The Impact on Productivity in ICD-10-CM/PCS:
Issues Found in the Current ICD-9-CM Environment at Montefiore
Mazette H. Edwards, MA, CDIP, CCS, CPC-H, AHIMA ICD-10 Approved Trainer
Disclaimer
The information contained in this presentation is intended to be
used for informational purposes only. It represents results based on
studies conducted at Montefiore, in New York.
Analyses are supported by findings of leaders and participants of
conducted study. They are presented to exemplify the impact at
Montefiore and should not be taken as confirmed results for all
institutions. It is recommended that all institutions conduct their
own studies tailored to suit their policies and needs.
Individuals are encouraged to contact presenter if they have any
questions about the information found in this presentation.
Agenda
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Introduction and Objective
Background Information: Montefiore
ICD-10 Implementation Timeline
Dual Coding vs. Duplicate Coding
GEMs
Tailored CDI
Benefits of Dual/Duplicate Coding
Game
Takeaways
Questions
Overview
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Improve quality
Decrease cost of healthcare.
Preparation is key
Montefiore has prioritized preparation for ICD-10CM/PCS since 2011
• Productivity when coding with ICD-10-CM/PCS
• Methods
Objective
• To compare coding methods and the effect they will
have on productivity;
• To identify issues when coding discharges in ICD-10CM/PCS and the effects they will have on productivity
and revenue;
• To optimally resolve the issues and derive ways to
improve the current environment for ICD-10-CM/PCS
“Go Live”
BACKGROUND INFORMATION
Montefiore
Montefiore
To heal, to teach, to discover, to advance the health of the communities we serve
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As the academic medical center and University Hospital for Albert Einstein College of Medicine,
Montefiore is a 1,418 bed health system nationally recognized for clinical excellence - breaking
new ground in research, training the next generation of healthcare leaders, and delivering sciencedriven, patient-centered care
Epicenter of high quality patient care in the Bronx and surrounding areas in New York; provides
healthcare services to more than two million people in the Bronx and Westchester County with
86,500 discharges; 12,939 outpatient surgeries; 830,000 outpatient visits and 301,000 Emergency
Department visits
Montefiore is ranked among the top hospitals nationally and regionally by U.S. News & World
Report. For over 100 years Montefiore has been innovating new treatments, new procedures and
new approaches to patient care, raising the bar for medical centers in the region and around the
world
Montefiore believes in providing coordinated, compassionate and leading-edge healthcare.
Through highly integrated teams of physicians, nurses, social workers, mental health professionals
and other caregivers, Montefiore pioneers a seamless system of care focused around the patient
Montefiore is distinguished among premier academic medical centers for its deep commitment to
the community
Montefiore
Transition from a hospital to a world renowned Health System
Westchester
Square
Medical Office
The Children’s
Hospital at
Montefiore
(CHAM)
North Division
(Wakefield
Hospital)
Weiler
Hospital
Moses
Hospital
Mount Vernon
Hospital
New Rochelle
Hospital
Montefiore
Health Information Management Department
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The Health Information Management Department (HIM) at Montefiore is responsible for
operations and provision of services at all divisions, cancer registry operations, and
registration data integrity and quality
HIM Department is committed to providing accurate and timely health information that
meets the clinical, administrative, and financial needs of the healthcare community, while
maintaining the confidentiality of patients
Transitioning from Hybrid to EHR
• Medical record generated in a paper format
• Paper record is sent to HIM for prepping, scanning, and indexing
• Medical record uploaded to EPF for virtual availability to users through Montefiore
network
• Medical Audit Analyst review charts in EPF to code patients’ visits and submit query
forms for any vague, unclear, or missing information.
