Dual Coding in Preparation for ICD-10: Emerging Best Practice

ICD-10:
Dual Coding in Preparation for
Emerging Best Practice
the rationale for dual coding
Lisa Fink, MBA, RHIA, CPHQ | Kathy M. Johnson, RHIA

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Dual Coding in Preparation for ICD-10: Emerging Best Practice
Table of Contents
3 Introduction
4 Rationale for Dual Coding
6 Dual Coding Methods and Study Design
9 Dual Coding Approach:
100 Percent Dual Coding vs. Focused Projects
11 Example Worksheets to Plan Dual Coding Projects
14 Challenges
15 Conclusion
16 About the Authors
18 Care Communications’ ICD-10 Services
18 Additional Online Resources
Connect with us
to learn more and
to help ensure a smooth
transition to ICD-10

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An e-book by Lisa R. Fink, MBA, RHIA,
CPHQ, Senior HIM Consultant and
Kathy M. Johnson, RHIA, Vice President
and General Manager, Data Quality
and Coding Compliance.
Introduction
Experts in the healthcare industry suggest that dual coding in ICD-9 and ICD-10
CM/PCS (ICD-10) is an integral part of ICD-10 implementation plans. The
delayed implementation date of October 1, 2014 provided organizations an
additional year to work on ICD-10 plans and activities, and an opportunity
to gain experience with dual coding. Coding 100 percent of patient records
in both ICD-9 and ICD-10 for a period of time prior to October 1, 2014 may
have initially appeared to be the ideal strategy; however, the challenges of
budget constraints, coder shortages, education and training needs, and
new system implementations suggest a more efficient strategy is to perform
multiple dual coding projects, which are more focused and limited in scope.
We will discuss this emerging best practice in this e-book.
While some consultants have recommended doing dual coding for six to
twelve months prior to the go-live date, at Care Communications we suggest
starting dual coding projects as soon as possible and continuing as needed
through post implementation evaluation. These studies will inform evolving
strategies for conducting beginning and advanced ICD-10 training activities
for coders and users, improving clinical documentation, developing ICD-
10 coding policies and procedures, and reengineering coding workflow as
needed for a successful transition to ICD-10.
ICD-10:
Dual Coding in Preparation for
Emerging Best Practice
a more efficient strategy
is to perform multiple dual coding projects.

4
Rationale for Dual Coding
As organizations consider how they will accomplish dual coding, they must
first be clear about their reasons for dual coding. Knowing how results will
be used helps planners design their dual coding projects to most efficiently
achieve their objectives.
Below is a list of the common reasons for including dual coding in your ICD-
10 implementation.
1. Financial Modeling and Analysis: Results of dual coding will assist with
financial modeling and analysis. Coding the same records in both ICD-9
and ICD-10 code sets provides data that can be grouped to MS-DRG’s to
determine where reimbursement will differ between ICD-9 and ICD-10.
While revenue neutrality may be the goal of the Centers for Medicare
and Medicaid Services (CMS), it is not reality in every case. Identifying the
potential revenue changes specific to your patient population enables your
organization to more accurately prepare budgets and associated strategies.
Organizations need to know how and when payers plan to change
reimbursement formulas and contracts prior to the ICD-10 go live. Data
from a dual coding project will assist organizations in reviewing current
payment contracts and negotiating future contracts.
Organizations need to know
how and when payers plan to
change reimbursement formulas.
2. Developing the ICD-10 Workforce: Dual coding as
part of ICD-10 education and training will provide coding
staff with valuable practice prior to the go live. Practice
reinforces education and training, increases confidence,
and improves productivity. Coding real world patient
records with both code sets provides coders with valuable
ICD-10 coding practice, allowing them to critically think
through and apply the principles they learned in training
to the types of cases they will regularly encounter in their
facility after October 1, 2014. Equally important, it provides
managers with an opportunity to better identify staffing
needs leading up to and following the go-live date.

