Contact with Nonvenomous Frog, Subsequent Encounter

EDITOR’S NOTE: This article focuses on physician engagement and ICD-10 education. However, the term “physician” includes everyone licensed and credentialed to record a patient diagnosis, such as wound care and other clinical staff.

St. Joseph’s Healthcare System (SJHS)in Paterson and Wayne, N.J. is truly an ICD-10 success story. Under a new administration and clinical documentation management process (CDMP) program, System physicians spent 2015 immersed in a system-wide effort to transform their ICD-10 awareness and anxiety into lasting, proficient, and efficient documentation skills to satisfy medical and coding needs. System Health Information Management (HIM) Director Denise Bino coordinated this effort, drawing on 45 years of experience with the System and her extraordinary organizational and people skills.

The System’s medical staff is composed of single physicians in private practice, plus large and small groups, with employed physicians, residents, attendings, and consultants in every imaginable specialty, some found only at SJHS. A virtual United Nations, the physicians are as diverse as the population they serve, from inner cities to suburbs, some born in the hospital, others new to the area, and even the country. So, how did we teach these 1,300 physicians ICD-10 specificity?

An ICD-10 steering committee was established, comprising key staff from every department ICD-10 would touch: outpatient and inpatient, education to marketing, registration to physician, and all in between. Marketing, education, and other non-ICD-10 departments rounded out the team. Creative self-starters, the committee members were united by the vision, mission, and goal of ensuring that our physicians were all set for success. Since we were supported by the administration, the CFO personally approved necessary project budgets developed as we planned and proceeded. The committee met weekly to ensure coordination of efforts, but members often worked independently, touching base in the hallways or at other meetings to accomplish agreed-upon objectives.

Standard tools, such as countdown calendars and clocks, memos, emails, newsletters, and posters were used endlessly to remind physicians not only that they needed to prepare for ICD-10, but also how to do it. We escalated the use of two tools already in place. At every meeting with physicians, one-on-one or in groups, we passed out “think in ink” pens from HIM and “I (heart)” M&Ms (with real ICD-10 codes) supplied by me and “prescribed” as “ICD-10 antidepressants.” Doctors love pens almost as much as they love chocolate.

We needed an easy way to identify physicians who needed help with ICD-10 from those who did not. We had 2,000 metal buttons made. The buttons, designed to fit on hospital name tags, clearly delineated where in the ICD-10 educational process each physician was.

Red buttons with a hand in the “stop” position also asked, “are you all set for ICD-10?” We distributed lots of red buttons to create an awareness and buzz that got hospital and office staff and physicians to stop and talk about ICD-10. Purple buttons, reading “I’m an all-set leader!” were given to committee members and other leaders (the CFO) who could answer questions about ICD-10 or tell physicians where to get answers.

When physicians completed their first ICD-10 training session, they were presented with a yellow “I’m working on ICD-10, R U?” button. As 2015 progressed, ICD-10-prepared physicians voluntarily traded in their yellow badges for green ones reading “I’m all set for ICD-10, R U?” Some were awarded purple badges by task force members who had been asked to identify leaders who could help us prepare physicians. Very quickly, physician name badges sported a yellow button (I suspect some wanted to avoid questions from the janitors, food service staff, and patients curious to know why their physician didn’t have a button).

We started off big, with three days of documentation fairs, including iPad prizes upon completion of all 10 documentation educational stations, T-shirts, food, and fun in the physician lounges. Committee members and staff from many departments manned stations to help with the electronic health record (EHR), an ICD-10 app, coding, CDMP, and other documentation questions. A volunteer sketched caricatures. Our ICD-10 help line and email help were introduced, and we handed out CDs with the ICD-10 ALL SET DOC-U-MentationSM videos. These fairs were followed by smaller events geared to specific problems later in the year. The most recent one celebrated Valentine’s Day 2017, with “more to love about ICD-10 and documentation.”

We also created educational and memory tools. Since physicians learn medicine using mnemonics, I summarize ICD-10 specificity into the ICD-10 ALL SET DOC-U-MentationSM mnemonic. I color-coded it, designed a logo, and focused all teaching around documentation for severity of illness (SOI) using ALL SET. I instructed physicians to remember ICD-10 specificity every time someone asked them, “all set?” (You would be amazed how many times a day a non-medical person uses this phrase.)

We designed a plastic card that attaches to the hospital name badges. On one side is the ALL SET mnemonic, on the other are details of the O in dOcumentation. Cards were handed out at all lectures and fairs, and a supply was left everywhere physicians congregate. CDMP, HIM, and I carried them in our pockets to give to physicians lacking one on their badge. While our folks attached the ALL SET card to their badge, we used the time to teach them something about ICD-10 documentation.

We took the adage “location, location, location” seriously, and relocated ICD-10 education and meetings to the physician lounges, so the ICD-10 ALL SET DOC-U-MentationSM project was ever present, even during downtime. As the ICD-10 consultant, my “office” space was placed in the physician lounges. The in-lounge conference room was used for most of my lectures. I left the door open to invite curious physicians to join in or just listen from afar.

Our lecture series started with an ICD-10 introduction and the ICD-10 ALL SETSM mnemonic. Every lecture started with laughter and a chocolate high as I dispensed M&Ms and practiced psychotherapy as physicians vented about the changes in medicine. Two keys to success with physicians are bringing food and giving them a chance to let off steam and feel validated. Then, it is easier to get them engaged in change.

