At the Margins

Why the Canadian ICD-10 experience doesn't tell the whole story

by Lulis Navarro

By now it’s almost certain that the ICD-10 transition will occur on October 1 as scheduled, barring any last minute congressional intervention. Lately we’ve been talking to many members preparing for the transition and a consistent concern is coming through loud and clear: productivity.

More specifically, many organizations expect their coder productivity to take a hit as they adapt to the new coding system, along with additional downstream implications such as backlogs, payment delays, and potential changes in labor requirements—including outsourcing or additional hiring.

Naturally when attempting to prepare for the likely hit on their revenue cycle, many organizations have looked for benchmarks to help estimate what the initial coder productivity decline might look like. Sadly, much of the available literature doesn’t provide any concrete answers and doesn’t alleviate much of the uncertainty. Let’s look at some prior examples.

The Canadian ICD-10 transition

We’ve heard a few members cite the Canadian experience as the basis for an expected 50% initial drop in productivity related to the ICD-10 transition. This benchmark can be traced back to one study—hardly a robust body of literature—published by Humber River Regional Hospital in Ontario, Canada after it implemented ICD-10 in 2003.

While this study foreshadows a productivity decline, it’s not an apples to apples comparison. There are several situational differences between the Canadian transition and the impending U.S. transition that make it challenging to extrapolate such productivity decline to what’s ahead.

Factors that increased transition complexity for Canada

  • Canada switched from paper to electronic coding at the same time. U.S. hospitals will not face this added hurdle.

Factors that decreased transition complexity for Canada

  • Canada implemented ICD-10 only in the hospital setting. This makes the Canadian transition arguably simpler than the one the U.S. is about to experience, as ICD-10CM will be employed across all health care settings in the U.S.
  • Canada’s procedural coding system expanded from 3,500 to 20,000 codes; the U.S. system will change from 4,000 to approximately 72,000 codes. U.S. coders will have to learn more codes in ICD-10 and will be required to be more specific in their charts than Canadian coders.
  • Canada has a single-payer system. The government was able to make centralized decisions regarding training and footed the bill for the transition. All hospitals were equally ready for ICD-10, which is certainly not the case in the U.S. where hospitals vary in preparedness for the change.

Examples closer to home

Unfortunately, the U.S.-based research on ICD-10 doesn’t paint a perfect picture either. Two ICD-10 field-test projects, conducted in 2003 and 2013, showed productivity declines similar to the Canadian benchmark. However, the coders in both these studies were “cold”—meaning they had never been exposed to ICD-10 before the field test.

Many hospitals’ coders have already had the opportunity to practice using the new code set by dual-coding. The field test results do not reflect any learning curve, making it hard to predict what hospitals that have dual-coded can expect after October 1.

Taking a data driven approach to stay on top of productivity declines

Given the lack of reliable industry benchmarks, one of our progressive members created a productivity database to capture dual-coding performance, including the number of charts per hour their coders completed under ICD-9 and the number of the same charts completed under ICD-10. This member is collecting this information weekly and using it to estimate the productivity declines they can potentially expect under ICD-10. They are also planning to use this data to help assess when they’ve regained their pre-ICD-10 coding productivity after the transition.

While the Canadian experience and the U.S. field tests foreshadow a general decline in productivity after the ICD-10 transition, the reality is likely to be different across organizations based on the level of preparation and training invested to date. Measuring your productivity in ICD-9 and ICD-10 before the transition can help provide a baseline, helping you understand if and when you approach prior productivity levels, and communicate needs for resources internally.

A checklist for a smooth ICD-10 transition

We've compiled and organized must-do steps into a downloadable checklist you can share with your teams.