Happy ICD-10 Anniversary

October 14th, 2016
ICD-10, Transition

A little more than a year ago, tensions were high as the healthcare industry prepared for the transition from ICD-9 to ICD-10. After all, the threat of delayed—and denied—reimbursements was real. While Medicare committed to a one-year grace period during which it wouldn’t penalize providers for not using the most specific diagnostic codes available—as long as those codes fell into the correct code family—no one knew exactly how private payers were going to process the new codes (not to mention how providers and billers themselves were going to handle using such an enormous code set). Well, it turns out things went pretty well all the way around. Now, that’s something to celebrate. Here are some of the highlights from ICD-10’s first year:

More than 13 million ICD-10 claims were successfully processed in the first month.

According to this RevCycle Intelligence article, RelayHealth Financial reported that it had successfully processed more than 13 million ICD-10 claims—worth more than $25 billion—in the first 19 days of the transition alone. While there were some dips in productivity and a few workflow hiccups—a survey conducted in June by the American Health Information Management Association (AHIMA) found that overall coding productivity decreased by 14% and accuracy decreased by .65% after the transition—most providers reported that the “implementation process went smoother than expected.” This Healthcare Dive article echoes that sentiment. Michael Munger—a family physician with Saint Luke’s Medical Group in Overland Park, Kansas, and president-elect of the American Academy of Family Physicians (AAFP)—said, “The fear that this was really going to impact us financially because of the potential inability to process the new codes really never transpired.” Apparently, the AAFP tracks error rates, and it found that the error rate after the transition was the same as it was for ICD-9: 10%.

However, some EHRs weren’t holding their own.

Some providers did run into challenges with their EHRs. In the above-cited Healthcare Dive article, Richard Bruno—AAFP board member and resident in a joint family and preventative medicine program in Baltimore—said: “The challenge has been with the transition, especially within the medical records system, using the electronic health record and making sure that it’s searchable and that the right codes are associated with the right people, as these are tied to payment.” Munger’s practice actually had to upgrade its EHR recently in order to adapt to the greater level of coding specificity required after October 1, 2016. According to Healthcare Dive, Bruno believes that one of the major issues with the new code set is that it is “still tied to a fee-for-service billing structure that rewards [providers] for getting more detailed in their diagnoses.” He hopes that the move to more value-centric care and payment structures will help the entire process, because these new structures won’t hinge as much on “getting accurate diagnostic codes.”

And causation coding proved difficult.

While the challenges inherent to causation coding aren’t new—they existed in ICD-9 as well—many providers are finding it difficult to get the desired level of specificity in ICD-10 because they simply don’t have the necessary information. According to Barbie Hays—a coding and compliance strategist for the AAFP—“You can code out to it happened in a ranch style home or a split level…and there are some insurance companies that have started wanting that, but most are not.” She goes on to explain that there are opportunities for the Centers for Disease Control and Prevention (CDC)—and the ICD-10 governing committee—to provide additional guidance around the use of causation codes. However, it doesn’t appear to be high on their priority list right now, as they’re still focused on the codes for the injuries and illnesses themselves.

That being said, the AMA agrees that the transition went well overall.

The same Healthcare Dive article also reported that the American Medical Association—the organization that pushed CMS to institute the one-year grace period—believes the transition went well, as there was “no major uptick in Medicare claims rejections.” However, the AMA plans to continue monitoring the process now that the flexibility period has ended—as there’s still the possibility for “potential disruptions and changes that could result when more specific coding is required.”



How did your clinic fare in the transition to ICD-10? Are you celebrating a successful year—or a challenging one? Tell us your experience in the comment section below.

