ICD-10 Implementation Success Stories

Welcome to the success story section where you can read the achievements and progress of how practices and hospitals across the country are successfully working towards ICD-10 implementation. In this section practices and hospitals share key components of their transition, lessons learned, and the challenges they face.


Baystate Health System

Walter Houlihan is the Director of Health Information Management and Clinical Documentation, reporting to the VP of Clinical Informatics and Chief Medical Information Officer at Baystate Health in Springfield, MA. He is also the current President of MaHIMA and an Advisory Board Member of ACDIS. Jennifer Stebbins is the ICD-10 Project Manager along with being the Director of Clinical Informatics and also reports to the VP of Clinical Informatics. Baystate Health today includes a level 1 academic medical center, three community hospitals, over 80 outpatient and primary care facilities, a visiting nurse association and hospice, a regional reference laboratory, and a health insurance company. The system has won an SDI award for being among the 100 Best Integrated Health Networks in the US for the past 13 years. Baystate was also named to Hospital & Health Networks HealthCare’s Most Wired list in 2014.

Actions Taken to Prepare for ICD-10

Under the direction of the office of Health Information Management and Clinical Documentation Baystate Health has been conducting ongoing preparation and staff training across all components of the delivery system. Examples of the resource commitment and activities that highlight Baystate’s ongoing efforts and commitment to ensuring a successful transition to ICD-10 are as follows:
  • The Health Information Management and Clinical Documentation professional staff includes 8 nurses, a physician and 57 professional coders.
  • Baystate conducted an ICD-10 financial impact analysis by having one year of medical records from each facility analyzed to determine the % of records in each specialty where the current clinical documentation would be at potential risk under ICD-10. This enabled the HIM team to further review the potential risk identified in order to determine if documentation and/or coding could be enhanced to accurately capture the severity of the patient and services rendered to mitigate the potential financial risk.
  • There are approximately 80 ambulatory practices within the system, many but not all are employed physicians.
  • During 2014, with the full support of senior medical leadership, Health Information Management educated these providers on the importance of complete and specific documentation with clinical specialty-specific introductions to ICD-10 along with an emphasis on clinical documentation requirements and specialty-specific case study examples.
  • These training programs have also focused on defining the actual benefits of the increased specificity of ICD-10 for the physicians themselves and for their patients.

Some Specific Benefits of ICD-10

There are a number of examples of how the added specificity of the ICD-10 code set will provide added value. These include:

  • The ability to accurately capture the severity of a patient’s illness and conditions is critical. If a physician feels that he/she “treats sicker patients” ICD-10 will help them portray themselves accurately in their physician profile data.
  • A major benefit of ICD-10 will be its contribution to continuity of care for a physician’s patient throughout the other parts of the delivery system. Asthma diagnoses are one example of how greater specificity of patient condition information under ICD-10 will help ensure appropriate subsequent follow-up care.
  • ICD-10 will also help further overall research efforts on patient populations.

Lessons Learned from Baystate’s Efforts

Baystate BuildingBaystate has learned from experience that having the full support of medical leadership along with face-to-face engagement with physicians are the most effective means of preparing their practices, and the delivery system as a whole, for the upcoming ICD-10 transition. Physicians will benefit from the level of clinical documentation required under ICD-10 because it will help to validate the medical necessity of all of their requests for patient referrals. A key point to stress with the providers is the critical importance of complete and specific clinical documentation now with ICD-9 and in the future with ICD-10. It is also important to always bring the discussion of the need for complete and specific documentation back to providing optimal care to each patient. Ask the physician, would you treat your patient differently if you read in the medical record from the previous provider that your patient had “congestive heart failure” vs. “acute or chronic diastolic congestive heart failure”? Their answer should be… “Yes, it would make a difference on how I would treat the patient” and that is the main reason for improving documentation.

Humana

Sid Hebert is the ICD-10 Program Manager for Humana Inc. responsible for assisting Humana with implementing the revised HIPAA 5010 electronic transaction standards and the ICD-10 code set. Mr. Hebert has participated in ICD-10 Monitor’s Talk Ten Tuesdays and BCBS’s Open Line Friday, speaking on topics ranging from “Navigating to ICD-10” to “A Payer Status on ICD-10.”

ICD-10 Provides an Opportunity to Improve the Monitoring of Chronic Diseases

One of the greatest ICD-10 benefits will be derived from the improved ability to target chronic diseases earlier in the onset stage and facilitate the analytics required to better identify the effectiveness of different procedures and clinical support systems. Currently, Humana is building an ICD-10 Chronic Condition comparative reference capability for its medical management analysis programs. This will allow Humana to compare and analyze ICD-9 and ICD-10 chronic condition code categories to predict trends and clinical outcomes for chronic conditions. Humana analyzed the adjudication process end-to-end and rewrote medical policies, benefit plans and provider contracts using ICD-10. Humana is building an “early warning system” which can determine from a member’s ICD-9 information whether or not there is a variation in the member’s ICD-10 information. The system can then verify that a person’s information is accurately coded in ICD-10.