Utilizes Looking Glass (formerly eCHARMS) by Streamline for our abstracting system
Impact On The Organization
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ICD-10 will impact all sectors of healthcare
Diagnostic and procedure codes are utilized from the start of healthcare services through the
patient experience, from data creation to data use, and control reimbursement
It is projected that there are significant costs and negative impact associated with ICD-10
transition
– 10%-50% decrease in coder productivity
– Fourfold increase in existing DNFB and A/R days for up to nine months postimplementation
– Up to a 25% increase in re-works from claim rejections, adjustments and inquiries
– $50 million to $250 million in productivity loss among physicians
– Denial rates expected to increase 10% - 25%
– Over-coding due to inexperienced coders will lead to a potential increase of 10% - 25% in
RAC/MIC backlogs
Evolution ICD-10-CM/PCS
In 2011, Montefiore commenced training in the HIM Department in
preparation for the ICD-10 transition
2011
Anatomy & Physiology detailed review
Conducted by NYHIMA ICD-10-CMPCS series
2012
Pathophysiology detailed review in
conjunction with CDI nurse managers
•Specific diseases were targeted each month
ICD-10-CM-PCS combination of:
•3M educational modules
•In-house ICD-10-CM/PCS trainer
•9 hours per week in class training on:
•New coding guidelines
•New code set structure
•Documentation required
•Reinforcement of pathophysiology
2013
Coding in ICD-10-CM/PCS
•Dual coding
•Duplicate coding
•Refresher on problematic areas:
•Cardiovascular procedures
•Pregnancy
•Nervous system
•Musculoskeletal system diagnoses and
procedures
ICD-10 NOW
• Montefiore’s HIM Department began coding records with ICD-10 in mock trials, in
December 2012
• Training and communication will continue throughout 2014
• The HIM Department at Montefiore hypothesizes that if the organization is
thoroughly prepared for “Go Live,” the productivity of Medical Audit Analysts will
not be severely affected, and the benefits of ICD-10 will overwhelmingly outweigh
the negatives, if any
METHOD
Identifying the problems when coding with ICD-10-CM/PCS in the current environment
Defining The “Method to our Madness”
• Dual Coding
– Medical Audit Analyst (MAA) assigns both ICD-9 and ICD-10 codes in a
single coding session
– MAA first assigns ICD-9 codes, then assigns ICD-10 codes in same
setting
• Duplicate Coding (variation of dual coding)
– MAA codes discharge in ICD-9
– Another MAA codes same discharge in ICD-10
• Native Coding
– Coding discharge utilizing usual procedure (abstracting, codebook etc.)
• General Equivalent Mapping (GEMs)
– Utilizing program to convert ICD-9 codes to ICD-10
Benefits and Goals
• Benefits of Coding Analysis
• Dual Coding / Duplicate Coding
– Time to practice for ICD-10
– Actual revenue impact once change happens
– Analyze data to pinpoint diagnoses with high risk for losses with inadequate
documentation
– Train physicians in what is needed to refrain from reimbursement loss
– Identify need for additional coding resources
– Full preparation for ICD-10
• To prevent current productivity loss due to using resources to code in ICD-10
– Hire consultant companies to currently code discharges
Method I.
Perform Dual Coding Analysis
1. Select 10 Medical Audit Analyst (MAA) to natively code
current discharges with an average length of stay (LOS) of 7
days for Medicare and Medicaid patients in ICD-9-CM
2. The same group natively codes the same discharges in ICD10-CM/PCS
3. Each MAA is given 10 inpatient discharges to natively code in
7.5 hours, to maintain current average coding productivity
Method II.
Perform Duplicate Coding Analysis
1. Select 5 MAA to natively code current discharges with an
average length of stay (LOS) of 7 days for Medicare and
Medicaid patients in ICD-9-CM
2. Select another 5 MAA to natively code the same discharges in
ICD-10-CM/PCS
3. Each coder is given 20 inpatient discharges to natively code in
7.5 hours, to maintain current average coding productivity
RESULT INTERVENTION
Number of Charts Coded Daily
Montefiore Dual Coding Productivity
Results
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20
18
16
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12
10
8
6
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7 Month Trial Period
Average # of charts expected to be coded according to average productivity (18
charts)
Average # of charts actually coded in ICD-9 and ICD-10
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Dual Coding Analysis
Due to decrease in productivity, dual coding
method was terminated before the end of
projected trial
Increase in days in A/R
DNFB not maintained
Expected to code 18 cases in both ICD-9 and
ICD-10
– 9 discharges in ICD-9;
– 9 discharges in ICD-10
Actual average coded discharges: 6 total
RESULT INTERVENTION
Number of Charts Coded Daily
Montefiore Duplicate Coding Productivity Results
18
16
14
12
10
8
6
4
2
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Number of charts expected to be coded
Number of charts coded in ICD-9
Number of charts coded in ICD-10
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7 Month Trial Period
Number of charts coded in ICD-10
Number of charts coded in ICD-9
 Productivity in ICD-9 was maintained
 Decline in discharges coded in ICD-10
Number of charts expected to be coded
Duplicate Coding Analysis
• Inpatient coder productivity rates:
– Currently codes 18.75 encounters per day in ICD-9-CM
• Converts to a rate of 2.5 encounters per hour
» 24 minutes to code each encounter
– Inpatient coder in ICD-10-CM/PCS system
• Currently codes 10 encounters per day
– Converts to a rate of 1.3 encounters per hour
» 46.2 minutes to code each encounter
• Time to code same encounter doubled; resulted in decreased in productivity
• Duplicate Coding method proved to be more productive however, than Dual Coding
method.
