The transition to ICD-10-CM/PCS has been a roller coaster ride for HIM professionals. The industry has prepared, delayed, prepared, delayed, and prepared again—this time with the expectation that the new coding system will finally go live on October 1, 2015. With its ups and downs, ICD-10 implementation has posed challenges and barriers for everyone, including providers, payers, and vendors.

In this article, Maria Muscarella, assistant vice president of HIM and privacy officer at Newark Beth Israel Medical Center, an affiliate of the Barnabas Health System, a seven-hospital health system in New Jersey, and Manny Peña, chairman and chief executive officer of H.I.M. ON CALL, an outsource coding vendor, compare their experiences related to ICD-10 progress, challenges, and continued barriers.

What effect, if any, did the ICD-10 delays have on operations?

MUSCARELLA: The first delay allowed many organizations, including Newark Beth Israel Medical Center, to focus on coder training and readiness. For example, Barnabas Health in Livingston, NJ, partnered with a local college to provide on-site coder training in anatomy and physiology, medical terminology, pharmacology, and pathophysiology.

After receiving basic training, all coders subsequently underwent a four-day intensive on-site ICD-10 boot camp. Newark Beth Israel also worked closely with the coding staff to ensure that all coders received their CCS credential. Our goal was to help coders hone their coding skills so they would feel comfortable learning ICD-10.

PEÑA: Both ICD-10 delays have complicated the transition to ICD-10 for coding companies. When the 2013 deadline was first announced, many vendors—including H.I.M. ON CALL—added additional coders to ensure coverage. When the first delay was announced, we had to embark on the costly effort to retrain these individuals in ICD-9. Since then, our coders have had to maintain ICD-9 and ICD-10 knowledge.

Vendors also needed to make the difficult decision of whether to retain some or all of these individuals in the interim. Training requires vendors to take coders out of current production, which often results in a loss of business. As a vendor, it’s difficult to recoup that loss of revenue. Vendors must essentially sacrifice revenue to ensure readiness.

What has been the most significant ICD-10 challenge to date?

MUSCARELLA: One of the biggest challenges pertains to organization-wide momentum. Justifying the need for ongoing financial resources is difficult when there are multiple delays. Another challenge is ensuring that all of our systems and IT are ready for ICD-10. This requires end-to-end testing and monitoring.

Luckily for Barnabas Health, all HIM directors report to the chief financial officers, who understand the importance of funding the ICD-10 initiative. We also have a corporate vice president of HIM who has been instrumental in ensuring ICD-10 training for coders.

PEÑA: The biggest challenge is to prepare for something that may or may not happen. It takes a lot of attention, time, and resources. There are many business decisions that must be made.

Another challenge for many vendors is being able to cater services to each client’s unique needs. Their various needs add an additional layer of complexity today in ICD-9, and it will be even more so in ICD-10. For example, vendors have to have a thorough understanding of the culture in each organization. Some hospitals use a more conservative approach to coding, while others are more aggressive in their code capture. Some hospitals have established internal coding guidelines, while some “think” they have them, and others don’t have any at all. And patient populations and service lines also vary from facility to facility.

Matching a coder’s skills to the unique needs of the organization will be challenging in ICD-10 if the coding vendor is not currently coding for that hospital in ICD-9 or already familiar with the hospital’s records and related coding intricacies.

How difficult has it been to ensure adequate coder training?

MUSCARELLA: Like most hospitals, we’ve had to look externally to find coverage so our internal coders could engage in training. We’ve partnered with a couple of outsource coding vendors to accomplish this. We also have a very tight process for managing the “discharged not final billed.” In addition, our coders are very dedicated and work hard to maintain an efficient workflow.

Throughout 2014, we’ve provided ongoing refresher training to our coders, including some advanced ICD-10 training. In December, one of our coding managers attended an AHIMA Train-the-Trainer session to become a certified ICD-10 trainer. She now provides intensive ICD-10 training for all coders. She also keeps track of coder progress to monitor for any opportunities to provide remedial education.