Simulated ICD-10 Testing Used to Evaluate Top-20 High Risk Claim ICD-10 Categories

Humana LogoHumana has conducted ICD-10 end-to-end testing using simulation data and has seen minor variations in processing ICD-10 claims compared to processing ICD-9 claims. As of October 27, 2014, 11 providers are currently participating in the voluntary full end-to-end testing through Humana’s payer and provider collaboration program. This testing is critical to facilitating partner ICD-10 readiness for providers (Facility and Physician), clearinghouses and billing agents and seeks to identify improper ICD-10 coding, DRG shifts, and whether the proper clinical documentation was used to support the code. To do this, Humana has tested 100 simulated claims in the top 10 to 20 high risk areas by provider for ICD-10. Providers are then asked to code the high risk claims in ICD-10 and submit them through the clearinghouse network. Once this is done, Humana has then shared with participating providers a detailed breakdown of the adjudicated claims and testing results. The goal of Humana’s ICD-10 testing program is to resolve potential ICD-9/10 errors in documentation and data manipulation which could result in incorrect payment and denial of benefits. Humana is looking to expand the program in order to identify the possible coding patterns that may result from the ICD-10 transition.

Kaiser Permanente

C. Thomas Hartman, Jr., M.D. is a physician consultant at the Permanente Federation and is one of the physician leads for the National Kaiser Permanente HealthConnect® team. KP HealthConnect is the organization’s electronic health record and integrated clinical/business system. Prior to his current role, Dr. Hartman was Assistant to the Associate Medical Director and Physician Manager of Operations for Southern California Permanente Medical Group. He joined Kaiser Permanente in 1976 after completing a Pediatric internship and residency and Allergy-Clinical Immunology fellowship. Most of his clinical career was at the Kaiser Foundation Hospital, Bellflower (Downey), where he served as Assistant Area Medical Director and Chief, Department of Allergy and Clinical Immunology.

Kaiser Permanente’s Phased ICD-10 Rollout Proves Successful

Since September 2013, Kaiser Permanente has implemented a phased approach to introducing ICD-10 into the clinical terminology and related codes used by clinicians across its integrated delivery network. Today, Kaiser Permanente has more than 10,000 clinicians using ICD-10. The success of Kaiser Permanente’s ICD-10 implementation centers on three concepts:
  1. Involving clinicians early in terminology and workflow decisions
  2. Intensive review of workflow implications and functionality available in Kaiser Permanente’s electronic health record, known as KP HealthConnect, to support the transition to ICD-10
  3. Conducting early training and actively engaging not only clinicians, but other members of the healthcare team.
To involve clinicians, Kaiser Permanente created a governing body known as the Terminology Working Group. This working group was composed of clinicians from various specialties ranging from allergists to vascular surgeons representing all the Permanente Medical Groups. The group met on a bimonthly basis to review changes necessary to clinical terms in Kaiser Permanente’s Convergent Medical Terminology (CMT), as well as the related ICD-9/ICD-10 mappings. Kaiser Permanente created CMT for use in the electronic record and has donated the terminology system to the National Library of Medicine where it is available free of charge to the health care community.

With ICD-10, payers and providers will be able to utilize the more specific data to improve research and measurement of health outcomes.

In addition, an ICD-10 Clinical Workflow Group was established to analyze the workflow implications of ICD-10 and CMT. The Workflow Group initially met monthly and focused on three major areas where ICD-10 has the greatest workflow impacts: injuries, obstetrics, and mental health. The group also participated in the creation of training materials for both clinicians and members of the health care team. Kaiser Permanente did not take a “Big Bang” approach to the ICD-10 rollout. Instead, the transition was introduced in logical groups of terms called “clusters”. Laterality was introduced where needed as part of the clusters beginning in September 2013. Next, training on clinical documentation and coding was conducted in phases, beginning with injuries and followed six weeks later by obstetrics and mental health training. After each training period, the corresponding terminology was introduced. As a result of the recent ICD-10 delay announced in spring 2014, Kaiser Permanente has not yet implemented a small group of medical specialty terms that are specific to ICD-10 codes.