Method III.
• Analyze Coding Productivity Utilizing GEMs
1. Select 5 MAA to natively code current discharges with an
average length of stay (LOS) of 7 days for Medicare and
Medicaid patients in ICD-9-CM
2. Select another 5 MAA to code the same charts in ICD-10CM/PCS utilizing electronic software for mapping.
3. Each coder is given 20 inpatient cases to code in 7.5 hours, to
maintain current average coding productivity
GEMs: Not a hidden “charm”
• Inefficient way of learning the ICD-10 coding methodology
• Compromise in quality
• Takes time away from coding and transfers it to deciphering
best code match based on chart documentation
– Does not decrease amount of time necessary to code
discharge in ICD-10
– Need to rescan and abstract charts for added information
• Inaccuracies in code assignment
• Revealed documentation issues
Duplicate Coding Overall Results
• Revealed issues in documentation that would negatively impact productivity and
reimbursement
• Cases unnecessarily difficult to code with ICD-10-PCS due to insufficient
information
• Site and laterality were key missing notes abstract
– MRI’s, X-Rays and CT scans: no record of contrast medium
– Injections and infusions: no record of administered site
– Port-a-cath and vascular catheters: no specification of insertion site, no specification
of artery or vein
– Vague descriptions of physical and occupational therapy
– CABG: no specification of which vein (greater or lesser, left or right) the graft comes
from
– Vague descriptions of fetal monitoring
– PTCA: unclear about exact coronary artery sites angioplasties were performed on
– Blood transfusions: Sparse information on kind of blood product, administration,
autologous vs. non-autologous
– Neoplasms: Laterality absent
ANALYSIS
Solution, Summary, Closing
Eye-Opener, Pocket-Closer
• Dual Coding
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Time consuming
Coder abstracting and coding the same encounter twice
Decrease in productivity
Increase in days in A/R
• Duplicate Coding Method more productive, less impact on reimbursement
• Mapping utilizing duplicate coding did not improve productivity, repetitive
process
• Mapping utilizing dual coding would negatively impact reimbursement
• Duplicate along with CAC may improve productivity in future
• Documentation downfalls revealed for ICD-10
– Increase in Physician queries for ICD-10
Clinical Documentation Improvement
• Major benefit of dual coding process is tailored CDI
• Training is tailored for clinicians in respective specialties
– Decrease amount of time dedicated to training
– Shows benefit of specificity for reimbursement
– Decrease in amount of records queried
– Decreases hindrances on coder productivity
– Elimination of ambiguous information
• Physician documentation assessment
• Enhance completed medical records with implementation of
electronic health records
• Holistic approach
Benefits of Duplicate Coding Process
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Measure productivity impact
Revenue reimbursement analysis
Identify physician query opportunities
Coder training
Generating data for end-to-end testing
Possibly improve documentation
Impact Case Mix Index
Increase in SOI and ROM scores
Takeaways
• Updating of policies and procedures ( Coding
Department)
• Continue to training and educational preparation
• Documentation for both diagnoses and procedure
codes
• Looking at top 10 DRG's in ICD-9-CM
• Looking at the top 10 diagnoses in ICD-9-CM
Summary
• The study performed allowed the HIM Department at Montefiore
to unravel issues MAA face daily
• Understanding from a primary perspective gives Montefiore
outlook on efficient changes which should be beneficial to the
implementation of ICD-10-CM/PCS
• Upon completion of further training, and installation of upgraded
technology, Montefiore plans to conduct another assessment to
observe how the Coding Unit will perform with the proposed
solutions
• With the addition of Electronic Health Records (EHR), Computer
Assisted Coding (CAC), further demo coding in ICD-10-CM/PCS,
Montefiore feels confident in preparation for ICD-10-CM/PCS GO
LIVE!
Thank you!
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Mazette H. Edwards
Director of Clinical Coding Practice
914-349-8144
maedward@montefiore.org
References
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http://ahima.org
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http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10_Introduction_060413[1].pdf
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http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10LargePracticesChecklistTimeline.p
df
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http://www.montefiore.org/
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http://streamlinehealth.net