Falling from Grace: How to Deal with the End of the Flexibility Period

September 26th, 2016
ICD-10, Preparation, Transition

It’s the end of September already, which means we’re only days away from the end of Medicare’s ICD-10 flexibility period—the year-long grace period in which CMS did not deny claims solely due to lack of code specificity. Beginning next month, though, the gloves are off—and, as a result, denials may increase. If you’ve been using this last year to become an expert on the nuances of the new code set—including how to use your clinical knowledge and documentation to select the most specific code available—then you may not even notice a change. If not, there are still a few things you can do to prepare. Here’s what you should know about the end of the flexibility period (as summarized from the Q&A portion of this CMS doc):

There will be no extension—and no phase-in period.

According to CMS, the grace period will end on October 1, 2016, and there will be no extension or phase-in period, because “providers should already be coding to the highest level of specificity.” The ICD-10 flexibility period was only put into effect so contractors performing medical reviews wouldn’t deny claims based solely on lack of specificity if there was “no evidence of fraud.” But, beginning October 1, providers must choose the most specific codes available—or risk claim denials.

CMS has three pieces of advice to help you prepare:

  1. Don’t use unspecified codes when a more specific one is available. (If you’re wondering how specific your codes should be, there’s no black-and-white answer. You must code to the highest level of specificity you can, while ensuring your documentation supports your coding choices—which brings us to number two.)
  2. Ensure your clinical documentation supports your code selections.
  3. Know that many major insurance carriers never implemented a grace period at all, which means many providers are already successfully using specific codes. In fact, according to a survey cited by CMS, providers have, for the most part, transitioned from ICD-9 to ICD-10 with little issue. (In other words, stay calm and carry on.)

Providers may still use unspecified codes—if the situation warrants it.

According to CMS, providers should report the most specific code available that’s supported by clinical knowledge and documentation. However, there are situations in which unspecified codes “are acceptable, even necessary”—such as “when sufficient clinical information is not known or available about a particular health condition to assign a more specific code.” CMS uses the example of a patient with a diagnosis of pneumonia: if no additional information is available to help the provider or coder determine the specific type of pneumonia the patient has, an unspecified code would be acceptable. To learn more about unspecified codes, check out these resources.

CMS is prepared to handle these changes.

CMS believes that the success of the initial ICD-10 transition proves that the organization is ready to handle new codes and processes. As such, they expect no delays with their enforcement of the post-grace period rules or the 2017 code update. This update includes the deletion of certain codes, the introduction of some new codes, and the revision of some code descriptions. “While this year’s update includes many new codes, the new clinical concepts are minimal,” CMS explained. The Center also notes that similar code updates occurred annually up until a freeze was established to help providers and payers prepare for the ICD-10 transition. As with any update, CMS recommends that providers:

  1. “Determine which codes affect their practices, and
  2. Focus on clinical concepts behind new codes.”

Audits will look just like they did before the ICD-10 transition.

As of October 1, 2016, CMS review contractors may deny claims due to lack of code specificity—and notify providers regarding issues and the steps necessary to correct those issues—in the same way that they did prior to the ICD-10 transition on October 1, 2015. To avoid audits, CMS says, “the provider community should code claims to the degree of specificity supported by the encounter and the medical documentation.”

There are more resources if you have questions.

For more ICD-10 coding resources, visit the Provider Resources section of the CMS ICD-10 website. There, you’ll find a complete list of the 2016 ICD-10-CM codes and code titles. You can also find the updated 2017 ICD-10-CM code set for services you provide on or after October 1, 2016, here. CMS updates the NCDs and LCDs whenever new codes are added. You can learn more about NCD updates on CMS’s ICD-10 website and LCD updates in the searchable Medicare Coverage Database.


While some experts do expect an increase in denials following the end of the Medicare’s flexibility period, CMS doesn’t seem too concerned. How do you feel? Is your clinic prepared? Have you been coding to the greatest level of a specificity up to this point—or do you plan to up your game now?

