Briefing: supporting the implementation of ICD-10 July 2014
Contents Section Page 1 Why ICD-10? 3 2 Industry-wide support 4 3 ICD-9 vs ICD-10 5 4 Example: ICD9 vs ICD-10 6 5 Planning the transition 7 6 To code or not to code? 8 7 Case Study: HCA International 9 8 Support & tools 10 9 Timescales 11 10 Frequently asked questions 12 About CCSD.. 16 2
1. Why ICD-10? ICD- 9 (the current diagnosis classification) is out of date the NHS updated to ICD-10 over 20 years ago does not accurately represent medical diagnoses associated with healthcare today Absence of accurate diagnosis coding undermines the commissioning, delivery and monitoring of quality healthcare Provides a better understanding of patient needs, complexity, pathways and treatment Improves granularity, specificity and accuracy of clinical documentation Allows the assessment of hospital case mix and management of clinical risk Facilitates comparisons of UK and International healthcare Provides supporting information for claims and care pathways 3
2. Industry-wide support The final Competition and Markets Authority report recommended a robust system of diagnostic coding, such as ICD-10 outlining it is essential to allow the production of meaningful information for patients as, without this data, it is not possible to distinguish between consultants and hospitals with poorer outcomes and those with sicker patients. The Private Healthcare Information Network (PHIN) supports the implementation of ICD-10 to facilitate transparency and comparison of private healthcare information The Clinical Coding and Schedule Development (CCSD) Group, who manage procedure coding schedules, support the industry-wide implementation of ICD-10 Healthcode receive and map ICD-10 codes Some providers have implemented ICD-10 4
3. ICD-9 vs ICD-10 13,000 ICD-9 codes => potential 68,000 ICD-10 codes (18,000 used in NHS) ICD-10 is more specific and detailed, such as recording location/place of occurrence ICD-9 five character numeric numeric => ICD-10 four character alphanumeric ICD-10 coding structure: Character 1 letter corresponding to chapter in classification Character 2-3 number corresponding to category Character 4 number corresponding to disease site, disease type or individual disease Numerous diagnoses can be recorded against a patient episode Primary diagnosis is the main condition treated or main symptom Secondary diagnosis are secondary conditions or comorbidities, e.g. diabetes Can use dagger and asterisk codes to show where an underlying condition is the cause of the disease 5
4. Example: ICD-9 vs ICD-10 ICD-9 ICD-10 Malignant Neoplasm of Oesophagus 150 C15 Cervical part of oesophagus C15.0 Thoracic part of oesophagus C15.1 Abdominal part of oesophagus C15.2 Upper third of oesophagus C15.3 Middle third of oesophagus C15.4 Lower third of oesophagus C15.5 Overlapping lesion of oesophagus C15.8 Oesophagus, unspecified C15.9 6
5. Planning the transition Understand your activity Analyse, assess and audit your hospital and patient casemix Review your records Review medical documentation and records to ensure the information required to produce accurate ICD-10 coding is evident Assess systems/processes Understand what system changes need to be required to accommodate ICD-10 codes Utilise mapping tools where possible to limit significant enhancement and costs Use learning and systems, processes and people used for recording NHS coding Plan implementation Develop plan with piloting process to ensure wider implementation is tested and benefits realised Training Train clinical, administrative and coding staff to ensure they have a broad understanding of ICD-10 coding and systems Support potential industry-wide collaborations on training to provide qualified resources 7
6. To code or not to code? The NHS employs clinical coders to provide diagnosis and procedure coding Having accredited clinical coders will ensure ICD-10 coding is at it s most accurate Cost and availability of coders would present significant challenges to private healthcare providers support industry-wide training developments to ensure trained resources are available Other factors, i.e. systems and documentation, will cause inaccuracies Analysis of activity, mapping, training, technology and implementing systems could limit coding and costs Utilisation and leverage learning of existing coding networks and systems used for NHS activity should be maximised Coders can focus on complex cases and reviewing/assuring the quality of coding to improve effectiveness and reduce costs Introduce an internal/external audit programme to assure the accuracy of coding 8
7: Case Study: HCA International In 2013, HCA International embarked on a project to implement ICD-10 and OPCS coding of private healthcare activity into its London Hospitals. It engaged Capita, a provider of clinical coding services, to assist with the implementation of systems, processes and resources to deliver clinically coded activity. This involved: undertaking an initial assessment of patient complexity and medical documentation to scope need and requirements updating systems to ensure key documentation is recorded and available to code developing coding policies, procedures and query resolution system undertaking coding awareness sessions with hospital and clinical staff use Capita accredited clinical coders to deliver coding centrally at its Marylebone offices regular audits to assess the accuracy of coding develop and implement reporting on activity, performance and outcomes Initially a pilot project was undertaken to develop systems and processes. HCA now code approximately 2500 patient discharges per month using coders centrally located at its Marylebone office. It is benefitting from having this rich, granular level of information to: assess the casemix of its hospitals identify patient comorbidities risk adjust performance and outcome metrics provide information for case identification and review
8. Support & tools Various tools are available, e.g. from Healthcode, CHKS etc., to map ICD-9 codes to ICD-10 Healthcode can take ICD-10 codes and map coding to individual insurer contracts Data and coding consultancy organisations, such as CHKS, can provide implementation support, training, audits and clinical coding resource CCSD, working in partnership with healthcare providers, will support the implementation and development of coding in the private healthcare industry and work with the NHS, in particular the Health and Social Care Information Centre, to align and support the development 10
