Mounting an informed, intelligent transition to ICD-10

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 - Ben Strong, MD
Benjamin W. Strong, MD (ABR, ABIM), Chief Medical Officer, vRad

Countless healthcare providers of every type heaved a sigh of relief when CMS announced a one-year grace period following the Oct. 1, 2015, launch of ICD-10.

At a volume of 6 million studies per year, perhaps no one in radiology had more at stake than vRad when the agency flipped the switch on ICD-10’s soft launch on Oct. 1, 2015. Yet, just four months into the transition, the radiology services leader reports a successful transition at more than 2,100 client-provider sites.

The company has seen zero increases in the time it takes to post charges, no increase in denied claims due to medical necessity and a rise of zilch in days sales outstanding (DSOs), which is the time it takes to get reimbursed for completed work as a direct result of the transition to ICD-10.

More striking still, vRad has realized a 19% reduction in addenda requests coming in from coders seeking more information than they received in their radiology reports. The reduction cuts across vRad’s entire practice, including preliminary reports (for which ICD-10 compliance is far less relevant than it is for final reports).

How did they do it (particularly with limited control of processes at many client sites)?—and what can others learn from their labors? These questions and others are answered in a new vRad white paper detailing insights, best practices and pearls for providers wisely seeking to attain full ICD-10 code specificity in the months leading up to the hard deadline of Oct. 1, 2016.

Shannon M. Werb, Chief Operating & Information Officer

The practice’s CMO, Benjamin W. Strong, MD (ABR, ABIM), and COO/CIO, Shannon Werb, fleshed out the essence of the white paper—ICD-10: An Informed and Intelligent Transition—in a recent conversation with Medical Imaging Review.

Multidisciplinary mission

The pair recall how vRad started ramping up for ICD-10 in earnest in early 2014, when October of that year was still the expected launch date.

“October 1st felt like a looming brick wall given the complexity of providing imaging services for thousands of facilities—each with unique internal ordering processes and nomenclature,” Werb says. “We knew we had to lay a foundation for having a common, standard set of procedures so that when our clients ordered services from us, we knew exactly what those services were and how they related to services ordered by other clients.”

With input from medical leadership and numerous vRad departments (including account management, client services and billing compliance), Werb’s technology team set out to build a solution. They started creating a way to convert all clients to a standardized procedure set—and an expanded one in anticipation of ICD-10’s 70,000 possible codes—without interrupting the way the customers currently did business with vRad.

That meant creating a solution that would allow all 2,100-plus client facilities to order a study using their own unique internal naming conventions; one hospital’s “ultrasound gallbladder” is another hospital’s “ultrasound right upper quadrant” or “ultrasound liver.” Descriptions that facilitate the protocoling process are not standard across practices or facilities—even if they are all part of the same integrated delivery network with a common EMR.

“Creating a standard procedure set was a mapping and normalization exercise on steroids,” Werb explains. This was the beginning of Phase 1 of the project—or “Speaking the Same Language” as it is referred to in the white paper. It took the company almost a year and a half to complete.

Applying the 80/20 principle

Once the common-language foundation was built, Phase 2 was initiated. The white paper refers to this stage as “80/20 Relevant Reasons,” a bit of wordplay on the management-science principle that roughly 80% of the benefit comes from 20% of the work.

The idea was to “fully understand those customers and procedures that were most impactful for us in assuring success,” Werb explains. The company’s billing-compliance team performed a detailed assessment to shed light on commonly ordered imaging procedures. Their analyses enabled the team to focus on a subset of inputs, and still cover 99% of our billed volume. The team also looked hard at what clinical information was commonly coming in and what was too-often missing.

“How could we use this information to make it easy for our clients to provide all the information needed for ICD-10 compliance with a minimal amount of change to their existing internal workflows?” Werb asks. These insights led directly to focusing vRad’s design and development efforts in Phase 3, or “Automated Intelligence.” This final phase entailed building out the technology necessary to support the collection of standardized procedures and the additional clinical information required by ICD-10—all within an order-management system and dashboard with which vRad’s client base was already familiar.

“The biggest challenge was creating an environment where the customer is going to provide us with more clinical information without feeling like they actually did that,” Werb explains. “We knew we had to make it easy, quick and painless for them. For most companies, time is money. For a radiology practice, time is also the difference between positive and negative patient outcomes. The more time on the front-end, the less time our physicians have to be doctors and deliver quality care.”

The result was an “intelligent branching” system, by which the technologist is walked through a highly customized process to identify the relevant reason for exam—in steps that are richly complex in the core technology, yet elegantly simple for the user.

Growing medical knowledge

CMO Strong also saw the ICD-10 challenge as an opportunity for vRad to raise its game and consistently get better clinical information from referring physicians, across all customer segments. He was vocal in cheering the team on as members developed intelligent branching into a foolproof way to turn vision into reality.

The result is an ICD-10-compliant approach with serial question options and their associated check box answer set, each one intelligently informed by answers to the preceding question set. For example, when a technologist tries to enter simply “pain,” as has so often been the case in the past, a series of questions appear: “Where?”… “Acute or chronic?”… “Is there fever?” … “Is there trauma?”

The software assembles the answers into a readable sentence which prepopulates the radiologist report header from which an ICD-10 code can be generated. Moreover, Strong emphasizes, the information is automatically prepped for analysis from a data-analytics standpoint.

“Our radiologists have the robust clinical history they need,” Strong says. “Our coders and billers have the ICD-10-compliant information necessary to generate a code. And our analytics processes have ordered standardized clinical histories on which we can base our estimations of resource utilization and outcomes.”

Strong pauses, then conveys his excitement over the analytics aspect of the system.

“If you think about what effect on patient care all this is going to have, honestly it’s almost incalculable,” he says. “This is going to enable an analytics approach using standardized clinical histories that will allow us to carefully evaluate the resource utilization of imaging across ERs throughout the country—and tie that, ultimately, to patient outcome itself.”

Patients at the center

Another bar-raising feature of vRad’s ICD-10 solution is a highly integrated radiology report formatting software program entitled rScriptor by Scriptor Software that uses natural language processing to check for (and alert to) errors, omitted diction required for ICD-10 and PQRS compliance and internal report inconsistencies. This analysis is performed real-time allowing the radiologist to correct any reporting error before the report is signed. It also checks for the reporting of critical findings such that communications to referring physicians are expedited.

Werb closes the interview by stressing that vRad’s ICD-10 work undergoes continuous quality improvement.

“We are not done yet,” he asserts. “CMS did provide a grace period, but, in October 2016, they are going to ratchet up the specificity one more time. We have the same level of passion it took to get us to this point with ICD-10 and the solutions we’ve already rolled out ensure readiness for vRad and our partners.

“We believe our approach is very stepwise and logical. It points toward making sure that patients are receiving the right care at the right time—and that studies are interpreted by the right physician with the right information—so that patients have the best outcomes and highest-quality experiences.”

Read the vRad white paper ICD-10: An Informed and Intelligent Transition or contact a vRad Expert Advisor.