New Codes Ahead: What You Need to Know About the 2017 ICD-10 Update

August 18th, 2016
ICD-10, Preparation

After much deliberation, the Centers for Disease Control and Prevention (CDC) released the new 2017 ICD-10-CM codes on June 24, 2016. According to Laurie Johnson, MS, RHIA, CPC-H, FAHIMA—the director of health information management (HIM) consulting services for Panacea Health Solutions, Inc. and author of this ICD10 Monitor article—there are “1,974 additions, 311 deletions, and 425 revisions,” resulting in a total of 71,486 codes. These codes will go into effect on October 1, 2016—and remain in effect through September 30, 2017. Here are the changes to the codes in Chapters 13, 19, and 20—the chapters that are most relevant to physical therapists:

Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue

Johnson reported that CMS added: “bunion, bunionette, pain in joints of the hand, more specificity to temporomandibular joints, cervical disc disorders at specific levels, atypical femoral fractures, and periprosthetic fractures.”   

Chapter 19: Injuries, Poisoning, and Certain Other Consequences of External Causes

Apparently, CMS made a “significant number of additions [to] the specific fractures to bones of the skull”—as well as “various fracture types of the foot.” There also are “title revisions to complications involving prosthetic devices; new stenosis of cardiac stent codes, and additions to complication types, including breakdown, displacement, infection, erosion, exposure, pain, fibrosis, thrombosis, and leakage.”

Chapter 20: External Causes of Morbidity

According to Johnson, the CDC also updated several vehicular accident codes and “added contact with paper or sharp objects, overexertion, and…the choking game.” (We don’t even want to know what that last one entails—although it may be scarily self-evident.)


For the full list of ICD-10 changes, check out Johnson’s blog post in full here—or, refer to the CMS 2017 ICD-10-CM files here. While Johnson mentioned that the 2017 ICD-10-CM Official Guidelines for Coding and Reporting and General Equivalence Mappings (GEMs) were conspicuously missing from the newly released documents because they were “still pending,” both documents are now available in CMS’s list of files.


Just like you prepared for the initial launch of ICD-10 back in 2015, it’s time to hit the books again. You’ll want to be sure everyone in your clinic fully understands how these changes impact your practice and processes before CMS’s year-long grace period comes to an end—and these new code changes go into effect—on October 1. If you’re using an EMR, you’ll also want to check with your software vendor to ensure your system will be updated with the new codes so you can receive accurate payment for your services.

The Six-Month Mark: An ICD-10 Status Update

May 17th, 2016

Even after all of the pushback and panic, the transition to ICD-10 seems to have been a successful one. And over the last six months, pre-switch fears about denials, lost revenue, and reduced productivity have proven to be mostly unfounded.

Maybe that’s because providers worked hard to prepare for the transition—or maybe it’s that payers are being more lenient about their requirements (Medicare “grace period,” anyone?). Whatever the case may be, life in the ICD-10 world seems—for the most part, anyway—to be business as usual. In fact, according to a recent Physicians Practice survey:

  • 47.3% of the digital publication’s readers haven’t seen any changes in their denial rates;
  • 60% of practices haven’t seen any impact on monthly revenue; and
  • Denial rates are at a relative baseline, with less than 1% difference between ICD-9 and ICD-10.

The results of this survey seem promising, and news on the ICD-10 front remains fairly quiet. And as the old adage goes, “No news is good news.” Right? Not so fast.

The Silence

Just because we aren’t hearing about problems doesn’t mean they aren’t occurring. This ICD-10 Monitor article highlights a few of the biggest issues that could cause a ruckus:  

  • Medicare Administrative Contractors (MACs) are still working to correct and update local coverage policies. This might sound like a good thing—and it is. However, what MACs aren’t doing is automatically accepting the claims that Medicare wrongly denied (ugh). That means providers have to do the legwork to resubmit those claims.
  • Some EMRs automatically map ICD-9 codes to ICD-10 codes, which is causing costly coding mistakes. Furthermore, some software are just too burdensome to use, and that also has caused unnecessary coding mistakes and drops in provider productivity.
  • A number of the commercial plans that follow Medicare guidelines are incorrectly denying claims based on the NCD and LCD errors. That means—again—that providers are suffering the consequences of the payers’ mistakes.

