A little knowledge can be a dangerous thing. But when your hospital or medical practice is transitioning to ICD-10, knowing enough but not too much may be the secret to making that transition uneventful.

“When they put me on it, I didn’t even know what ICD-10 was,” says a nonchalant Tricia Hough. Hough is the director of operations improvement at the University of Rochester (N.Y.) Medical Center (URMC). Her superiors made her the ICD-10 Implementation Project Director for the entire system, which includes 261-bed Highland Hospital, an affiliated hospital, also in Rochester. 

Tricia Hough
Tricia Hough, director of operations improvement at the University of Rochester (N.Y.) Medical Center, leads the ICD-10 transition team for the entire university-based healthcare system.

With an undergraduate degree in mechanical engineering, a master’s degree in engineering management, a master’s degree in business administration, a background in retail process redesign and no previous healthcare experience before joining URMC in January 2012, Hough was a curious choice to lead the ICD-10 transition at the university-based healthcare system. 

But after almost two years in her role, it’s clear Hough is the perfect choice. Highland is one of the most prepared provider organizations in the country for the transition to ICD-10 — a change that still has many hospitals and medical practices incapacitated by fear.

Hough credits Highland’s high state of ICD-10 readiness to a talented, skilled and dedicated transition team. Its members provide the on-the-ground clinical, financial, technical and coding expertise needed to pull off such a monumental change in how healthcare providers record episodes of patient care. Instrumental to the team were representatives from the system’s ISD, HIM/Coding, Educational Services and Patient Accounting departments.

“As a healthcare outsider, my ability to lead this project is completely dependent on a great team that can do the real work required to make sure we’re prepared,” Hough says. 

Hough’s ability to see the big—and inevitable—picture and to avoid getting snagged in the weeds by the increase in diagnostic and procedure codes from 24,000 to 155,000 has kept Highland’s transition plan on track and on time. 

Given her background, Hough has approached the ICD-10 transition as a system redesign project. She’s applying engineering principles and her retail supply chain experience to make the transition successful. Central to that approach is realizing that changing one end of a process will lead to changes in other parts of the process, identifying where those other changes are, measuring the impact of those changes and mitigating any negative effects of those changes.

“You need to start early and test everything,” Hough says.

For Highland, early means two years. Even after HHS delayed the effective date of ICD-10 by a year to Oct. 1, 2014, the hospital, which discharges nearly 20,000 patients a year, stuck with its plan and began “dual coding” this past October. Highland kept its foot on the pedal and has been coding patient cases using both ICD-9 and ICD-10 ever since.

That early-and-often approach has allowed the hospital to dispel two of the biggest fears facing providers: coder productivity and a drop in revenue from claims not being paid because of coding issues. Some experts have estimated as much as a 69% decline in coder productivity and as much as a 60% drop in revenue from deferred claims.

In terms of productivity, Highland’s coders have become proficient in ICD-10, and the hospital has seen only a slight drop in output because of the change. In fact, after working with ICD-10, the hospital’s coders much prefer the new system to ICD-9, which they say is less intuitive, according to Rochelle Nichols, manager of coding for URMC.

In terms of revenue, dual coding has identified potential coding trouble spots that could lead to unpaid claims and a temporary hit on revenue if not addressed properly. In response, Highland, which generated about $301.2 million in operating revenue in its fiscal year ended June 30, targeted coder training and education on those trouble spots.

“Where we’ve found a negative impact, we’ve been able to mitigate the problem,” Hough says. “It’s not nearly as bad as we thought it would be.”

In keeping with its systematic approach to the transition, Hough and her transition team made a list of 170 external vendor and payer information system applications for the entire university health system that need to become ICD-10-compliant by Oct. 1 and prioritized the applications based on potential revenue impact on the system. 

To get off the list, a vendor or payer must demonstrate that its particular IS application can handle ICD-10. To date, 90 applications have been scratched off, leaving another 80 to go. By prioritizing the list, if some of the vendors or payers at the bottom aren’t compliant by Oct. 1, it won’t be a “show-stopper” in terms of delayed revenue coming into the system, according to Hough.

By minimizing if not eliminating financial hiccups in the transition to ICD-10, Highland is demonstrating its belief that better business health means better patient care. Any drop in revenue no matter how temporary could mean a corresponding reduction in expenses that could negatively affect services to patients or important capital outlays.

Hough and Highland, though, recognize that their stoic, just-get-it-done engineering approach may not work with every stakeholder, especially when ICD-10 has become an emotional issue for many, particularly doctors. (Highland has more than 1,200 physicians on staff.) So, they’ve deliberately incorporated some emotion into their transition plan. 

In regular communications on the transition to employees and physicians, the hospital offers specific examples of how the new coding system will benefit patients. In one communication, the hospital noted that ICD-10 allows caregivers to document suspected patient cases of domestic abuse – a situation for which ICD-9 had no codes.

While pulling on a few heart strings with one hand, Hough and her transition team are quick to wave away any ICD-10 hysteria with the other. 

“We tell people not to get caught up in the hype. Don’t fixate on the volume of changes but on why the system is changing,” Hough says. “You don’t have to know the code for an injury caused by falling space debris. If that happens, we’ll look it up.”

What is looking up is Highland’s level of readiness for ICD-10, which Hough breaks into three segments: technology, people and process. She estimates that the hospital’s technology readiness level is at 80%, with July 1 being the target to be at 100%. 

For both people and process, Hough says Highland intentionally doesn’t want to be at 100% until about one month before ICD-10 becomes mandatory, with a slow and deliberate ramping-up in training, education and practice until then. If Highland is at 100% readiness too soon, those involved may forget what they’ve learned, and the hospital’s performance could be stale come Oct. 1 – much like college football teams looking rusty in a bowl game after not playing for six weeks since their regular season ends.

“At the end of the day, it really doesn’t matter what you think about it,” Hough says. “It’s coming, and you have to get ready for it.”

For those provider organizations just beginning their journey to ICD-10 readiness, Highland’s strategy of putting an engineer in charge and approaching the transition as a retail process redesign project may be the unemotional—albeit effective—solution to a highly charged and seemingly insurmountable change in how they document and bill for patient care.


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