Preparing the Nonclinical, Non-Coder for ICD-10

As the U.S. healthcare system moves closer to the Oct. 1, 2015, ICD-10 implementation deadline, clinicians and coders continue preparing for this immense change in healthcare reimbursement and clinical documentation practices. While medical office operations and management continue to focus on ICD-10 education, it's important to determine the appropriate education levels of non-coding, nonclinical staff needed for ICD-10 education. Determining the details in ICD-10 education is an important consideration that an astute leader will want to eagerly identify according to their practice needs.

A practice leader's focus on educating the nonclinical, non-coding staff might include reviewing the following positions: scheduling, registration, accounts payable and accounts receivable, laboratory, revenue cycle specialists, and file clerks. For the ICD-10 transition to flow as smoothly as possible, it is imperative that all staff have knowledge of the new coding system and understand how it will impact their current positions.

In order to determine the correct level of education, analyzing current job positions should commence. This includes the review of policies and procedures, specific job aides and toolkits, work flow, and finally, transparent communication with the team. Furthermore, the revenue cycle process should be reviewed to ensure all staff with revenue cycle interactions are appropriately educated in ICD-10.

Here are some suggested processes a practice leader may follow in order to establish appropriate training in ICD-10 according to job position, including giving a brief refresher on the revenue cycle processes, and common positions that normally interact with the cycle and its specific stage. While every effort is made to cover all non-coding, nonclinical staff, it is up to the practice leader to review all positions and determine the best way to proceed with ICD-10 education for their team.

Revenue Cycle

A healthy revenue cycle is a key to a successful physician practice. A practice leader should review his current revenue cycle processes and take into consideration where the individual practice's revenue cycle starts and stops, as well as determine each staff position's interaction with the cycle.

Before education can be delivered, and staff positions are analyzed, it is crucial to remember the flow of the revenue cycle from the initial intake of patient information to zeroing out the balance in the patient's account. This will ensure a successful ICD-10 training for practice staff.

The process of a medical office revenue cycle usually resembles the following:

1. The patient calls to schedule an appointment.

2. Registration obtains prior authorization from insurance for the patient visit, if appropriate.

3. The patient presents for her scheduled appointment and signs required paperwork.

4. The physician examines the patient and documents the visit on the patient's chart.

5. The coder receives the chart and assigns the codes according to the physician's documentation.

6. The claim is sent to the payer.

7. Reimbursement is issued for the visit, if appropriate, according to the patient plan and contract.

8. Accounts receivable processes the payment and a statement is sent to the patient if monies are owed.

9. The patient pays the balance on her account.

10. The patient's account for that date of service is at zero balance. The revenue cycle process is complete for that patient encounter.

In order to understand how a staff member interacts in the revenue cycle at each level, analyzing positions is a must. Below is a sample of how this process might look and which staff member might interact at each level:

1. The patient calls to schedule an appointment and speaks with a scheduler. The scheduler will need to do a quick intake on the patient's insurance, reason for visit, if the patient is new or established, or if he has a referral. Appropriate steps must be addressed to obtain authorization for the visit. In order for this to occur, the scheduler will need to give the patient's insurance payer an appropriate ICD code.

2. The patient arrives for the visit and checks in at the front desk. The registration specialist will confirm the patient's information and insurance, as well as collect any copays due at that time. He may also take the original requisition slip if referred by another physician. Depending on work flow and practice size, the scheduler may have to select an ICD code (the reason for the visit) for pre-authorization purposes and/or to place on the patient's superbill.

3. The patient is seen by the physician. The physician documents the patient complaint and proposed treatment, if any, in the medical record. Diagnoses and any procedures are added to the superbill. The patient checks out, the chart is completed by physician, and routed to the coder.

4. The coder reviews the chart and assigns ICD codes according to the physician documentation. The encounter is sent electronically at midnight and routes to the insurance payer.

5. The payer issues payment to the physician. Your accounts receivable or billing department processes the payment. Any monies owed are sent by the patient to the billing department. Once the patient account is zero, the claim is closed.

The ICD-10 planning phase begins with determining each staff's interaction with the revenue cycle. This can occur by reviewing processes and work flow as well as policies and procedures. Scheduling, registration, filing, billing, accounts payable and receivable, release of information, revenue cycle specialists, and privacy and security staff should be asked for the tools they use every day with current ICD-9 codes, so they can be updated to ICD-10 codes.

Structuring Training

Once the quantity of existing ICD-10 knowledge is determined, training can be disseminated to staff through a variety of delivery methods. Face-to-face, written, electronic, or a combination of two or more can be used. Four hours to eight hours of training could be sufficient, but will be determined according to the needs of each staff member. This training should be completed at least one month prior to Oct. 1, 2015.

A detailed four-hour ICD-10 training agenda may look similar to the following, starting with the morning session:

• An overview of the healthcare system and why it is expanding from ICD-9 to ICD-10.

• The differences between the two classification systems.

• The impact on various physicians and healthcare positions.

• How the medical practice is preparing for ICD-10, to include timelines, parallel testing, upgrades, and go-live date.

• A question-and-answer session.

The afternoon agenda can be customized according to position, need, size of practice, etc. For a registration specialist, the training may look similar to the following:

• An overview of current work flow practices and where ICD-9 codes appear.

• An overview of any current daily job tools, such as coding, billing, or insurance software or interfaces.

• Updated policies and procedures to include the communication protocol with physicians regarding specific coding questions.

• Process flow changes, if any.

• ICD-9 to ICD-10 crosswalks, if available, pertaining to the practice and job title.

• Updated fee tickets with ICD-10 codes.

• Available resources: coding books, anatomy toolkits based on staff position, designated coder-of-the-day team member who can be contacted should a question arise, etc.

Additional spot training can occur after the initial training as a refresher for staff members who encounter ICD codes in their positions, followed by regular education meetings following the implementation date. The practice leader may also wish to monitor claim denials, and map back to specific steps in the process in order to further fine tune ICD-10 training with all staff (clinical and nonclinical). Lastly, updating policies and procedures, process flow charts, coding tools, and reference cards will help ensure a smooth transition for a practice.

When implementing ICD-10 in a medical practice, it's critical for a practice leader to review all nonclinical and non-coder positions, and to assess the ideal amount of training for each position. Understanding the revenue cycle and what each department contributes to the cycle will be useful in determining appropriate training methodologies for ICD-10.

Crystal Clack, RHIA, CCS, is a health information management excellence director in AHIMA's coding and data standards division. She can be contacted at crystal.clack@ahima.org

© 2015 American Health Information Management Association (AHIMA). Reprinted by permission.

This article originally appeared in the July/August 2015 issue of Physicians Practice.