So, if problems are occurring—but not yet garnering much attention—how do we know the true status of ICD-10? Furthermore, how will these problems affect the future of ICD-10 claim submission?

The Future

Despite the aforementioned issues, CMS is forging ahead with more ICD-10 changes. In fact, in 2017, a hefty crop of new ICD-10 codes will join the code set. “To date, there are 1,900 new ICD-10-CM codes proposed for the October 2017 release,” the AAPC announced. “Of that number, there are 313 deletions and 351 revised codes.” That means ICD-10’s future is looking more complicated than ever. Not only will providers need to account for new codes, but also payers are expected to tighten up their claim acceptance requirements this fall (after the conclusion of Medicare’s “grace period” is over). And once the rest of the major payers start becoming more strict with their coding rules, we’ll truly see whether providers have been coding specifically enough—or if they’ll need to work harder to ensure payment in the future.

The Work

Ultimately, to be successful in the age of ICD-10, providers need to put in the effort to code as accurately as possible. But, how do you know if your coding practices are up-to-snuff? One way practices can get a pulse on their coding know-how is to conduct internal audits. Once you have an idea of which codes are getting denied—and why—you might start seeing patterns. From there, you can work to correct common issues, and thus, reduce your denial rates.


What news have you heard about ICD-10? Is your practice experiencing problems, or does it feel like nothing’s changed? Fill out the form below to tell us about your experience.

Wake Me Up When September Ends: What Happens When the ICD-10 Grace Period is Over?

May 11th, 2016
ICD-10, Preparation

ICD-10 has been in effect for more than six months now—and the Earth is still spinning, the sun is still shining, and the birds are still chirping. So, it would appear that the transition to ICD-10 had way more bark than bite, but appearances can be deceiving. On October 1, 2016, Medicare will terminate its grace period, and some experts are predicting a spike in denial rates after that date. If you’ve been using these last few months to not only get comfortable with the new code set, but also learn how to identify—and use—the most specific code available for each patient, then you have nothing to worry about.

On the other hand, if you’ve been using crosswalking tools to convert ICD-9 codes to ICD-10, and you’ve focused only on the code groups you use most often, then you don’t necessarily need to worry, but you do need to change your ways. “That is why [providers have] done as well as they have so far,” said Mary Jean Sage, president of a billing and coding consulting company called The Sage Associates, in this Healthcare IT News article. “But they need to take the next step and start looking at codes beyond their immediate scope and adding more specificity.” And you’ve got about five months to do it.

According to Deborah Grider—an ICD-10 trainer approved by the American Health Information Management Association (AHIMA)—providers also must take into account the need to document medical necessity: “Without a specific diagnosis code and validation of medical necessity, a claim is not considered valid,” she said. Grider also warns providers not to assume their codes are correct simply because they received payment. Payers may reimburse providers and then retract the payment later if documentation and coding don’t demonstrate medical necessity. This is especially important given the soon-ending grace period, because providers have been knowingly reimbursing despite less-than-optimal coding.

So, how can you ensure your practice is prepared to use the most correct, most specific codes when September ends? Here are four things you can do right now:

1. Train Staff

We still have five more months before the grace period officially ends, which is just enough time to get really good at all things ICD-10. Start by gauging your staff’s current understanding of ICD-10 codes, and then fill in the gaps with as much information and supplemental curriculum as you can. While you’re at it, be sure everyone is familiar with your payers’ policies. That way, you’ll know how each carrier evaluates medical necessity—and what you’ll need to do to demonstrate it.

For more information about ICD-10, check out this guide. There, you’ll find info on the ICD-10 coding structure, the seventh character, surgical aftercare, and preventing code denials.