The ICD-10 Transition Had No Productivity Impact

Following the implementation of terminology changes for ICD-10, Kaiser Permanente did not observe a negative impact on productivity. In the near future, Kaiser Permanente plans to look at usage of the terminology designed for ICD-10 and identify the benefits of ICD-10 to patient care and treatment outcomes. With ICD-10, payers and providers will be able to utilize the more specific data to improve research and measurement of health outcomes.

Lessons Learned

Kaiser Permanente LogoKaiser Permanente’s ICD-10 implementation showed several lessons learned:
  • Physician involvement is critical to a successful ICD-10 implementation;
  • Developing training materials for both clinicians and members of the health care team is an effective and efficient approach;
  • Enlisting specialty and primary care physicians as champions for the ICD-10 implementation helps to gear the training to the specific needs of clinicians;
  • Building strong partnerships with vendor(s) can make the ICD-10 transition process much smoother;
  • Establishing honesty and trust is essential so implementation challenges, software limitations or development issues can be openly shared.

University of Mississippi Medical Center

John Showalter, M.D., MSIS, is a practicing physician board certified in General Internal Medicine and Clinical Informatics serving as the Chief Health Information Officer at the University of Mississippi Medical Center (UMMC). He has been very active over the past few years in preparing his organization, including its staff, technology, and physicians for the transition to ICD-10. UMMC was prepared and would have been ready to implement ICD-10 on October 1, 2014.

Actions Taken to Prepare for ICD-10

Some of the activities and accomplishments that highlight UMMC’s ongoing efforts and commitment to ensuring a successful transition to ICD-10 are as follows:
  • Developing a Clinical Documentation Excellence program for the university that engages physicians by specialty to identify and overcome specific ICD-10 challenges.
  • Sponsoring monthly ICD-10 Lunch and Learns to broadcast ICD-10 concepts and practical education across the campus, building a library of presentations available on demand to all physicians and staff.
  • Recruiting and developing internal Physician Champions to push out ICD-10 information and participate in ICD-10 priority setting and problem solving by specialty.
  • Acquiring software to allow internal data analyses to isolate high-risk areas for transitioning to ICD-10 by specialty and working with physician leadership to understand risks and track the success of change initiatives over time.
  • Providing free, accessible code set and transition project management training across the state to reach independent practitioners in rural locations. These sessions have focused on topics such as what ICD-10 means to your practice, how to leverage existing CMS materials (including the Roadto10), benefits to patient care, and what the practices need to do now to prepare.
  • UMMC and Dr. Showalter are also providing support to the Mississippi ICD-10 Collaborative to get information and assistance to smaller practices across the states that are not part of larger integrated delivery systems.
  • UMMC has focused on being alpha and beta test sites for payers (Mississippi Medicaid, Medicare, BCBS) and doing end-to-end testing using both hospital and selected professional claims data for the most common procedures in order to help physicians who may not be able do the testing.
  • In the last few months UMMC’s efforts have focused more on communicating the benefits of ICD-10.

…the ICD-10 code set allows clinicians to specify where a breast mass occurs so that notes on the treatment and personal history of the mass are easily interpreted by other care givers in the future.

ICD-10 Will Add Greater Detail and Specificity to Patient Care

Dr. Showalter finds value in the ICD-10 code set through its increased granularity which allows for important distinctions in clinical care to be recognized within the coding system. By introducing the concept of laterality, improving the specificity of the codes, and allowing categorization of events and circumstances, the code set supports a more complete picture of patient care. For example, the ICD-10 code set allows clinicians to specify where a breast mass occurs so that notes on the treatment and personal history of the mass are easily interpreted by other care givers in the future. In today’s system, it takes careful reading of the record to understand if a mass is the same one as had been previously discovered and treated or if this is another, separate occurrence. Another example Dr. Showalter cites as a benefit of a fuller set of codes is the current ICD-9 code diagnosis of motor vehicle accident with multiple trauma. With ICD-10 details, you will also later know that it was collision of a van with a motorcycle and that the operator was intoxicated; the kind of information that provides clear public health and public health policy benefits. A final example he noted was with Asthma diagnoses that, under ICD-9, have such little specificity that a physician continually needs to go back into his/her notes for the details on the nature and severity of the patient’s problems, which is information that will be captured by the ICD-10 code problem list. Having important details about the patient’s asthma can aid clinicians in making quick decisions when providing acute care.

Lessons Learned from UMMC’s Efforts

UMMC CampusPhysicians need to hear that ICD-10 will benefit patient care through improved information sharing and—more importantly—that physicians don’t need to be overwhelmed by the sheer volume of codes. Analysis of administrative claims data and record reviews at UMMC has shown that UMMC’s physicians are already familiar with the majority of clinical terminology and documentation requirements that will be intrinsic to ICD-10. One example was that UMMC cardiothoracic surgeons were already dictating notes to the full extent needed for ICD-10. Physician efforts should focus on the approximately 10-15% of codes that their current clinical documentation does not satisfy and the small portion of the code set that each physician uses. By narrowing the scope of impact to those codes actively used by each physician, the challenge becomes much more about working on specific phrasing and not about worrying over codes that will never be used.

