Peak Welcomes New Director of Coding & CDI

We are excited to welcome Lidiya Ter-Markarova, BA, RHIT, CCS, AHIMA ICD-10 Certified Trainer who joins the Peak Health Solutions Team from Palomar Health, a 450 bed multi-hospital health system in San Diego County where she was the District Director of Coding, Charge Services/CDM, and CDI. Lidiya has also worked and taught a Coding course at UCSD and she has held Coding leadership positions in several prominent medical centers in Washington state. 

 Lidiya’s expertise includes healthcare systems improvement, healthcare documentation and coding compliance, and streamlining processes of coding, charge capture, and revenue cycle.  Lidiya was also instrumental in designing an effective strategy to counteract the adverse impact of  RAC and MIC audits. She recently contributed to a ICD-10 Coding resource which is in the process of being published by AHIMA.

We are very excited that Lidiya has joined Peak Health Solutions as Director of Coding and Clinical Documentation Improvement.  In this capacity she will provide oversight of all remote and onsite coding, auditing, training, CDI, and RAC services.  She will also be actively involved in our ICD-10 transitional activities as we prepare our clients and workforce for this monumental cutover.  Lidiya’s leadership, technical and clinical experience will enable Peak to reach new heights in all of our service offerings.

ICD-10: Staying the Course

Dear Healthcare Colleague,

Following the announcement from the Centers for Medicare and Medicaid Services (CMS) Acting Administrator Marilyn Tavenner and Health and Human Services Secretary Kathleen Sebelius to revisit the timeline for transitioning from ICD-9 to ICD-10, followed by the statement last week that a notice of proposed rulemaking will be issued, Peak Health Solutions fielded calls from concerned clients. Cassi Birnbaum, MS, RHIA, CPHQ, Vice President of Health Information Management spent most of her time at HIMSS working with Industry Leaders, and providing guidance to AHIMA members and those involved in ICD initiatives on strategies to guide their respective organizations.  She also outlined several advocacy approaches to convince the industry to “stay the course”.

Ms. Birnbaum, spent time with CIOs, CMIOs and other Physician leadership at HIMSS to identify opportunities to address the AMA’s assertion that the provider community is not ready.  Are there ways that we can engage this group in our transition strategy? Is there a rapid response approach that will provide a focused approach?  Peak Health Solutions has closely monitored CMS, American Medical Association, AHIMA, HIMSS, CHIME and the positions to advise and address the needs and concerns of our clients who rely on Peak for their coding, auditing, training, clinical documentation, ICD-10, and risk adjustment services and solutions.

Many of our clients are contacting us for guidance, in anticipation of a likely delay from October 2013 to a later deadline. Peak is advising clients who are questioning the need to stay on track with their ICD-10 implementation road maps or if they should delay the kick-off of their impending engagements to to forge ahead.  “Derailing a transitional effort midstream could result in the need to expend more resources later, and re-jump starting this monumental effort, will result in more stress to organizations in the long run”, according to Birnbaum.  We have outlined a few key recommendations to help you and your organization to ride out this current “political storm”:

1.     Invest in clinical documentation improvement.  This is not only the foundation for ICD-10, but improved documentation also has the following direct and immediate benefits to:

• Improve patient care through complete, accurate and relevant documentation.  Peak’s focus is on assuring that the patient’s story is reflected in the record and working with clinicians to reduce extraneous documentation or unnecessary template artifact which detracts from the critical clinical content.
• Defend the record against payment denials, RAC audit exposure, and other compliance audit activity.
• Improve the case mix index
• Reduce unbilled accounts associated with incomplete documentation requiring retrospective queries.
• Improve clinical data capture which will provide a rich clinical repository from which to perform research, support quality improvement activities, and provide a targeted approach to focus on clinical specialties which require additional guidance and support.

2.     Continue to invest in the training of your coders.  Many organizations have only recently started to perform their gap analysis.  If there is a delay this will enable you and your organization to assure that your coders have a solid base from which to expand their knowledge base.  Start with the core training requirements related to anatomy, physiology, and patho-pharmacology, as well as opportunities to improve their understanding of coding system logic and principles. We recommend that you perform an ICD-10 coding review and analysis to assess the documentation and coding gaps and target the education and training strategy based on these findings.

3.     Turn to Peak to extend your HIM and CDI department’s capacity as you gear up for the transition.  We are there to assure you and your organization are successful as we move to ICD-10 as well as meeting the challenge presented by Stage II Meaningful Use.

Also for your reference, AHIMA prepared a print-ready downloadable PDF fact sheet on the importance of advocacy on ICD-10 implementation, Ten for 10: Top Ten Reasons We Need ICD-10 Now.

