CMS guidelines, and CMS’s General Equivalence Mappings (GEMs). Having this information accessible from within the tool and having the ability to annotate and adjust mappings and descriptions will reduce time associated with accessing these information sources from various locations while providing historical reference and audit value.

So whether licensing a tool from a 3rd party or building your own – with or without the assistance of a consultant – consider functionality and features beyond simple mapping and translation.

Monday, July 16, 2012

5 Things I Learned in My First Year of Blogging

A couple hours ago it came to my attention that my first blog post was made exactly one year ago today on July 16th, 2011. Woo Hoo! A year!? Wow…time really does fly!

I was informed of my Blogging Anniversary by an observant young Communications Specialist named Ashley W. who shall remain anonymous at this time.  I think Ashley saw a recent post on 10 HIT bloggers on Twitter
. Ashley sent me an email of introduction and noted that I made my first blog post on 7/16/11- that it was my 1 year anniversary. Thanks Ashley! Leave it to a woman to notice an anniversary! :)

So I thought I'd share some thoughts about my 1st year of blogging:

What were my concerns about blogging - one year ago on July 15th, 2011?

Would it be fun, help me grow and be worthwhile? (I’m all about fun, growth and value. Blogging had to offer these paybacks - otherwise I'd rather be fishing.)

Would I have to goof with a bunch of technical stuff? (I do that all day long and I didn’t want any additional technical complexity after hours.)

Would I unwittingly share something I shouldn’t? (I ddin't want ANY current or former employers and clients to think I was spilling any secret beans.)

Would it impact my Self/Family/Work/Others balance? (I’m short on time, I have a large family to attend, I work a lot and I’m trying to give back to others. I'm trying to be careful about where I spend my time.)

Might it bruise my sensitive male ego? (I get bruised easily enough. I wasn’t sure I wanted to risk adding the general public to my list of potential bruisers.)

What can I now share about my first year?

I’m having fun, growing and seeing value – way more than I expected! (I like being able to share my thoughts, information with others and generate opportunities to meet others via social media and in real life. I’ve made many valuable contacts. I’m still having fun with my blogging!)

It’s technically easier than I thought. (Blogspot, Wordpress or whatever…they’re all pretty easy to work with. If you can browse and click, you can blog. Don’t worry…have fun!)

Blogging requires a clear thought process. (It takes a concerted effort to stay within “the boundaries” and not unwittingly share something you shouldn’t. I believe I’ve done this.)

Blogging takes some effort – but not much when you do it in small bits and use available tools. (I’m learning that “less is more; more or less.” And I’m becoming way more tool savvy. My time sink is sinking!)

I feel I’m a better, stronger person due to my blogging. (I’m learning that sometimes I don’t have anything interesting to write about; so I don’t. But I’ve also learned that blogging is cathartic – sometimes you just got to just talk with yourself and throw those thoughts away.)

And that’s what blogging affords me: a chance to have fun, hone my thinking processes, make an effort, and talk out loud to no one and everyone - all in an effort to gain strength.

So What’s My Plan for Next Year?

That’s a post for another day. In the meantime, go blog about something!

Shim - Steve

Monday, July 9, 2012

What’s the Risk in Using ICD-10 Risk Scoring Tools?

The “ICD-10 Playbook & Financial Risk Calculator” available on the HIMSS website is a tool to “help providers assess their ICD-10 financial risk exposure, identify ways to mitigate that risk, and augment their accounts receivable.” Here's how it's billed:

By simply answering a short survey, providers receive unique insight into the powerful impacts of ICD-10, steps they can take to address those impacts and ways to augment their accounts receivable even before they complete their conversion to ICD-10," said Juliet Santos, HIMSS senior director of business-centered systems.

Indeed, tools like this one can be useful for the awareness they raise in those who use the tool and chew on its output. For that awareness building alone, I think it’s probably a good thing for those facing the ICD-10 mandate. I’d also offer that one should be very careful relying on a simple tool as opposed to readily available checklists or qualified advisory services.

ICD-10 isn’t a game

First and foremost, be clear about the science and math behind any tool used to assign a risk score that may influence your decisions and pathway on such an important endeavor as ICD-10. Ask yourself...

- What’s the methodology for deriving the risk factor?

If it's "proprietary" and can't be shared, I'd suggest questioning its accuracy and value.

- From where were the peer indexes to which each risk factor is compared obtained? 

ICD-10 is one of those Vujà dé events: "you've never been here and neither has anyone else." Are the peer indexes derived from others who’ve used the tool? If so, what’s to say other users accurately responded to the assessment? What about people – like some I know – who just took the assessment to learn about it and randomly answered the questions? :)

Does it make sense?

Some parts/questions seem to have little relation to actual risk. For instance, how do the following questions impact risk? At least in any meaningful way.

In what state is your organization located?
- Does the tool creator have some special knowledge of states that are “more risky” than others?

Are you a nonprofit?
- How does the tax status of a healthcare facility impact its need to perfect ICD-10 compliance?

What most closely describes the function in which you work?
- Is there a higher perceived level of confidence or change to risk score if a Coding & Charge Entry Person completes the assessment vs. a Finance staff member?

Tools must be objective

Moreover, be sure to measure the "subjective questions." It’s hard to accurately assign a score to these type of questions. For instance, what’s the differentiating factor between scoring  an outcome of “very poor,” “poor,” “well,” and “very well” on the following types of questions?

- How well do your coding and charge entry teams work with your revenue cycle teams?

- How would you evaluate the workload of your coding and revenue cycle resources?

- How would you rate physician adherence to the policies and procedures in place for patient record documentation?

Consider the real value? What are the alternatives?

What’s the risk of using a risk assessment tool like this? I’m thinking that the few “mitigation suggestions” offered may actually limit or mask ones ability to consider and appreciate other information. Many “Risk Mitigation Factors” are obvious and have been available from various associations and “quasi-governmental organizations’ in one form or another for quite a while. 

So do a little research, ask some additional questions on your own and revisit this site where my next post will consist of a list of checklists and other “tools” I think are every bit as valuable as any free vendor tools.