Schuylkill Health System, Pottsville, Pennsylvania

Schuylkill Health System (SHS) is a comprehensive health system serving the residents of Schuylkill County, Pennsylvania. SHS is comprised of two hospitals, a rehabilitation center, multi-specialty medical group, home health agency, school of nursing and multiple health and medical centers. The mission of SHS is to make a positive difference in the scope and quality of healthcare available for the surrounding community. SHS leadership understood early on that the greater specificity that ICD-10 captures in a diagnosis code will provide better data for capturing and improving patient care throughout the health system and began concerted efforts to transition to ICD-10.

System-wide Gap Analysis Identifies Four Key Areas of Focus

SHS conducted a system-wide gap analysis that revealed the impact of ICD-10 across all areas of the organization. As a result, SHS identified four key areas that would serve as the areas of focus during the transition from ICD-9 to ICD-10.
  • IT – SHS systematically engaged vendors to ensure that software and systems would be up to date and compatible with ICD-10.
  • Health Information Management – SHS identified the need for increased education among members of the HIM department regarding the increased specificity required by the new code set and developed suitable training programs.
  • Finance and Revenue – SHS Finance Department systematically engaged payers and updated contracts to reflect the modifications that would be necessitated by CD-10.
  • Physician Education – SHS recognized that the transition to ICD-10 will impact community physicians as well as hospitals, clinics, and other providers and created a steering committee in 2012 to develop an action plan to help physicians transition to ICD-10.

ICD-10 Oppotunities: Case Highlights

  • Understand that ICD-10 transition permeates the entire health system and community
  • Conduct a gap analysis
  • Systematically address transition issues
  • Engage physician and practice management staff
  • Engage community physicians

Lessons Learned

SHS LogoTo engage physicians for ICD-10 education, SHS created a collaborative plan with local physicians’ practices.
  • The practice managers were first engaged to create allies. With the assistance of the practice managers, an assessment of their practices was done to see where they were with their ICD-10 preparation. SHS’s involvement gave the practices an assurance that they had their support during this transition process.
  • Physicians were engaged with the help of the practice managers. With practice managers on board with the ICD-10 planning, physician engagement was easier. The education for the physicians was conducted in small group setting with a more conversational-like structure instead of a lecture.

Memorial Healthcare System, Florida

Memorial Healthcare System (MHS) is a leader in providing high-quality health care services to South Florida residents. Today, it is the third-largest public health care system in the nation. To ensure that MHS could document and accurately reflect the care delivered, they began its process of preparing for the transition of ICD-9 to ICD-10 in 2012. A steering committee was initiated, work teams were selected and physician champions were recruited from the medical staff to lead the way forward with ICD-10.

ICD-10 Oppotunities: Case Highlights

  • Physician Leadership was the key to successful ICD-10 implementation.
  • A strong communication plan was a crucial component to a successful trial of ICD-10.
  • ICD-10 will provide better information for an accurate reflection of the quality of care provided.

Physicians Champions Lead the Way Forward with ICD-10

The ICD-10 transition process began with an extensive work plan. A key milestone of the work plan involved the recruitment and selection of 50 physician champions from across the Healthcare System. The Physician Champions provided strong physician leadership throughout the ICD-10 transition.  A few of their ICD-10 leadership activities included:
  • Reviewing ICD-10 related communications to physicians and their practices;
  • Contributing to and validating physician training strategies;
  • Facilitating physician participation in training sessions;
  • Validating modifications to EHR vendor documentation tools and templates;
  • Encouraging and training physicians to document to the level of specificity required to support the diagnosis.
The Physician Champions successfully engaged the physicians from multiple specialties in the transition process, raised awareness of the benefits ICD-10 (better data leads to better care and ultimately, population health)

Lessons Learned

MHS Logo
  • Physicians respond positively to strong physician leadership.   Early involvement of Physician Champions helped to increase physician awareness and adoption of ICD-10.
  • A strong communication plan is an essential component to a successful trial of ICD-10. Using a variety of communication channels helped to reach a larger physician audience; including emails, posters, letters, post-cards, etc.
  • Branding the ICD-10 Campaign, helped raise organizational and physician awareness of the importance of ICD-10.
Disclaimer: Any views or opinions presented in this use case are solely those of the author and do not necessarily represent those of CMS.