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In ICD-10, the total
possible procedure codes
increase from approximately
13,000 to 68,000.
3. Clinical Documentation Improvement (CDI): Additional benefits will be
gained by identifying opportunities for CDI. In ICD-10, the total possible
diagnosis codes increase from approximately 13,000 to 68,000; possible
procedures codes increase from 3,000 to 87,000, which will result in more
granular data. To achieve such granularity, patient records must include
significantly more specific clinical documentation. Early ICD-10 coding
presents the opportunity to review the documentation for the necessary
specificity. Documentation problems can be identified and solutions such
as clinical documentation improvement programs can be updated, focused
physician training can be developed and implemented, or documentation
policies and/or data capture templates can be revised.
4. Workflow Re-engineering: Changes in workflow may be needed
in the ICD-10 environment. Coding with ICD-10 prior to go-live also
provides an opportunity to evaluate the workflow and adjust it as needed.
Testing new workflow design is important especially at the time of
implementation for new technologies, such as EHR’s or Computer-Assisted
CDI and Computer-Assisted Coding (CAC) software.
5. Reporting: Reporting processes may need to be adjusted. Reports used
for quality reporting, research, trending, or auditing should be reviewed to
determine the impact on these reports, if any, by ICD-10. Analysis of the
reports affected by ICD-10 data should be modified prior to the go-live
date.
6. End-to-End Testing: It is critical to the successful implementation of ICD-
10 that data flows in a timely and accurate fashion through all the internal
systems as well as external systems such as those at clearinghouses
and payers. The latter will determine readiness to process claims for
reimbursement.

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Dual Coding Methods and Study Design
Dual coding is labor intensive and thus an expensive undertaking for
organizations. To be as efficient and effective as possible, some organizations
have moved away from planning for 100 percent dual coding for a specified
period of time, towards developing meaningful, limited scope dual coding
projects with clearly define the goals, methods and study design appropriate
to each project’s objectives.
For example, dual coding projects that provide the opportunity for coders
to practice as part of training, would look different from ones done to
determine the adequacy of clinical documentation. Planners would choose
a dual coding method, and determine the sample size, time period to cover,
and how records would be sampled, i.e., random sample, by physician, by
specialty, by diagnoses, procedures, or MS-DRG.
The following are examples of methods being used in dual
coding projects.
1. Simultaneous Dual Coding by an Individual Coder:
Using this method each coder would first use the ICD-9
code set and then the ICD-10 code set to assign codes
to a record. Coding the record in both code sets in
the same sitting is most efficient, and is a good choice
when the goals of the project include accomplishing
a reasonable volume of production coding as coders
practice ICD-10 skills.
simultaneously is most efficient.
in both code sets
Coding the record

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2. Dual Coding of One Record by Two Coders: If one of the goals of the
organization is to assess additional resources required in the coding of
ICD-10, production time should be measured by using two coders to do
the dual coding, one coding with ICD-9 and one with ICD-10. This method
will reduce the bias of reviewing the same record twice.
3. Dual Coding and Inter-rater Reliability: With this method several
coders code the same record in ICD-10. This method allows for coders
to practice, but it also enables the study results to be used to establish
a measure of inter-rater reliability. When several coders code the same
record, followed by an educational discussion about the matching and
mismatching codes selected, the degree of agreement among coders can
be measured. Results from inter-rater reliability studies can be used for
developing an organization’s ICD-10 policies and procedures, as well as
the quality and productivity standards that the coders will be expected to
meet. This method is a good choice if the goals of the project are more
educational in nature, and in the long term should lead to better data
quality as evidenced by a high rate of inter-rater reliability.
4. Use of Temporary Staff for Dual Coding: Use temporary or outsourced
staff to code in ICD-9 and submit claims while regular coding staff code
100 percent of discharges in ICD-10 for three to six months prior to the
October 1, 2014. This approach has the potential to make the transition a
smoother process for the coders and physicians as they will have worked
out the challenges prior to the go-live date. This method provides data for
multiple uses to include financial modeling, testing and reporting.
Regardless of method chosen, if sampling,
care should be taken to stratify the sample of
cases to ensure that all major diagnostic and
procedure categories are included.
<<<<<

