ICD-10 and
Medical
Transcription
The Perfect Storm
Copyright, C. Tessier, 2012
Claudia Tessier RHIA
May 4, 2012
Full Disclosure
• I am a consultant with an international firm
(ID Information and Documentation in
Healthcare) that designs coding software and
is introducing its ICD-10 software into the US.
• Thus, much of my ICD-10 knowledge comes
from them – BUT I learned and taught ICD-9
coding years ago.
• Of course, you know where my MT knowledge
comes from! And I am here as your advocate.
The Strategic View of Medical Transcription
• “Evolving” medical transcription
practice and business models
• Increasing adoption of
technologies: EMR, SR, CAC, NLP...
• Impending transition to ICD-10
• Need for qualified coders
Integrate Medical Coding
with Transcription
The Perfect Storm of Opportunity
Just what is ICD-10?
• ICD: International Classification of Diseases
– Standard classification: general epidemiological reporting, also health
management and clinical purposes
– Started in 1850s, 1st edition 1893: International List of Causes of Death
– WHO became responsible in 1948 with 6th revision - first edition to
include morbidity causes in addition to mortality
• ICD-9 – adopted in 1977
• ICD-10
– Endorsed by 43rd World Health Assembly in 1990
– Adopted by WHO member states in 1994
– US is among last few countries to adopt ICD-10
• Initial adoption date: October 1, 2013
• HHS has proposed delay to October 1, 2014
Why not stay with ICD-9?
Because it’s…
• Designed for reporting morbidity and
mortality
• Lacks structure and granularity for clinical
decision making and research
• Matches imperfectly in more than 95% of
cases
• Can’t keep up with advances in medicine and
healthcare
• Can’t be relied on to support continuity of
care and management
The ICD-10 Challenge
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Increase from 17,000 to 155,000 codes
25% to 50% decrease in coder productivity
Increase in 3 % error rate to 6% to 10%
Denial rate increase 10% to 25%2
• 10%+ charts will not have documentation
specific enough for coding2
Huge changes and demands
Increased specificity in ICD-10-CM
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Laterality
Episode of care – initial subsequent, sequelae
CC/MCC
Acuity
Anatomic detail
Supporting lab values
Qualifiers: severity, chronic/acute, accompanying conditions, etiology,
fracture type, etc.
Causative agents, drugs, diseases, genetics
Disease processes connected to common manifestations
Alcohol, tobacco, and drugs
Expanded codes for injury, diabetes, alcohol/substance abuse,
postoperative complications
Updated clinical terminology (e.g. diabetes mellitus, malignant/benign
hypertension - e.g., 6 diabetes mellitus categories
Changes in time frames specified in certain codes, e.g., trimesters
Lack of specificity
more physician queries
Benefits of ICD-10
• That increased specificity will
– Improve cost analyses and resource utilization
– Enhance comparability for volume, cost, morbidity and
mortality
– Facilitate opportunities for quality improvement
– Improved revenue stream resulting from documentation
improvement
– Enhance disease management and protocol development
– Support meaningful use
– Facilitate strategic positioning
– Facilitate epidemiological and bio-surveillance activities
Source: Rose Dunn “Better Late than Never: How to Catch up with ICD10-CM/CPS in 2012,” AHIMA ICD-10 Summit, April 2012
Convergence of Initiatives
ICD-10
Meaningful Use
Clinical Analytic
Dashboards (BI)
Lower Medicare
reimbursements
ACOs
Medical
Homes
PQRI
DRG-driven
reimbursement
cutbacks
Value-based
purchasing
Better Documentation = Improved Coding and Improved
Information for Patient Care and Reimbursement
Changing Regulatory Environment
• Federal/state payment initiatives and reforms
impact documentation and coding
• ICD-10 will bring greater demands
– Clinical documentation must be more specific
– Coder productivity will drop
– Training will take coders and CDI specialists away
from daily workflow
Relationship between EHRs and ICD-10
• Some EHRs are successful without structured
documentation BUT
• Specific structured clinical data are needed to
achieve meaningful use AND
• ICD-10 clinical documentation must be highly
structured
• Therefore, the documents you transcribe will
become increasingly structured
ICD-9 to ICD-10 Transition
Impacts Coders
• Coders need expanded clinical,
medical language, anatomy and
physiology, pharma, lab data
knowledge.