Specialty lectures were based on specific clinical conditions seen by the physicians scheduled for the lecture. However, ICD-10 specificity and severity of illness (SOI) were used as the vehicle to introduce basic clinical documentation improvement (CDI), medical necessity, case mix index (CMI), payor edits and denials, and related topics physician are not taught in training.

We knew we had to develop tools to help doctors maintain ICD-10 skills and orient new residents and attendings, so we worked with IT and developed and recorded a video series that broke down longer lectures into short segments. The IT department installed files on the hospital intranet that included the ALL SET videos as well as our recorded CPT® and clinical documentation videos, along with resource documents and helpful articles. The ICD-10 ALL SET DOC-U-MentationSM videos played on a continuous loop on a TV in each physician lounge.

At each hospital, my “desk” was in view of the coffee machine so I could greet physicians and answer their questions. Before October 2015, I would ask, “are you ready for ICD-10?” Now, I ask, “how’s ICD-10 treating you? Anything I can help with?” The usual answer is “no,” but after they get their coffee, most gravitate to my desk, take a seat, and ask something about which they just thought.

The lab worked with us to make the hospital antibiogrammore physician-friendly, and I taught physicians how to use it for infection specificity. They were handed out at all lectures, and a supply was kept in the lounges. ICD-10 code frequency reports will be used to remind physicians how important organism specificity is and will let them compare themselves to their colleagues.

Recognizing the importance of documentation from many sources, ICD-10 lectures ranging in length from five minutes to two hours were incorporated for all medical staff, specialty department, and resident meetings. Resident orientation included an hour of material about ICD-10, with a teaser about documentation. Follow-up lectures were scheduled and the intranet folder advertised.

Enlisting the aid of office staff was important, since physicians generally spend more time in the office than the hospital these days. We developed seminars for staff to help with ICD-10, office forms, and code sheets. We opened the ICD-10 lectures to office staff and met in small groups with them to discuss the problems they were having preparing. We educated them about ICD-10 ALL SET DOC-U-MentationSM and gave them my specificity guide and code sheets. We have continued private practice support in exchange for denial information.

These physician-oriented efforts were coordinated with those focused on CDI, coding, IT, offices, clinics, and other departments. As we proceeded with physician preparation, IT did integration testing, application remediation, and reports. IT even had an uneventful rollout of a new EHR three weeks before ICD-10 went live.

Revenue cycle operations activities included HIM dual-coding in four stages; review and remediation of forms and reports with ICD-9 codes; patient access scripts and bulletins sent to physician offices; coder assistance during registration; and patient financial services integrated testing of all payers and internal translation crosswalks for superbills. Each of these efforts contributed to a smooth transition.

The communications department assisted with the i10 ALL SET DOC-U-Mentation SM videos, posters, a weekly “The Road to ICD-10” bulletin emailed system-wide, and a “library” of reference information in the physician lounges.

The education department provided all physicians and residents with mandatory online Precyse University ICD-10 training and set up a Precyse app on each physician’s phone upon completion of required modules. User-role-specific modules were provided for staff in related departments for billing, registration, and clinic staff.

Compliance was monitored by the continuing education department and reported at weekly steering committee meetings. Committee leaders entered the status of their projects on a shared drive to monitor all activities. On a weekly basis, a graph of physicians in each stage (red, yellow, and green, or purple) tracked physician progress and was also posted in the physician lounges.

As Oct. 1, 2015 approached, we set up a command center for 24/7 on-site help and questions.

On Oct. 1, 2015, we served physicians an ICD-10 birthday cake as part of another documentation fair to celebrate the successful birth of ICD-10, giving them time to ask one last question! Preparation success enabled us to close the command center, transferring a few remaining questions to the help line at the end of day two.

Coding did a sample test of Oct. 1 discharges for all payors and services at both facilities. They were monitored to ensure that all bills processed before the remainder were dropped.

We ended our ICD-10 prep efforts with a bang when a team of hospital departments, dressed as ICD-10 codes, won first prize at the SJHS Paterson 2015 Halloween Parade. I had the honor of going as the princess kissing the frog (W62.0XXA, contact with nonvenomous frog, initial encounter) and enjoyed watching Ms. Bino playing me and leading our team my documentation fair attire of an opalescent lab coat, glasses, long skirt, and sandals.

Physician education continued during 2016 as we researched codes, answered questions, and queried Coding Clinic more than 200 times. Going forward, we plan to teach ICD-10 documentation in all physician orientations; provide access to the videos and articles on the intranet; distribute antibiograms and ICD-10 ALL SET DOC-U-MentationSM cards, specificity guidebooks, and code sheets; and to give regular “booster shots” until all physicians document severity of illness and specificity out of habit, or in response to EHR prompting. To this day, the SJHS mascot ICD-10 frog visits the physician lounges to bring news.

One need only listen to the quality of the questions our physicians ask to realize how much they learned about documentation and IICD-10 from our efforts. Although they do not always know the how, they have learned why they need to document accurate SOI and where to get help doing it right the first time. Annually, we will provide physicians and their offices with the published code changes. And SJHS has hired an in-house CDMP medical adviser for ICD-10: the next generation … someday we may even change our thinking from RVU to ICD-10 SOI plus outcomes.

Just think, it is now about 500 days since the birth of ICD-10, and it seems like just yesterday!

My thanks to everyone at St. Joseph’s for making our efforts such a success. Physician engagement led to an uneventful ICD-10 conversion; acceptance of the need to accurately represent severity of illness; and a willingness to keep learning how to document accurately for correct coding.

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Photo courtesy of: ICD10 Monitor

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