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Using claims data for dual coding, or using CMS’ General Equivalence
Mappings (GEMs) of ICD-10 to ICD-9 codes are tempting methods being
used in some organizations, but not recommended. Coding from claims data
without reviewing source documents in the patient record does not allow for
the specificity necessary for accuracy. Using claims data can lead to coding
errors as a result of guessing the appropriate code in the absence of clinical
documentation.
Coding in ICD-9 and GEMs mapping to ICD-10 may seem like a time saver
but can compromise data quality as many codes lack true one-to-one
matches. These methods make analysis of the data for dual coding purposes
flawed. GEMs are intended to assist users to understand, analyze, and
manage the translation of one code set to the other. The GEMs help users
manage large data sets and are not intended to replace using ICD-9 and ICD-
10 directly. An excellent reference for the appropriate use of GEMs is offered
by the American Health Information Management Association (AHIMA) in
their 2009 Practice Brief, Putting the ICD-10-CM/PCS GEMs into Practice.
Caution: Methods not recommended
based on lessons learned
Limited use of mapping can potentially improve efficiency of
the process if the coder maps ICD-10 to ICD-9 codes and the
edits the ICD-9 by reviewing the chart as needed. Mapping
from the more granular ICD-10 to the less granular ICD-9 is
more accurate than mapping from ICD-9 to ICD-10.
Using claims data for dual coding can
lead to coding errors.

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Dual Coding Approach:
100 Percent Dual Coding vs. Focused Projects
There is no “cookie cutter” approach to dual coding that will work for
all organizations. Coding 100 percent of patient accounts in both ICD-9
and ICD-10 code sets for a period of time prior to October 1, 2014 will
produce ICD-10 coded data that can be used in a multitude of ways and
provides coders practice time with records.
While this process may be a perfectly acceptable approach in some
organizations, the biggest drawback for other organizations is the cost and
availability of the human resources needed. It is estimated that organizations
that choose a 100 percent dual coding approach will need to double their
coding staff to dual code all accounts for the period of the study. While the
estimated productivity loss at ICD-10 go-live is 30 percent, early work with
predictive staffing models demonstrated 100 percent coding productivity
loss during periods of dual coding.
There is no “cookie cutter”
approach to dual coding that
will work for all
organizations.

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A more efficient use of coding staff resources is planning for a series of
dual coding projects, designed to fit the specific needs of your organization.
The following questions can be used to help plan and prioritize dual
coding projects.
What are your goals or biggest coding concerns?
What are your documentation concerns or documentation
improvement challenges?
What are the types of cases most impacted by the ICD-10 change
(i.e., Orthopedics)?
What data elements should be collected from each dual coded case
in the project?
How will you define your sample, and how will it be stratified;
will random or systematic sampling be applied to each stratum?
What time periods should the samples cover?
What dual coding method is the best fit to obtain the data
needed to address your goal or concern?
What is your timeline for conducting the projects? What dual coding
projects should be done closer to the October 1, 2014 go-live date,
and what dual coding projects could be done in advance of the
go-live date?
For each project, prepare a worksheet with the answers to the relevant
questions above.

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Example Worksheets to Plan Dual Coding Projects
Example 1
Project Planning Worksheet for ABC Hospital –
Reimbursement Analysis – Orthopedic DRG’s
Goals 1. Determine possible changes to reimbursement.
2. Test claims with payers.
Data Collection Use ICD-10 codes for testing natively from actual records rather
than relying on a translation tool.
Sample Select sample from ABC Hospital’s top 5 high-volume Orthopedic
DRG’s. Include records from every member of Orthopedic
Department; to further define the sample, one or two of the
higher volume payers will be included in the sample.
Coding Method ICD-10 trained coders will code 5 records per day in both ICD-9
and ICD-10 per the sample selected.
Timeline The project will begin in the third quarter of 2013 and continue
until ICD-10 go-live for ample analysis time.

