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Transitioning to ICD-10

The clock is ticking on the deadline to begin submitting claims utilizing ICD-10 code sets, yet few hospitals have made significant inroads into the transition. With no indication that the October 2013 deadline will change, facilities that are not already deep into the transition will find themselves scrambling to comply -- not an ideal approach to a process that will ultimately drive billing and reimbursement.

One danger in rushing the ICD-10 transition is the risk of overlooking key downstream systems that, though rarely discussed, will nonetheless be impacted by the new code set. Failure to give proper weight to these systems in the compatibility assessment will have significant long-term implications. Information will not flow properly, critical historical data may be lost and, most important, coding and billing will be inaccurate or noncompliant, which will impact the facility's bottom line.

A Significant Undertaking
According to the American Health Information Management Association (AHIMA), plans should be well underway on a comprehensive systems audit for ICD-10 compatibility. Yet a July 2010 AHIMA survey found that an astounding 45 percent of inpatient facilities have not taken any steps toward compliance and just 3 percent have completed the systems audit. (Dimick, Chris. "Three Short Years: Organizations Lagging in 5010 and ICD-10 Progress." Journal of AHIMA 81, no.9 (September 2010): 22-26.)

This procrastination is problematic because of the sheer number of downstream systems that must be evaluated. Some are obvious, such as scheduling, medical record abstracting, laboratory and radiology information systems into which chief complaints, diagnoses and/or procedure information and charge capture are entered and transmitted to the electronic health record (EHR) or billing system.

Others are less obvious but just as critical to the transition process. These systems include:

  • Pathology systems
  • Microbiology systems
  • Cardiac catheterization
  • Cardiovascular
  • Echocardiogram
  • EKG
  • Emergency department information systems
  • GI lab systems
  • OR scheduling
  • PACS
  • Pharmacy/medication management
  • Pulmonary
  • Quality assurance/risk management
  • Registries (Trauma, Cancer, etc.)

It is not unheard of for a 500-bed hospital to have 60 or more downstream systems that are clinical in nature. A 350-bed hospital could easily have 30 such systems.

Whenever these systems have some capacity for capturing, sharing and/or storing an ICD code or whenever the data they generate flows directly or indirectly to the billing or EHR system, they must be evaluated and upgraded as appropriate. That means one hospital could be faced with 60 system upgrades or replacements within the next 3 years.

Identifying Impacted Systems
In a perfect world, identifying and assessing downstream systems would be as simple as reviewing the hospital's system integration map and tracing the interfaces to determine which feed the billing or EHR systems. Unfortunately, many downstream systems operate off the IT grid. It is not uncommon for the chief information officer (CIO) to be unaware of systems in clinical or administrative departments currently in use but not on the master IT integration map.

That is why a truly comprehensive ICD-10 system assessment audit requires detective work. It may begin with IT, but it cannot end there.

A successful assessment requires an in-depth understanding of how clinical, business and finance departments and their unique systems interact with each other in terms of work- and dataflow. This knowledge allows the auditor to pinpoint which systems should be pulled into the assessment.

For example, one downstream system that can easily be overlooked in an ICD-10 assessment is the EKG. When an EKG is performed, data is captured as a procedure code charged from the cardiology department and subsequently sent back to the billing system. The EKG result may be sent back to the EHR, in which case the format of that result should be evaluated to determine if it is structured data. If so, it will likely need to be upgraded to ICD-10.

Another example is when a hospital is also a reference lab. Specimens are often delivered to the laboratory and registered directly into the laboratory information system. Testing is performed and the results are sent to the ordering physician. The laboratory system, and this specimen-handling workflow, must be compliant with ICD-10. Thus, the laboratory system may be capable of capturing appropriate ICD-10 codes to transmit to the billing system. The lab staff must also be trained on ICD-10.

These are not the types of systems, workflow redesign or training needs that would typically come up in an evaluation conducted within the confines of IT unless the auditor had a good business or clinical knowledge of how these systems interact with the EHR and/or billing systems. By sitting down with other clinical departments and business units, it will be possible to uncover the more obscure systems that are nonetheless critical to a successful transition.

The Time to Start Was Yesterday
The challenge for late starters is not just the sheer magnitude of the ICD-10 system compatibility audit. It is also identifying which systems will need to temporarily function in a dual ICD-9/ICD-10 environment and devising a strategy for doing so.

It may be necessary to utilize crosswalks that will convert data automatically. However, that won't be possible for the 5 percent of the ICD-9 codes for which there is no ICD-10 equivalent. Alternative strategies for data conversion will be necessary. What's more, strategies will differ from system to system based on the capabilities of each, as well as the data model, level of integration with the EHR and billing system and the provider's use of that system.

This is why it is important to start system assessments now by experts who can take a big-picture approach focused on work- and dataflow within and between departments. Knowing where to look and what questions to ask will ensure that the final ICD-10 systems audit and implementation plan is truly comprehensive, including the many downstream systems that are critical to success.

Beth Just is CEO and president of Just Associates, a data integration consulting firm specializing in patient data integrity solutions for the HIM, health informatics and health IT markets, and a member of the AHIMA Board of Directors. She can be reached at


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