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Q&A with Industry Leader Donna Pizzulli, Chief Operating Officer of Cybergistics

Industry leader Donna Pizzulli helps answer some common questions about two major transitions facing health care providers in the near future: ICD-10 coding and electronic health records (EHR)/electronic medical records (EMR).

Donna has four decades’ experience working in the health information management field, and prior to founding Cybergistics served as Senior Vice President at the New Jersey Hospital Association. She is one of just 115 HIM professionals to achieve Fellowship status in the American Health Information Management Association (AHIMA).

The US Department of Health and Human Services (HHS) mandate to replace the ICD-9 medical codes with the new ICD-10 codes will increase the current 14,000 codes to 70,000—a significant change. What first steps should hospitals be taking to prepare for this implementation and to comply with this regulation?

It is indeed a big transition. Hospitals and providers should initially identify the existing software, products, and applications that contain or use ICD-9 codes, including any file exports and/or imports that send ICD-9 data to other applications that will be required to process ICD-10 data. They will also need to identify any existing health plans, payers, and medical groups and/or managed care contracts that contain ICD-9 codes.

How will we know what training will be necessary for our staff?

It’s best to conduct an assessment of a hospital or health care organization’s training needs—not just for coders and billers, but also for the entire staff. Implementing hospital-based physician education is also important. Providers will have to strategize on how to deal with the learning curve, and how to absorb the temporary increase in DNFB days.

Given the amount of time and effort required of hospital staff to implement the new ICD-10 codes, what do you estimate the financial impact on hospitals to be?

Hospitals will certainly have to bear some financial expense to prepare for the ICD-10 migration; this expense will ultimately depend on how efficiently the implementation is handled. However, lack of detailed information in the ICD-9 code assignment, and the practice of lumping newer procedures with older ones, can make administrative costs high due to requests for additional documentation and/or rejected claims.

So the new ICD-10 codes can ultimately reduce costs?

With the greater code set in ICD-10, providers should expect fewer rejected claims. At the same rate, hospitals and health care organizations should review medical records to identify documentation requirements to support the greatest potential for revenue gain or loss under ICD-10.

Are there other fringe benefits to the new ICD-10 codes?

The more descriptive ICD-10 codes will provide higher accuracy in the quality of care “report cards.” Patients are becoming very savvy about referring to “report card” data; positive scores from these report cards can help attract patients to a specific hospital, increasing that hospital’s volume.

How are hospitals expected to find the time to train their physicians and staff on ICD-10?

With ICD-10, records will require more time to code, as proven by countries who have already implemented it. But the improved code structure should reduce error because it will help decrease subjectivity—but only if the staff are properly trained and have the proper foundation of anatomy and physiology. Finding the time may be a challenge, but the time spent should produce real benefits.

The deadline for healthcare organizations to adopt ICD-10 procedure codes has been pushed back from October 1, 2013 to October 1, 2014. Does this delay mean that hospitals now have enough time to adequately prepare for implementation?

There is a silver lining to this delay; it has actually created the perfect opportunity for all hospitals to take a second look at their clinical documentation, particularly for inpatient records, and determine what will be needed to support the more robust ICD-10 codes. It will also allow time to review any physician education needs. While 2014 may seem far away, providers who take advantage of the time to prepare will be best positioned when the date arrives.

Another major transition looming is the imminent mandate for electronic medical records. Thanks to incentives and penalties established through The American Recovery and Reinvestment Act of 2009 (ARRA), hospitals and healthcare providers must adopt and demonstrate meaningful use of the practice of electronic health records (EHRs) and electronic medical records (EMRs) by as early as 2014. What are the challenges that hospitals will face managing the migration from a paper-based records system to a hybrid and ultimately an electronic system?

Hospitals are in various phases of migration to an electronic health record, and the hybrid record (EHR with a paper chart or document imaging) is very common. Some paper is unavoidable, such as outside correspondence, consent forms, documents that have yet to be digitized. Hospitals need to determine whether non-digital records are duplicative or part of their legal EHR, and then develop procedures for retention.

Are there specific concerns if a hospital or health care organization’s hybrid system includes document imaging?

If document imaging is chosen as a companion to the EHR, staff needs to be trained to perform the important function of prepping, scanning, and indexing these documents. Metrics need to be established and workflow monitored to assure that scanning backlogs and bottlenecks do not develop. This workload can be significant.

Migrating to the EHR system from a paper-based system is going to take hospitals and healthcare organizations years to completely implement, given its complexity. How can hospitals manage the overload of duplicated information?

Forms inventory and control is an important component of the migration process. Prior to implementing electronic health records, a complete inventory should be undertaken, and duplicative, unnecessary and outdated forms should be removed from use, rectified, or replaced with an electronic version.

Since health records will eventually be electronic, what are the important considerations when storing original physical records off-site?

If no specific retention requirements already exist, providers should draw on available sound resources and establish an internal record retention policy. It’s important to ensure that records designated for off-site storage are not duplicative, and that they are properly labeled with a pre-established destruction date.

How long should original paper records—ones that have been imaged—be archived?

The current challenge is determining just how long imaged records should be retained, and when they should be destroyed. An error or omission from the original scanning can be missed by the internal QA process and require access to the stored records. This decision requires careful planning and oversight.

There are plenty of regulations about what constitutes a “legal” paper health record. Is there a definition of what constitutes a legal electronic health record?

It will always be important to ensure that information remain accessible for its ultimate purpose, regardless of the format or user involved. With the implementation of EHR, the Internet, and consumers’ increased interest in managing their health information, the definition of the legal health records has become more complex, but no less paramount. Organizations should seek input from the medical staff and the organization’s legal counsel, while complying with federal and state regulations, accreditation standards, and third-party payer requirements.

What is the main purpose of a legal health record and why is it important?

Because there is no “one size fits all” definition of the legal health record, it is imperative that healthcare organizations define their legal health records. The major purpose of the legal health record is to document the services provided in response to a patient’s injury or illness, along with the patient’s response to the treatment, as legal testimony; support the decisions made in a patient’s care; and to support the revenue sought from third-party payers.