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<<<<<
Example 2
Coder Education
Goals 1. Provide all coders the opportunity to practice coding in
ICD-10 following training.
2. Reinforce concepts learned in training.
Data Collection Obtain ICD-10 codes natively from medical records.
Sample A sample of 5 records per high volume DRG’s per month
will be included.
Coding Method Because this is an educational goal the inter-rater reliability method
will be used. Record(s) will be selected and each coder will
individually code the record and code selection will be discussed.
Timeline Following ICD-10 training for all coding staff this process will be
implemented by the second quarter of 2014 and will continue
until ICD-10 go-live.

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Example 3
CDI Practice
Goals 1. Provide CDI staff with the opportunity to practice being more
specific in the query process.
2. Reinforce concepts learned in training.
3. Work with physicians to help them understand the level of
detail that will be queried.
Data Collection Obtain ICD-10 codes natively from medical records.
Sample Focus will be high dollar cardiac surgery accounts. Any account
that demonstrates a preliminary DRG in the 215 – 265 range will
re-coded in ICD-10 for query practice purposes.
Coding Method CDI staff will code records in ICD-10 to determine if more
documentation specificity is necessary to correctly code in ICD-10.
If not, the physician query process will be initiated.
Timeline A three month test of this process will occur first quarter 2014.
Results will be analyzed to determine if further testing is needed.

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Challenges
Completing dual coding projects is not without its challenges. As payers are
not accepting claims with both ICD-9 and ICD-10 code sets, dual coding
for purposes of actual reimbursement is unrealistic. However, if anticipating
reimbursement and making budget preparations is the goal, dual coding has
value for these internal preparedness purposes. After October 1, 2014, dual
coding operations may still be needed to submit claims to payers who are
not HIPAA covered entities, such as Worker’s Compensation and Automobile
Insurance, or other payers who may not be ready for the ICD-10 environment.
Having dual coding strategies in place will assist in this workflow going
forward.
The sheer volume of accounts to be dual coded may present a challenge. As
discussed above, a well-designed sample can provide valuable information to
organizations. Utilizing the top 10 to 20 MS-DRG’s, principal diagnoses, and
principal procedures is one effective way to determine a sample. Another
way is to review current issues the organization may be having with denials
or other reimbursement delays. This focus allows the organization to select a
meaningful sample and start working to correct problems.
Software challenges
may need to be addressed.

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Software challenges may need to be addressed. In particular, test
environments may not be as robust as full production environments. In order
to perform full-scale end-to-end testing of ICD-10 claims, all test systems
in the process should be able to handle the claims with minimal manual
intervention. Any identified problems will need to be amended in both the
test and production environment to ensure smooth, accurate processing
of data.
Conclusion
Dual coding as a series of well thought out projects will enable organizations
to accomplish a variety of ICD-10 preparation and implementation goals in
a cost effective and efficient approach. Planning for these projects should
begin as soon as possible. Well thought out dual coding
projects will enable orgaizations
to meet ICD-10goals
cost effectively.