PEÑA: The real question is, ‘Who has started their training?’ An introductory course is not adequate training, particularly for a coding vendor. We’ve been training our coders for three years, and although we’ve had significant positive results, logistical challenges still exist. One of the largest challenges is juggling the needs of today (ICD-9) versus adequate preparations for tomorrow (ICD-10) for both existing and new clients. Coding vendors also need to find adequate documentation for each of their clients that their coders can use to practice true ICD-10 coding. To fill this gap, we developed an internal training program and proprietary software called the Coding Assessment Testing Tool (CATT), which includes thousands of real medical record practice cases, with related answer keys approved by a forum of experienced ICD-10 coders. CATT includes a skill gap and rating system feature pinpointing each coder’s strengths and weakness, and that of a particular client. Coders spend time every week practicing within CATT to maintain their skills, and ensure consistent and accurate training.

As we head into the home stretch of ICD-10 preparations, what are your staffing concerns?

MUSCARELLA: Staffing and personnel changes have been difficult to manage over the last three years. In addition to filling immediate vacancies, we’ve also needed to plan for the future. We looked at anticipated productivity decreases based on industry standards and compared this with our current productivity rates. How many coders would we really need to implement ICD-10 and keep our department functional without impacting hospital finances? We reached out to several outsource coding vendors and began to work with them and acclimate them to our records.

Before the second delay was announced, we also worked with an executive search firm to aggressively recruit new candidates. We had filled nearly all positions when the second delay was announced. To ensure we could retain as many coders as possible, we looked at opportunities for internal promotion, and we also examined coder salaries system-wide to ensure consistency.

PEÑA: Many vendors hire seasoned coders, some of whom are nearing retirement age. Often there is a fear that these individuals will retire before ICD-10 is implemented, or find ICD-9 positions with regulatory agencies, such as the Office of the Inspector General, recovery audit contractors, etc. For example, nearly half of coders are over the age of 50, according to AHIMA. This statistic is based on data collected in 2013 from members as well as non-members. Only 6.3% of coders are under the age of 30, according to the same data.

The existing pool of ICD-9 coders cannot possibly handle the demands of ICD-10, particularly when all signs point to a dramatic decrease in productivity. The need to attract new talent to HIM coding continues and becomes even more acute with ICD-10.

I believe that hospitals have more opportunities to hire and mentor new coders. Many have established mentorship programs and are working with new graduates for ICD-10. Vendors, on the other hand, must focus their recruitment efforts on experienced coding personnel, as we are under contractual agreements for productivity, quality, and accuracy.

What other challenges do you anticipate facing between now and October 1?

MUSCARELLA: Dual coding will be a challenge for us. We haven’t begun to dual code yet, but we will start in March. We’ll ask coders to code five pre-selected records per week in ICD-10. Our certified ICD-10 trainer will also code these records, and then lead discussions with our coding staff on how each record should be coded. We’ll use records that may or may not require queries in ICD-10. This is important because it simulates a more realistic scenario and ensures that coders can recognize opportunities for queries.

PEÑA: There is incredible pressure on all outsource coding vendors to deliver high-quality and accurate coding. This pressure becomes even more demanding in ICD-10—particularly when it comes to ICD-10-PCS.

Our volume of inpatient coding increased significantly when the original October 1, 2013 deadline for ICD-10 was announced, and we expect the same to happen this year. We’ve already experienced the shift in case load, and at an earlier pace than in 2014. As we approach the implementation deadline, vendors must work particularly hard to deliver competent coders who can code procedures under the expanded complex PCS model correctly and efficiently.

Finally, an ICD-10 challenge that both providers and vendors face is accurate and complete clinical documentation. We are all dependent on clinical documentation. Clinical documentation improvement (CDI) programs have continued to move full speed ahead, but it remains unclear whether documentation will meet the demands of ICD-10. Our concerns include what physician queries will look like in ICD-10, how well coders will write the queries, and how new ICD-10 queries will be received by physicians.

Maria A. Muscarella, RHIA, is assistant vice president of HIM and privacy officer, Newark Beth Israel Medical Center. Manny Peña, RHIA, is chairman and chief executive officer of H.I.M. ON CALL, Inc.