The Impact of ICD 10 on Case Management in South Africa

This special international perspective takes a look at South Africa’s transition to ICD 10 coding, which case managers and related professionals are preparing to—or currently—grappling with here at home.

Initially, ICD 10 coding was introduced mainly to the private healthcare sector of South Africa in the late 1990s. From here a national task team driven by the government began to implement the use of ICD 10 coding on a national basis. Both government and private healthcare sectors were represented on the task team.

In 2005, ICD 10 became compulsory for all providers of service for the submission and payment of claims. A phased-in process ensued, aided by the publication of educational circulars. In this system, each provider became responsible for the coding of their own account; while this was not seen as ideal—due to the fact that a single patient profile was not presented—the current SA billing structure left no alternative.

Within the hospital environment, the case manager became the main person responsible for the clinical coding of a hospital event and hospital records. While getting used to ICD 10 helped during the early phases, it still caused a huge increase in the workload experienced by hospital case managers. At this point training was of vital importance, as accounts that did not adhere to coding rules were (and are still) rejected by funders.

Using “cheat sheets” became a major problem, which increased the importance of intensive training. While making sure that the quality of the coding is appropriate at the provider level, the medical schemes also experienced an increase in workload with call centre times increasing by as much as 30 percent, as more information was needed before a case could be authorized.

Soon after implementation, the impact became evident from the data supporting different areas of the industry—i.e., benefit designs of healthcare products, authorization processes, trends of diseases, chronic medicine benefit designs, bed assignments at hospital level, and tariff negotiations.

A Redefined Role for Case Managers

The role of the case manager has been permanently affected by these changes. As coding improves, so changes the planning around many aspects of patient care. Level of care, length of stay and discharge planning all were affected, with medical schemes having a more accurate picture of the patient’s health status. Standard predictable cases suddenly became easily identifiable, and more focus could be given to cases that really needed case management support and discharge planning.

The biggest challenge (persisting today) is that medical records do not contain sufficient and direct diagnostic information from the treating practitioner to enable the case manager to do relevant coding and planning. Often records will have a lot of information but little reference to diagnoses available. This is an ongoing battle between different departments and organizations. The reality is that incomplete diagnostic information eventually impacts the patient’s medical funding benefits.

Patient confidentiality was also suddenly under the spotlight. And while there is resistance among providers who believe this could be a breach of patient confidentiality, the reality is that in coding format the diagnosis is not immediately evident to the untrained eye. Once de-identified in statistical analysis, the identification becomes irrelevant.

Coming from direct experience with ICD 10 in the case management environment, here a few helpful tips to all case managers in the United States now facing the change over from ICD 9 to ICD 10.

• Make sure that you get the right training. As always, knowledge is power. IT will enable you to get a better picture of your patient and of the care needed.
• Make sure your coding is a true reflection of the patient’s health record, and that you have followed the coding rules. Following coding rules in ICD 10 is the biggest secret to success.
• Do not think that a “cheat sheet” with a few codes is the solution. Eventually, you will assign the wrong code. Ultimately, the party that will suffer the most because of lazy coding is the patient, and you will penalize your company on financial margins in a DRG environment, for example.

To all case managers in the U.S., we wish you all of the best on this new project. Yes, it will be strange and it will demand changes in your daily routine. But ultimately it is worthwhile and will be to the benefit of your patients as well as of your company.

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Erna Van Rooyen is a group case manager with Netcare Hospital Group. Carol Garner is the operations director with MSO South Africa. (Contact: erna.vanrooyen@netcare.co.za)