• Intelligent coding is the key to
accuracy
ICD-10 and Clinical Documentation
• Data integrity is the Issue
– Must capture specificity in documentation
– So, how to improve documentation accuracy
• Predicted 10% to 20% increase in
documentation in response to ICD-10
• Denials will increase initially
Medical Transcriptionists as Coders
• Both require knowledge of
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medical language
anatomy and physiology
clinical assessments
diagnoses,
treatments
procedures
pharmacology
pathophysiology
laboratory practice
• Both must be able to
– Read and understand patient medical records
– Abstract patient information quickly and accurately
– Research clinical information effectively
Impact of Connecting Coding with
Transcription
• Expanded pool of qualified coders
• Delayed or incomplete coding instances reduced
• Diagnoses and procedures supplemented by MTs’ knowledge of and
access to content
• Coding process facilitated and streamlined
• Improved clinical documentation
• Reimbursement based on more accurate, complete, and timely
coding
• Delayed reimbursement due to requests for supporting
documentation to support diagnoses diminished
• Clients potential for revenue increased
• More accurate, complete, and timely coding
• Clinical documentation services will provide valued service
to clients
potential for increased revenue
Coding Resources
• The usual – medical dictionaries, word books,
pharma and lab resources, etc.
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CAC – computer assisted coding
NLP – natural language processing
Remote coding
EHR-supported coding
Automated feedback
CDI efforts - clinical documentation
improvement
Use of Patient Documents
Coders
Medical Transcriptionists
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History and physicals
Discharge summaries
Consultations
Progress notes
Operative and procedure
reports
• Radiology reports
• Pathology reports
Coding with ICD-10
Crosswalk: ICD-9 to ICD-10
Clinical Documentation Improvement
• Migrating paper records to electronic via hybrids
• Deliberately discourages
– Copy and paste
– Handwriting
– Free text narratives
• Partial solutions
– Templates
– Speech recognition
– Direct entry via pick lists, pull-down menus…
Clinical Documentation Improvement
• Physician clinical documentation goals
– Standardized content and streamlined workflow
– Address quality and regulatory considerations
– Avoid financial penalties for poor documentation
– Enhance clinical value
• Technology advancements
• Workflow changes
Workflow Changes
• Documentation in multiple locations vs centralized
records
• Automated feedback to clinicians as they document
• CDI (clinical documentation improvement) programs
• Transcription-supported coding
• Concurrent coding via EMR
• Electronic queries generated within EMR
• Remote coding, chart reviews/audits
• Include query response TAT within suspension process
• Final coding
Concurrent CDI and Coding
• The route toward data improvement and
integrity
• Documentation leads to coding
• Ergo…
Opportunity!
Technology Changes Impact Coding
• Increased use of technology improves
productivity, compliance, consistency of
documentation and therefore of coding
– CAC, NLP
– ICD-10 crosswalks and mapping
– DRG Grouper
– Optimization of EHR-supported coding
– Electronic queries and templates
What is Computer-assisted
Coding?
• “…the use of computer software that
automatically generates a set of medical codes
for review, validation, and use based upon
clinical documentation provided by healthcare
practitioners.”
– Delving into Computer-assisted Coding
(AHIMA Practice Brief, 2004)
Impact of CAC on Coding
• First 9 months, expected 50% decrease in
efficiency
• CAC can offer gains up to 30%, reducing impact to
20%
• Staff augmentation necessary
• Increase coder efficiency
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Potential code alerts
Reports/results accessible online
Reduce paper shuffling
Automated workflow
CAC Goals
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Solid foundation for ICD-10 readiness
Seamless integration
Improved documentation
Improved quality
Greater productivity
Greater consistency
Real-time coding
Automation/integration of critical documentation data, e.g., POA, ROM, SOI
Reduce labor and outsourcing costs
Generate correct, compliant billing
Reduction in denials
Reduce A/R days and DNFB
Improves capture of patient severity
Facilitates identification of PSI/HAC
Integrates with CDI and improves DRG accuracy and potential queries to physicians
Improves coder and CDI staff satisfaction
Facilitate communication between coders, CDIS, clinicians, MTS
NLP and CAC
• CAC with natural language processing as single
platform is best solution
• Improves workflow and production
• Facilitates achieving CAC goals
What is NLP?