Peak is here to assist you in all of your HIM initiatives.  Please don’t hesitate to contact us for advice on how we can assist you as you recalibrate your implementation roadmap.

Cassi Birnbaum, MS, RHIA, CPHQ
Vice President, HEALTH INFORMATION MANAGEMENT

Haven’t Started ICD-10? It May Already Be Too Late

Gienna Shaw, for HealthLeaders Media , November 4, 2011

Rady Children’s Hospital in San Diego is further along in its ICD-10 planning than a lot of other organizations. Even so, says CIO Albert Oriol, they’re not yet in view of the finish line. Among the remaining challenges: training coders and physicians on the new system, assembling the right team, and ensuring they have the technology and tools they need to complete the project.

Rady, a 442-bed facility that is California’s largest pediatric hospital, got started early on ICD-10, in part, because leaders there realized it was “bigger than a coding project,” Oriol said during a recent ICD-10 panel at the College of Healthcare Informatics Executives (CHIME) fall forum. It’s so easy to lose focus in the face of other pressing technology projects, such as implementing electronic health records and preparing for meaningful use. It’s also easy to put your head in the sand and hope that the government will delay ICD-10. “I just don’t see it happening,” he said.

Although he’s “fairly comfortable taking risks,” Oriol wasn’t willing to gamble on an ICD-10 reprieve. Consider, he said, that poor ICD-10 preparation could increase your current denial rate by 1% – 3%. He asked the audience: Is that a risk you’re willing to take?

There’s a lot of apprehension among Rady’s coders—and one has already resigned, well ahead of the October 2013 conversion deadline, said Cassi Birnbaum, Rady’s director of health information and privacy officer. Conventional wisdom holds that many coders will change jobs or retire before the conversion, which will increase the number of disease and diagnosis codes from the current 15,000 to more than 150,000. Further, the new coding system is much more complicated and nuanced than ICD-9.

But it’s not just coding professionals who should be worried. ICD-10 experts say organizations that aren’t prepared could face significant increases in accounts receivable, rapid decreases in cash flow, high call volumes because of rejected claims, and risk of increased audits and sanctions.

And exactly how much it will cost to implement ICD-10 still largely unknown. “Pick a number, multiply it by 10, throw it at the wall, and see if it sticks,” Oriol said. You can predict staffing needs, but there’s no way to tell what impact errors and inefficiencies during the natural learning curve will have. “We have no idea,” he said.

Success depends, in large part, on getting the right people to manage the project, the CHIME panelists said. Rady has a steering committee with organization-wide representation, for example. At SSM Healthcare, a 15-hospital system based in St. Louis, health IT and human resources are working together to prepare for training, said project manager Carole McEwan.

One decision both organizations had to make: Should the team that implements ICD-10 be the same group that’s working on electronic health records? Here, the two organizations differed in their strategies.

SSM is currently implementing an EHR and many of the same people work on both projects. So the ICD-10 and EHR projects share a steering committee. It’s a well-functioning team, McEwan said, so it made sense to build on what was already there.

Rady went with a separate ICD-10 group that also incorporates members of the clinical documentation improvement team. CDI is a foundation for ICD-10 preparation, Birnbaum said. You can’t code what you don’t document. Bad documentation on the front end pollutes the stream, she added.

McEwan estimates SSM will ultimately provide more than 100,000 hours of training for ICD-10. SSM decided to build its own training system rather than purchase one off the shelf. It will create six classes to deploy throughout the organization. 
Physician training is just as important as coder training. “The bottom line is documentation,” said Birnbaum.

Rady tested ICD-10 using a full year’s worth of ICD-9 coding data, Birnbaum said. Primary care physicians did the same, also mapping out a year’s worth of clinical data on their own.

If you’re aiming for the October 2013 ICD-10 implementation deadline, you’re already too late, the panelists agreed. To be safe, organizations should be ready to go at least six months before that. These projects take time to “ramp up,” said McEwan.

“If you’re not ready by October 2013, that’s an excuse for [payers] not to pay you,” Birnbaum said.

CHIME: ICD-10 Conversion May Require 110,000 Hours of Education

SAN ANTONIO—Representatives from two facilities discussed the magnitude of ICD-10 implementation during an Oct. 27 town meeting session at CHIME11, the Fall CIO Forum.

“We’ve got a good start but we’re not seeing the finish line,” said Albert Oriol, vice president of information management and CIO of Rady Children’s Hospital in San Diego. “This is bigger than a coding project.”

“The bottom line is documentation,” said Cassi Birnbaum, MS, director of health information and privacy officer at Rady. “We have a perfect storm of initiatives with meaningful use, documentation and other efforts.” She said that the health information management department began its ICD-10 initiative early, more than two years ago, with coder education and awareness training. She found that “we really need to shore up documentation and weave into it the more granular, discreet documentation that’s necessary with ICD-10.”

