ICD-10 and Alternate Universes

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While the focus in session rooms at HFMA’s recent ANI meeting in Orlando was on the big three issues—value, efficiency, and quality—conversations on the exhibit floor centered more on day-to-day financial operations, like the upcoming transition to ICD 10. GallagherFirst, consider the sheer volume of data that will be generated and the implications not just for finance, but the entire organization. Because of that, Michael Gallagher, MD, CMIO, Health Revenue Assurance Associates, believes the topic should be a discussion point around the executive board table each and every week. What if, for instance, an IDN wants to do a central line infection improvement initiative? Due to greater specificity on everything from the central line catheter and the microorganisms involved in the infection, an organization will have to re-specify the report or rewrite the quality metrics, Gallagher notes. “Now you can go back to the microbiology in the ICD-10 codes, because it will be possible to specify with greater clarity what that microorganism is,” he says. “Suddenly, it’s not about the CFO and CIO getting codes right, it’s about the nursing staff, training, and population health.” There also is the issue of alternate universes: Even though you are prepared to pull the switch, some commercial payors will not be ready to accept your claims, triggering a lot of automated bounces. “You will have to renegotiate your carve-outs, and remap these indications to the codes that the payor will pay,” Gallagher advises. “Sitting down and working with Medicaid agencies and finding out how they will process and reimburse for ICD 10 is going to be very important. The way they may process behind the scenes may be that they will translate into ICD-9 or use a different grouper method, DRGs, for instance.” Secondly, consider the enhanced requirements for clinical documentation, a factor in speech vendor Nuance’s recent acquisition of J.A. Thomas & Associates (JATA) clinical services consultancy. “Now, when a patient has an acute MI, the physician just has to say the patient had an acute MI in the past 8 weeks,” explains Melinda Tulley, JATA SVP, clinical services and education. With ICD-10, greater specificity is required, including location in the heart, whether it was a STEMI or non-STEMI, and if there were any complications. Raymer“The challenge is getting physician buy-in,” Tulley says. JATA/Nuance uses a physician-to-physician training approach for ICD-10 clinical documentation readiness. “If there is a high-level of failure with this, then you want to know about it right away.” She estimates that 20% of diagnoses will need additional documentation. NLP to the Rescue The best documentation approach is a concurrent approach, but the reality in most facilities is that there is at least a day’s lag between the time the physician sees the patient and the time the clinical documentation team follows up. By the time the coders begin their part of the billing process, the patient has been discharged. Natural language processing tied to speech recognition will move the process into real-time, sending the documentation process upstream to where the physician dictates a report, Tulley says. Perhaps because the MModal speech recognition solution leans heavily on natural language processing, Michael Raymer, SVP solutions management, would like to skip over ICD-10 and go straight to ICD-11, which is more heavily based on the SNO-MED standard lexicon. “If we are going to upset the workflow, why don’t we do it to move to a common platform for how we document and how we bill?” he asks. “These are two different vocabularies that don’t have a crosswalk between—a perpetuation of the insanity in our health care system. MU is requiring SNO-MED.” The deadline is immovable, Raymer acknowledges, but the stakes are high. “If they are not able to code, they will have a dramatic impact on revenue,” he says. He estimates that 60% of the changes in ICD-10 are related to laterality. Raymer believes front-end speech coupled with natural language understanding, which encodes the dictation in SNO-MED, will provide physicians a strong assist in clinical documentation. “We think we are going to play a substantial role in the transition to ICD-10,” he says. One health system MModal is working with has taken a very proactive approach to ICD-10, implementing front-end speech complemented with narration everywhere in the health system. “The only place they are going to continue to allow old-school transcription is the OR,” Raymer says. Adding a further layer onto the alternate universes theme, this health system has already implemented ICD-10 and is cross-walking codes back to ICD-9 for billing purposes.