Managing Your Coders Through the ICD-10 Implementation

By Kris Knight, MBA, RHIA

At this point in the healthcare industry's implementation of 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 5 minutes and an Internet connection can saturate him or herself with ICD-10 implementation material. However, in combing through the "need to dos" and the "how to dos", there is one minor overlooked facet of this upcoming industry shift – managing your staff's crisis in 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% failure rate for adults to learn a second language.i Granted this specific example is 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, citing adult learning should be autonomous, catered to the individual's learning style, and pursued voluntarily.ii Let's couple this with Dr. David Wetzel's list of successful adult learner habits:

• Lack of procrastination
• Focus
• Specific goals
• Financial stability
• Vested interest
• Self-direction
• Good reading and comprehension skillsiii

This recipe does not offer much of a compatible environment for our coders' learning of ICD-10. Learning ICD-10 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 this new language.

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/her performance achieved under ICD-9, our coder is drastically less knowledgeable, considerably less productive and has no confidence in what s/he 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 an ICD-9 world.

Anticipate that your coding team will experience a heightened sense of anxiety and/or adjustment reactions once coding full time in ICD-10. The transition process could take as few as 3 weeks but 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 of hopelessness in actually being successful in coding ICD-10.

Taking a hard-lined approach to managing an employee's transition through this change is an option. Utilizing a tactic of "do this or else" could be effectual, however, ill-advised during these early stages of ICD-10 implementation. While hard to back factually, there are rumblings within the industry of rampant coder poaching once ICD-10 hits. These rumblings alone warrant keeping a supportive atmosphere that breeds loyalty.

Having recently managed a small group of coders through the transition from coding in ICD-9 to ICD-10, here are the two biggest lessons learned after guiding them through their migration:

• Consistent, repetitive messages regarding realistic performance expectations
Team members struggled with the immediate drop 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 3 to 5 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 projections-based protocols can be based on actual performance.

Consider this tool: Guide your team members through a visualization exercise where they recall their transformation of ICD-9 knowledge from their first coding class to their first day on the job coding through current 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. Use Canada's experience of about a year to fully make the performance transition into 10.iv

• Develop a practice chart program that provides immediate feedback.
The education plan I utilized contained four phases –
1. Anatomy & Physiology,
2. Clinical Management,
3. Procedural Coding System
4. Practice Chart Coding.

Phases one through three were the lectures, if you will, and were all completed prior to phase four. Phase four was then 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 2 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 them. Assign your coders to small groups to review each coder's answers and have them talk through individual philosophies on coding approach. 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 and will certainly rear its head as managers tackle their coding teams' migration from ICD-9 into the new ICD-10 world. 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 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 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 some decades. As road map 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 an ICD-10 world.

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.

i Han, ZhaoHong. Fossilization in Adult Second Language Acquisition. New York: UTP, 2004.

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