• A form of artificial intelligence
• Reads text and understands meaning from standard
dictation/transcription, SR, and templates with free-text fields
– Most cannot read images of text or handwritten documents
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Word-search functions for terms to support clinical findings
Compares new and old documents
Identify query opportunities improve productivity and accuracy
Auto-suggest codes
Crosswalk ICD-10 and guidelines to alert for additional specificity
needed
• Different types
– Rules-based
– Statistics-based
– Combination
• May give overwhelming feedback – need to discriminate
NLP: Stage 1 – Documents Uploaded
NLP Stage 2: Analysis and Action Begin
Major Concern re Transition to ICD-10
• Coder shortage and productivity
• Reactions/solutions
– Training
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Advance
At implementation
Ongoing
Sometimes funded
– Retention bonuses
– Sign-on bonuses
Opportunity!
What is Needed for MTs?
• Training for coding
• Understanding of computer-assisted coding
tools
• Understanding how NLP can be integrated
• Marketing of new value to transcription and to
its users
MTs have a Key Advantage
MTs do not
have to
unlearn
ICD-9
Training Requirements
• Variable depending on clinical knowledge and
knowledge of coding systems
• Medical transcriptionists
• Already have clinical knowledge
• Need to gain in-depth knowledge of coding systems but
do not have to unlearn ICD-9
• Need course work plus lab time
Training Options
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Internal resources
Colleges/community colleges/technical schools
Apprentice programs
Online programs
Websites
YouTube
Professional associations
MT resources, e.g. MT Tools Online
Coding Training
• AHIMA – approved coding certificate program
directory
– Find sites
athttp://www.ahima.org/careers/college_search/se
arch.aspx
– Search by state and by whether onsite or distance
learning
Coding Credentials for Hospitals or
Physician’s Offices – AHIMA*
• CCA – certified coding associate – first-level
• CCS: certified coding specialist – mastery-level
• CCS-P: certified coding specialist--physician-based
Note: The U.S. Department of Labor's Bureau of Labor Statistics projects a
20% increase in employment before 2018 for the Medical Coding and
Billing field, which includes medical coding and billing professionals.
This represents more than 37,000 new jobs.
• AHIMA coding credentials are the only ones currently accredited
by the National Commission of Certifying Agencies
Coding Credentials for Physician Offices
and Outpatient Hospitals – AAPC*
• CPC: certified professional coder – physician’s
office
• CPC-H: certified professional coder –
outpatient hospital
• CPC-P: certified professional coder – payer
• CIRCC: certified interventional radiology
cardiovascular coder
• Multiple specialty coding credentials
*American Academy of Professional Coders
2008 AHIMA Salary Survey for Coders
Coders working in consulting
services
• average salary of $57,700.
Otherwise, averages range from
• $36,502 for coders in home
health or hospice to
• $48,115 for those in nonprovider settings.
Medical Coder Salaries: 2011 AAPC survey
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Average for CPC was $46,900 (up $1400 from previous year).
Over half the respondents reported earning more than $40,000.
Recent Postings: Medical Coder Salaries
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Inpatient/DRG Coder
Remote coder
Coding Supervisor
Traveling IP Coders, Full travel
Home-based Lead Coder
Inpatient Coder
Corporate Coder
Senior IP/DRG Coder
$38-$59K
$43-$75K
$50-$60K
$50-$60K
Up to $60K
$56-$78K
$65-$75K
$68K
MT Salaries
• AHDI May 2002 salary survey: $31,400
• Occupational Outlook Handbook, Bureau of
Labor Statistics
– 2010 Median Pay
$32,900 per year
$15.82 per hour
• PayScale.com – national pay data 2012
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Hourly rate: $9.89 - $19.42
Overtime: $11.73 - $29.71
Bonus:
$0 - $12,83
Total:
$19,135 - $41,771
Remember?