Conversion to the ICD-10 standards is “somewhat of a hot potato,” Oriol said. “It’s like a train moving at high speed. We must decide whether to play chicken or take the wheel and drive to avoid hitting the wall that is ICD-10. We’re lucky that it didn’t take a lot for our CFO and clinical leadership to hear the message.”

Come the Oct. 1, 2013 ICD-10 implementation date, “if you’re not ready then payors have an excuse not to pay you,” said Birnbaum. “That will have serious repercussions.” To prepare, she said her facility is adding to its ICD-10 trainers and looking at learning management software. Those who have started their preparations more recently may benefit from some lessons learned. For example, Birnbaum recommended to the audience that they “make sure your vendor has the capabilities you want and the ability to slice and dice the data the way you want.”

She also shared that one of her facility’s primary care groups is right on top of the issue, having already mapped a year’s worth of claims. The lesson is to take advantage of the people and skill sets you already have within your organization.

ICD-10 presents “an optimal role for the CIO as a key leader and enabler,” said Carole McEwan, MS, ICD-10 project manager at SSM Health Care, a St. Louis-based healthcare system covering four states. The effort also needs clinical and revenue cycle ownership. Her organization found that a big decision was whether to centralize or decentralize the effort. “We worked to use existing groups and most are centralized. Niche applications in some facilities are decentralized. We assigned these to one owner to make sure the application is upgraded.”

Another big decision was whether to build or buy education. “We estimated that we’ll need 110,000 hours of ICD-10 education. HHS will build its own and create six classes.” She cautioned that there is a risk in implementing ICD-10 in too short of time. “It takes time to start rolling out the effort. If you wait too long, the ramp up time will be extremely difficult. You need to get lots of people on the same page and that doesn’t happen overnight. There are lots of tools available but they don’t make people move any faster.”

Birnbaum pointed out that there will be lots of competition for scarce resources—consultants, trainers and others that facilities may need for ICD-10 implementation.

When asked how to plan a ICD-10 budget, Oriol jokingly recommended that facilities pick a number and multiple it by 10. Training costs and the productivity impact on coding and billing are somewhat easy to estimate, he said, but beyond that, it’s difficult to plan.

Preparation Key to ICD-10 Success

By Joseph Conn

Posted: October 27, 2011 – 3:00 pm ET

Tags: ICD-10, Information Technology

The Boy Scouts’ motto, “Be prepared,” was the condensed message of three health information technology experts at a panel discussion more formally titled “Lessons from the Field: ICD-10 Strategies and Key Findings” at Wednesday’s opening session of the College of Healthcare Information Management Executives fall CIO forum in San Antonio.

The panelists were Albert Oriol, the chief information officer at Rady Children’s Hospital in San Diego; Cassi Birnbaum, director of health information management at Rady; and Carole McEwan, project manager for ICD-10 at the SSM Health Care system based in St. Louis.

Oriol said his organization’s leadership was fortunate that it was flagged early by Birnbaum to start preparations for the conversion to ICD-10. Under a federal rule, hospitals, office-based physicians, health plans and claims clearinghouses all must start using the International Classification of Diseases, 10th Revision diagnostic and procedural codes by Oct. 1, 2013.

But to Birnbaum, “We didn’t think it was too early. In HIM, we started about 2½ years ago with training and coder awareness.”

Birnbaum said Rady has an advantage in that the shift to ICD-10 will come after the “rapid implementation” of an electronic health-record system and work on a clinical documentation improvement program.

“There were a lot more carrots” dangled in front of staff than just ICD-10, she said.

It has been widely reported that coder productivity nose-dived at hospitals in Canada when it switched to ICD-10 nearly a decade ago.

At Rady, due to all of its advanced work, and some hope that computer-assisted coding will improve efficiency, Birnbaum said the children’s hospital should see a short-lived productivity drop of 10% to 15%.

But McEwan is less optimistic.

“We expect an immediate 50% drop,” McEwan said. After the initial six months, “We’re hoping that long term it will be under 30%. And I think that’s conservative, and I’ve done a lot of research on that,” she said.

Even with a fully functional EHR and computer-assisted coding, McEwan said, “we don’t know how much under” 30% that long-term productivity loss will be, so SSM is preparing now. “We’ve already begun staffing up.”

Oriel said one “critical decision” that has yet to be made and implemented in concert with the ICD-10 conversion is how to handle upgrades to a scattering of smaller databases within the hospital.

“Because we’re an academic institution, we do a lot of research and we have lots of (Microsoft) Access databases all over the place,” Oriel said. “We’re going to have to tackle that.” Should the hospital “forget the rinky-dink databases” and require all researchers to use one clinical data warehouse? “That’s going to be a tough decision.”

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