9. Timescales Planning the transition needs to be undertaken now a CMA remedy that must be addressed insurer and wider industry support Development, testing and implementation may take up to 12-18 months but will vary depending outcomes from transition planning, i.e. processes, documentation and system changes required, and overall service model deployed, i.e. deployment of coders, system/process automation, mapping BUT Tools, services and support arrangements are already established to undertake transition Leveraging off NHS systems and people will ease implementation Piloting, testing and training can happen now A phased approach by firstly coding primary diagnosis is achievable relatively quickly 11
10. Frequently asked questions Question Why is ICD-10 being implemented? Implementing ICD-10 will be expensive, who will pay? Answer The implementation of ICD-10 is a CMA report remedy and has industry wide support. There are considerable benefits to both providers and insurers. ICD-9 is 30 years out of date. It will allow private healthcare to have an up to date classification of medical diagnoses. It facilitates the identification of comorbidities and complexity of patient care and comparisons to NHS healthcare provision. Both providers and insurers will incur costs during the implementation of ICD-10. Insurers expectations will be no different from the current practice. A correct supporting ICD-10 code for each charge made will need to be submitted as is currently the case with ICD-9. Many hospitals already use ICD-10 for NHS cases. Existing NHS processes and systems can be adapted and updated for use for private healthcare claims. Providers should apply mapping, training of existing staff and utilisation of support tools to limit the impact on costs of implementing ICD-10 coding. Enhanced data accuracy will also probably highlight process and billing improvements. Industry wide support, such as training and development of staff, may be implemented to help share costs. 12
10. Frequently asked questions (continued) Question But NHS coding costs much more to do than PMI? What activity do we need to code using ICD-10? What will insurers used ICD-10 for? How often is ICD-10 updated? How do we get the coding resources required to implement ICD-10 when there is limited availability of coders to deliver NHS coding? Answer The NHS requires the coding of diagnosis and procedures using clinical coders which is resource intensive. These codes are the HRG grouper post discharge to determine charges. Insurers are not expecting a similar process in PMI. The CMA was not explicit in this and CCSD have asked for more information from them to clarify this. NHS organisations do not code diagnosis in an outpatient setting. Primary diagnosis could be implemented relatively simply but not implementing secondary diagnosis coding would lose some of the benefits of implementing ICD-10. The same as ICD-9 following the patient journey, ensure that the right care is given to its members and supporting evidence for payment. Amendments to ICD-10 vary and are published when the need arises. Coding requirements need to be firstly assessed and any existing networks used to deliver NHS coding should be used. There are a number of commercial companies who also can provide coding resources. However, most organisations will need to put training and development programmes together to build up the additional coding resources required. CCSD will support the implementation of industry wide training if possible. 13
10. Frequently asked questions (continued) Question Do we need to have qualified/accredited Clinical Coders? How long does it take to become an Accredited Clinical Coder? Can t clinicians do all the coding work? Answer No. Having qualified clinical coders is the best route to coding accuracy. However, existing staff who are familiar with anatomy, diagnoses and co-morbidities should be able to support claims submissions with suitable training and support. It is advisable that staff undertaking coding undertake an initial standards course and workshops for relevant specialties. However, it is recommended that coding is regularly reviewed and audited by qualified coders/auditors to provide assurance of its accuracy. 2-3 years. Within 6 months of starting coding, it is advised that a Clinical Coding Standards course is undertaken. This consists of 21 classroom sessions. Coders are then required to have 2 more use experience and undertake coding workshops on specific specialties. They can then take an exam to become an Accredited Clinical Coder. Once accredited, coders are required to have a refresher course every 3 years. They could, but experience shows that they naturally concentrate on patient care. They do need to be aware of clinical coding requirements and what information they need to supply for accurate clinical coding 14
10. Frequently asked questions (continued) Question How can I get training for staff, clinicians and clinical coders? What coding systems are available? What s the key to successful implementation? Answer Consultancies and individuals can provide training. CHKS provide training for existing or new staff from clinician awareness sessions to full ICD-10 training and ongoing support, depending on your requirements. For clinical coding training you should look for HSCIC and TAP accredited trainers. CHKS are affiliated to the NHS Cheshire and Merseyside Clinical Coding Academy who develop and deliver clinical coding training for the NHS. Several clinical coding systems are on the market, offering different capabilities and usually designed for the NHS or international markets. Hospitals would need to review their own requirements and seek expert advice about adapting existing system capability. Begin planning for the change from ICD-9 to ICD-10 now. Many insurers are thinking of adopting ICD-10 alongside other system changes. Having a robust plan for process change and including your clinicians in these plans. Clinicians are vital for obtaining the correct diagnoses and co-morbidity details. 15
The CCSD Group was formed in 2006. It consists of the UK s five major private medical insurers: Aviva, AXA-PPP healthcare, Bupa, PruHealth and Simplyhealth. The CCSD Group s objective is to establish and maintain a common set of procedure codes and narratives that reflect current medical practice within the independent healthcare sector. These are published in the CCSD Schedule. CHKS, part of Capita plc, are the largest provider of healthcare intelligence and quality improvement services in the UK. CHKS currently manage the CCSD Schedule of Procedures on behalf of the CCSD Group. Other services they provide include: clinical coding services, training, audit and mentoring to NHS and private healthcare providers expertise in evaluating systems and processes around data recording and coding unrivalled knowledge of healthcare data and payment systems market leader in coding and data assurance audit programmes industry leading healthcare activity benchmarking systems 16