• Three levels of medical transcriptionists
(per 1999 Hay Study)
• With integrated coding skills, medical
transcriptionists can create and enter the
Fourth Level
New career opportunity
Evolution of the MT Profession
Coding, CAC, NLP,
and CDI
Capturing
clinicians’ voice
and transcribing
1970s-1990s
Word processing,
computers,
internet, speech
recognition, and
EMRs
Trad’l capturing of
clinicians’ voice and
transcribing
1990s-2012
Computers,
internet, speech
recognition, EMRs,
structured data
entry
Trad’l capturing of clinicians’
voice and transcribing
What’s Next
To Quote a Colleague
• The Potential for MTs
– I really believe this [coding] is something many MTs can pick
up on easily. It’s such an easy transition because we have the
basic fund of knowledge that’s required in terminology,
anatomy and physiology, pharmacology, and pathophysiology.
– The rest really is about learning the rules for coding and
learning how to use your books to find the right codes…[e.g.,
being] able to identify what the primary diagnosis is in an
encounter. I believe we’ve been doing that for a long time.
– If you’re looking for a transition, I think this one has great
potential.
• Kathy Nicholls, Coding Corner Update, MT Tools Online, April 24,
2012
What do we need?
• A project that addresses both training and
integration of coding with transcription to
address
– Coding education requirements for MTs
– Process and flow requirements for integrating
coding into medical documentation/transcription
– Business models
• Rebranding!
Questions
• How much do we have to invest in training?
• How much of transcription productivity will be lost due
to coding?
• How much coding productivity and value will be
gained?
• How much can be charged for the integrated process?
• How much can MT/coders expect to be paid?
• What will it affect status and value of MT? Of coding?
• How will it affect patient care, reimbursement, CDI,
etc.?
• How will it affect our future?
So…
who will
benefit
from
this
perfect
storm?
Those with
Blue Sky
Thinking!
Thank you!
• For a copy of the slides and to learn more
– c.tessier@id-diacos.com
– 617-816-7513
Glossary of Abbreviations
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5010 – upgrade of HIPAA 4010. Revised medical billing/coding data of ICD-10-CM
& ICD-10-PCS will be accommodated by all covered entities in a better manner.
ACA – Accountable Care Act
ACO –accountable care organization
ADR – adverse drug reaction, additional documentation request
AHRQ – Agency for Healthcare Research and Quality
CAC – computer assisted coding
CC/MCC – complication/co-morbidity - major CC
CDC – Centers for Disease Control and Prevention
CERT – Comprehensive Error Rate Testing
CMS – Centers for Medicare and Medicaid Services
CPT – Current Procedural Terminology
DNFB – discharged, not final billed
DRG and MS-DRG – Diagnosis-related Group, Medical Severity DRG
GEM – General Equivalence Mappings
HAC – Health Administration Center (VA)
HEAT – Health Care Fraud Prevention and Enforcement Action Team
HCPCS – Healthcare Common Procedure Coding System
HEDIS – Healthcare Effectiveness Data and Information Set
Glossary of Abbreviations
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HHS – (US Department of) Health and Human Services
ICD – International Classification of Diseases
ICD-10-CM – ICD-Clinical Modification
ICD-10-PCS – ICD-Procedure Coding System
NCHS – National Center for Health Statistics
MAC - Medicare Administrative Coordinator
MIC – Medical Inefficiency Committee
MUE – medically unlikely edits
NCCI – National Correct Coding Initiative
OAG –Office of Inspector General
POA – present on admission
QIC –qualified independent contractor, Quality Improvement Council
RAC – Recovery Audit Contractors
ROM – risk of mortality
SNOMED-CT – Systemized Nomenclature of Medicine – Clinical Terms
SDX – secondary diagnosis
SOI – severity of illness
WHO – World Health Organization
ZPIC – Zone Program Integrity Coordinators