ICD-10 Staffing Issues Extend Beyond Coding

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The upcoming transition from ICD-9 to ICD-10 is not just a coding issue. It involves every department that touches a clinical code. Staffing needs reach far beyond health information management (HIM) and coding. Added workloads are predicted across virtually every hospital department.

This article lists three important areas of ICD-10 staffing impact beyond HIM: patient access, patient accounting and information technology (IT). Strategies for maintaining healthy staffing ratios in the midst of ICD-10’s inevitable hiring surge are also described. Finally, every healthcare provider strives to make the most of each full-time equivalent (FTE) and find long-term value in every hire. Centralized hiring for ICD-10 accomplishes these goals while also maintaining positive indicators for financial reporting and organizational balance sheets.

Revenue Staff Squeezed

Patient financial services staff on both the front end and back end of healthcare’s revenue cycle will be challenged by ICD-10. Any revenue process that impacts coding is predicted to experience workload increases. Furthermore, ICD-10 aftershocks will be long lasting.

Providers are expected to struggle with code change ramifications anywhere from 3 months to a full year following ICD-10 implementation. Here are three areas for revenue cycle concern:

  • Heightened focus on medical necessity checking in patient access is required.
  • Huge increases in claims suspensions within patient accounting departments are expected.
  • More denials due to invalid codes and failed claims transactions are inevitable.

Under ICD-10, revenue accuracy trumps revenue neutrality. All hands must be on deck to protect cash flow by producing clean, first-time claims. Despite these best efforts, spikes in denials are expected and inevitable. How quickly organizations are able to handle them may predict their fiscal health for years to come. Additional hands are a must!

IT Services Taxed
Information technology (IT) is another area for staffing concern. End-to-end testing between providers, clearinghouses and payers is slated to begin in 2013 with several national testing projects already underway. However, technology glitches between systems are probably unavoidable and most organizations’ IT staffs will be forced to serve in ICD-10 “first responder” roles. They will need to concretely know where ICD-10 diagnosis and procedure codes flow within and between systems. Understanding of other less-tangible code impacts, such as system event triggers that drive or are driven by ICD-10 codes, will be integral to successful testing and implementation activities.

From a data management standpoint, reports and queries that currently exist within and across a variety of systems must be evaluated and converted. The processes through which reports and queries are requested by end-users should also be assessed. Hospitals should not presume data requests are driven through a vetting processe that includes consultation with HIM or IT.

ICD-9 has been used by healthcare providers in the U.S. for over 30 years. Its’ tenure created pockets of “closet coding experts” outside of the HIM Department. While these users may be skilled at code selection within their areas of expertise, ICD-10 resets that knowledge base. GEMS mapping alone to translate ICD-9 to ICD-10 results in less accurate reporting and analysis outcomes over the long-term.

Beyond revenue cycle and IT, other departments will experience heightened workforce demands before, during and after the implementation of ICD-10, including clinical documentation improvement (CDI), education and compliance. One strategy being discussed is centralized staffing for ICD-10.

A Centralized Strategy Maximizes ICD-10 Resources

An organization’s ability to leverage ICD-10 knowledge workers across a variety of areas helps balance workforce demands and staffing metrics. Employee-to-volume ratios must be maintained; centralized ICD-10 staffing accomplishes this goal.

With centralized ICD-10 staffing, FTEs brought on board in HIM also serve as part-time or floating support for other ancillary departments. Workflows and processes are altered to “borrow” instead of “buy” additional personnel in non-HIM areas. A core team of ICD-10 expertise is created while the hiring of additional long-term FTE resources is kept to a minimum. Here are three centralized ICD-10 staffing tactics:

  1. Medical Necessity Checking in Patient Access Instead of physically locating an ICD-10-trained coder in the patient access department to assist with medical necessity checking, coders in HIM cover incoming patient access queries. Coders rotate responsibility for answering the patient access “bat phone,” thereby making the most of full-time coders and their ICD-10 knowledge.
  2. Claims Suspensions in Patient Accounting Historically, claims that suspend for edits and errors related to coding require return and intervention by HIM staff. However, billers and other patient accounting staff have learned to triage bill hold trends and claim issues themselves, routing them to the correct staff based on the type and timing of edits. With the transition to ICD-10, claim edits will likely increase, not only due to coding inaccuracies but also due to clearinghouse and payer claim logic challenges. In addition, there will be interface and custom claim edit issues. Evaluating the reason claims are in suspense requires new eyes and skill sets under ICD-10, as familiar diagnosis and procedure codes will no longer be represented. Finally, some payers may not be ready – or required – to transition to ICD-10 on Oct. 1, 2014. Some level of ICD-9 claim processing management must be maintained. Training, time and well-vetted processes for handling suspended ICD-9 claims requiring resolution should be considered.
  3. Physician Education and CDI Physician education regarding how clinical documentation impacts ICD-10 coding is essential. CDI programs are already in place in most hospitals to support this effort. However, these programs must be dramatically ramped-up for ICD-10.

ICD-10 coders hired in 2013 for dual-coding can assist CDI and physician education programs. These coders have spent months dual coding the organization’s live cases. They are well-versed in new documentation requirements and can serve as validators of the organization’s clinical documentation. Use their skills as far “upfront” in the documentation cycle as possible for maximum effectiveness.

Virtually everyone in healthcare will feel the staffing impact of ICD-10. Any long-term resource hired for ICD-10 should be leveraged throughout the organization. Skills must reach to other ancillary areas. This is the core tenet for justifying your centralized staffing strategy.

Justifying a Centralized Approach

A plethora of hospital key performance indicators include ratios evaluating manhours and/or FTEs per unit of service, occupied bed, discharge, admission or visitDramatic changes in staffing, such as those predicted for ICD-10, alter these metrics and the long-term financials of the organization.

By hiring personnel within one department and then using them to support ICD-10 in others, providers successfully balance staffing needs with long-term financial wellbeing. Depending on how an organization budgets, FTE-to-volume ratios contribute to financial health indicators, bond ratings and the ability to obtain new cash. Strategic addition of cross-functional staff provides organizations with the opportunity to efficiently increase workforce with a controlled number of versatile FTEs that can be flexibly integrated into areas of operational need.

Human resource considerations round out the justification for a centralized ICD-10 staffing strategy.

Human Resource Considerations

It is difficult to justify new positions in hospitals. So when they are approved, organizations must make the most of them. Centralized ICD-10 hiring helps organizations be more effective with their precious human resources in four ways:

  • Hiring and recruitment efforts are targeted within a central department.
  • Onboarding costs are reduced.
  • Time-to-hire recruitment cycles are shortened.
  • Retention is addressed centrally rather than department by department.

Employee retention will be particularly important as the Oct. 1, 2014, deadline approaches, ICD-10 talent becomes scarce and trained employees begin chasing higher salaries offered by vendors, outsourcing agencies and consulting firms.

Some ICD-10 retention strategies being used include:

  • Employee contracts in exchange for complete ICD-10 training
  • Re-organization of coding services to allow for cross-training of coding staff in different work types and service lines (which can be motivational for some professionals)
  • Identification of post-Oct. 1 revenue cycle roles focused on tasks other than ICD-10 production coding for professionals with strong ICD-9 and/or clinical documentation skills
  • Retention bonuses or incremental pay increases for performance milestones related to ICD-10 competency and productivity. Re-evaluation of remote and flex scheduling arrangements for coding staff if not previously implemented (to compete with other job opportunities that provide similar pay, but greater quality-of-life benefits)
Preparing for the Inevitable

Organizations can’t prevent the Oct. 1, 2014, earthquake, but they can prepare for it. ICD-10 staffing is one of the most critical areas to include in your plan. Resources abound and practical solutions for ICD-10 conversion are plentiful. The key component is time. Organizations should revisit staffing plans now and begin securing the right ICD-10 experts -before they disappear.

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About Author

Elizabeth Stewart, RHIA, CCS, CRCA

Corporate director of HIM, HRS

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