At this point in the healthcare industry’s push to implement ICD-10, we are inundated with articles that focus on the usual suspects – critical education needs, physician cooperation, systems and documentation assessments, and the elusive end-to-end testing. Any healthcare professional with five minutes and an Internet connection can saturate himself or herself with ICD-10 implementation material. However, in combing through the “need-to-dos” and the “how-to-dos,” there is one minor yet overlooked facet of this upcoming industry shift – managing your staff’s crisis mode during this change.
Have you ever tried to learn a new language as an adult? According to ZhaoHong Han, an associate professor of linguistics and education at Columbia University, there is a 95 percent failure rate for adults attempting to learn a second language.[i] Granted, this specific example reflects an effort most often pursued on a voluntary basis. However, mandatory learning, as is the case with ICD-10, offers a whole new set of circumstances to consider. Sandra Kerka explores problems with mandatory continuing education effectiveness, noting that adult learning should be autonomous, catered to each individual’s learning style, and pursued voluntarily.[ii] Let’s couple this with Dr. David Wetzel’s list of successful adult learner habits:
This recipe does not offer much of a compatible environment for our coders’ learning of ICD-10. Doing so is very similar to learning a new language. And coding professionals desiring to stay in the field post-Oct. 1, 2014 will have a mandatory obligation to learn.
Now, consider a typical, seasoned ICD-9 coder – knowledgeable, productive and confident. Furthermore, consider the ICD-9 infrastructure available – ample references, refined systems, time-tested. With the advent of ICD-10, this infrastructure goes away. What remains is a typical, seasoned coder now in chaos. Compared to his or her performance achieved under ICD-9, our coder is drastically less knowledgeable, considerably less productive, and has no confidence in what he or she is doing. The go-to resources readily available in ICD-9 do not exist for ICD-10 yet, so our coder flounders under the lack of structure currently (and historically) present in the world of ICD-9.
Anticipate that your coding team will experience a heightened sense of anxiety and/or adjustment reactions once it is coding full-time in ICD-10. The transition process could take as few as three weeks, but it may last a few months. In the live ICD-10 coding environment, the void of definitive reference material, combined with the urgency of recalling all that has been learned, results in feelings of being completely overwhelmed and a bit hopeless as it pertains to actually being successful in coding ICD-10.
Taking a hard-line approach to managing any employee’s transition through this change is one option. Utilizing a mentality of “do this or else” could be effective, however ill-advised, during these early stages of ICD-10 implementation. While hard to prove factually, there are rumblings within the industry of the potential for rampant coder poaching once ICD-10 hits. These rumblings alone warrant maintaining a supportive atmosphere that breeds loyalty.
Having recently managed a small group of coders through the transition from coding in ICD-9 to coding in ICD-10, here are the two biggest lessons learned:
- Consistent, repetitive messages regarding realistic performance expectations are key.
Team members struggled with the initial dropoff in coding knowledge and production. They had an expectation of “what I achieved yesterday in ICD-9, I can achieve today in ICD-10.” Even with intensive ICD-10 education, the first three to five weeks of full-time ICD-10 coding will be shaky at best, because the infrastructure – both nationally, in the form of Coding Clinic guidelines, and locally, at the facility level – will need to catch up or even be rewritten when projection-based protocols can be based on actual performance.
Consider this tool:guide your team members through a visualization exercise in which they recall their transformation of ICD-9 knowledge from their first coding class to their first day on the job through the present day. Emphasize the number of years it has taken them to reach their current proficiency in ICD-9. Remind them that this proficiency will come in time under ICD-10 as well. Cite Canada’s experience indicating that it takes about a year to make the performance transition to ICD-10.[iv]
- Develop a practice chart program that provides immediate feedback.The education plan I utilized contained four phases:
- Anatomy and physiology;
- Clinical management;
- Procedural coding system; and
- Practice chart coding.
Phases one through three were the “lectures,” if you will, and were all completed prior to phase four. Phase four then was approached as the class lab – actual hands-on coding of real facility records. Anyone who has ever tackled creating a completely redacted medical record library of practice charts can attest to its difficulty. Now layer in the coding of these records in ICD-10, as well as creating an agreed-upon answer key, and what you have is a fairly time-consuming process. The team was part of the answer key creation process and did not have immediate feedback on the charts coded. In hindsight, the two weeks allocated to phase four minimally facilitated my team’s ICD-10 coding confidence, because there were no answer keys available to reference, post-coding.
Consider this tool:establish an ICD-10 practice chart program that has a set answer key for all records, prior to any coders actually coding the charts. Assign your coders to small groups to review each coder’s answers, and have them talk through individual philosophies on coding approaches. Finally, work within your constraints to develop the practice chart program, prioritizing having a variety of records in your library rather than a large number of records. Anything is better than nothing, in this case.
Change management is an old business phrase that never goes out of style. It is ever-present these days and certainly will rear its ugly head as managers tackle their coding teams’ migration from ICD-9 into the new world of ICD-10. For a brief refresher on change management tactics, Penny Crow, CEO of Operational Strategies, offers these key points on the topic:
- Behavior cannot be changed without first changing the thinking – once you determine the thinking you are trying to change, identify how the overall thinking process impacts your operations and why the change needs to occur. Create a road map to manage the milestones of your implementation plan. Finally, align your team toward the goal and implement your change management plan. And remember to take the adage of “measure twice and cut once” seriously as you embark on this endeavor!
- Ask your team members what they think they need – while this advice is seemingly obvious and basic, Crow has found that most healthcare industry players do not pursue this tactic. However, it offers low-hanging fruit in helping your coding team learn, and better yet, retain, their ICD-10 education.
ICD-10 is no doubt one of the largest shifts the healthcare industry has had to tackle in decades. As roadmap execution is beginning, make sure to factor in managing your team’s migration through change. Even though it is a minor facet of your implementation, if overlooked it certainly has great potential to derail your team’s progress into ICD-10.
About the Author
Kris Knight is a project manager at Precyse, a leader in health information management (HIM) technology and services. She is currently working on an ICD-10 dual-coding program implementation for a large teaching medical center.
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- Han, ZhaoHong. Fossilization in Adult Second Language Acquisition. New York: UTP, 2004.