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Lisa Fink, MBA, RHIA, CPHQ, Senior HIM Consultant, Care
Communications, Inc. As a Senior HIM Consultant, Fink has performed multiple
ICD-10 engagements to include readiness assessments and implementation
planning. She has also supported hospital coding functions and post go live
system implementations through interim management.
In previous roles, Fink directed HIM departments, QI departments and managed
an IT department. Managing change was inherent in these roles to include
complete retooling of medical record filing systems, development and training
quality improvement processes, development of a systematic approach to
successful accreditation, and implementation and support of electronic
documentation systems.
ABOUT THE AUTHORS
Fink has held adjunct faculty positions in the business college
setting, the community college setting, and with two AHIMA
accredited schools. Her teaching focus has been ICD-9 coding and
other health information management courses.
Fink is a member of AHIMA, the National Association for
Healthcare Quality, and the Wyoming Health Information
Management Association (WYHIMA). Currently the President-Elect,
Fink has held all seats on the Board of WYHIMA multiple times.
She received a bachelor’s degree in HIM from Carroll College in
Helena, Montana and a master’s degree in business administration
from Regis University in Denver.

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Kathy M. Johnson, RHIA, is Vice President and General Manager, Data
Quality and Coding Compliance for Care Communications, Inc. (CARE) a national
health information management consulting company based in Chicago. Johnson
joined the CARE team in 1997 as a coding consultant with primary duties
of completing coding quality reviews, delivering coding education (one-on-
one training as well as small and large group settings), conducting operations
assessments and evaluating client coding compliance programs. Accepting a CARE
director position in 2003, Johnson oversaw consulting engagements focused on
data capture, coding classification, compliance and education. In her present role,
she provides strategic guidance as adaptation to the future state of coding and the
changing needs in the healthcare industry are underway.
Johnson is a veteran health information management professional with more
than 30 years of experience in a variety of positions, including health information
management department director, classroom and practicum educator and post
secondary health information program director, independent consultant and quality
improvement leader in the acute care setting.
Johnson’s articles have been published by the American Health
Information Management Association (AHIMA), Advance for
Health Information Professionals, HCPro and the Healthcare
Financial Management Association, and include:
Regulatory Alphabet Soup: Financial Implications of RAC,
MAC and HAC
POA Coding Requirements Create a Chilling Effect for
Hospitals
Effectively Managing RAC
5010 and ICD-10
Is It Too Early to Begin ICD-10 CM & PCS Education?
Johnson possesses a bachelor’s degree in health information
management and is an active member of AHIMA and has served
on the association’s Practice Councils.
ABOUT THE AUTHORS

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Visit us online today to request more information about how our services can
help ensure a successful ICD-10 transition at your facility, including:
Clinical Documentation and Revenue Risk Assessment
• We determine your facility’s Medicare revenue impact and help define
strategies to reduce risk.
• Utilizing CARE’s proprietary ICD-10 Code PredictorSM
(GEMs) technology,
we identify all cases that may be problematic in ICD-10.
• An all-important case-by-case review to validate documentation needs
and develop a customized action plan for clinical documentation
improvement.
Skills Assessments, Planning and Training
• Analysis of coding staff skills deficiencies.
• Comprehensive and facility-specific coding education and training
programs.
• E-learning platform or on-site training options.
• ICD-9/ICD-10 parallel and production coding support and planning
for transition staff levels.
ICD-10 Directors/Leaders
• Assistance of an ICD-10 expert to ensure thorough planning, project
management and efficiency in execution.
Visit our website: carecommunications.com/icd10
For questions and assistance with your ICD-10
implementation, contact Roberta Peters at 800-458-3544,
extension 153 or rpeters@care-communications.com.
Connect with Care Communications to learn
more about ICD-10:
LinkedIn | Twitter | Facebook | Google+ | YouTube
Additional Online Resources. Here are additional resources
that may be useful in making the transition to ICD-10:
ICD-10 Monitor
ICD-10 Watch
CMS ICD-10 web page
AHIMA ICD-10 web page
ICD-10-PCS Reference Manual
ICD-10-CM—National Center for Health Statistics
AHA Central Office ICD-10 Resource Center
Prepare for ICD-10 with Care Communications’ Customizable Services.

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© Care Communications, Inc. 2013

Dual Coding in Preparation for ICD-10: Emerging Best Practice

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Dual Coding in Preparation for ICD-10: Emerging Best Practice