2. Review Denials

While you certainly don’t want to make receiving denials your goal, you should make it a point to ensure they serve your best interest when they occur. After all, every denial is a learning—and training—opportunity. Instead of getting frustrated—which is a totally normal reaction—try to focus your energy on achieving a more productive end by using denials to further educate yourself and your staff. “Providers need to begin to monitor denials by type and take immediate action to remedy them,” Grider said. A common issue she sees is that billing staff aren’t properly trained on how to determine why a claim was denied. Thus, “Billing staff should be trained on the fundamentals of ICD-10,” Grider said. This will “ensure that they have a good understanding of the importance of specificity and what to look for when a claim is denied.”

3. Audit Coding and Documentation

Regardless of whether you’ve received denials to date, now’s a great time to conduct an internal audit to ensure your procedure codes, diagnosis codes, and documentation tell a consistent, complete, specific, and accurate story of medical necessity. To do so, take a random sampling of patient documentation. You then can use the information you gather from your audit to inform your training plan.

4. Establish and Monitor KPIs

To effectively monitor your practice’s coding and claim-payment prowess, Grider suggests monitoring key performance indicators (KPIs), including:

  1. Code frequency
  2. Coder productivity
  3. Volume of questions received
  4. Practitioner productivity
  5. Unspecified code usage
  6. Query increases or decreases
  7. Days from claim submission to payment receipt
  8. Claim denial rate
  9. ICD-10 denial types and reason codes
  10. Payment amount by payer
  11. Clearinghouse and payer edits
  12. System issues

Whichever KPIs you decide to track, be sure to establish benchmarks and goals. Then, monitor your team’s progress toward them, and communicate the results regularly.


Is your team prepared for the end of September—and the ICD-10 grace period? If not, send us your questions using the form below.

Want this blog post in handy checklist form? Download it here.

The Role of Benchmarking in ICD-10

March 18th, 2016

It’s been nearly six months since the US adopted the ICD-10 diagnosis code set. And overall, providers are feeling pretty solid about the transition. But, to truly call the ICD-10 switch a success, we need to look more at the facts than the feelings. And the best way to get straight to the point is to measure your own success through benchmarking. Here’s what you should evaluate:

Claim Rejection and Denial Rates

You should already know your pre-switch average rejection and denial rates (based on data from your claims containing ICD-9 codes). But, if you don’t, it’s imperative that you go pull some data from claims with dates prior to October 1, 2015. As this ACA International article points out, “Benchmarking is a key component to any effective ongoing revenue cycle management strategy.” So once you have your ICD-9 stats nailed down, you can use them as a benchmark for comparing your clinic’s current performance to its success prior to the transition. Why go to all that trouble? Because doing so will help you see whether the transition has had a positive or negative impact on your clinic’s claim acceptance. In this case, the old adage holds true: you really can’t measure what you don’t track. Plus, the more that payers—including Medicare—toughen up on their specificity requirements, the more rejections or denials you’re likely to see. And if that happens, you can use the data you’ve collected to turn that trend around. To do so, narrow down the codes you submit to the ones with the highest volume and value. Once you’ve identified these codes, you can then review the causes for the rejections, and work to resolve and prevent those issues in the future.

Payment Delays

Just because you’re not seeing a lot of claim denials doesn’t mean your clinic’s revenue hasn’t slowed in the wake of ICD-10. That’s because payers can take an average of 42 days to release payments, and you need to be aware of—and comfortable with—these delays. Now, you don’t have total control over this timeline, but when you know how long it takes to get payment from your payers, you’ll have a better idea of how to manage your cash flow. Furthermore, knowing these limitations can help you manage your response to denials, because you’ll have a good idea of how long it’ll take for a resubmission to be paid. And while you’re at it, this ICD10Watch article explains that “ICD-10 presents an opportunity for process improvements that will enhance the entire revenue cycle.”

Coding Questions

When your staff has coding questions, you should be making note of those questions and ensuring that you—or someone else in your clinic—is following up with answers. If you notice a particular question comes up over and over again, use it as an opportunity to educate your entire staff. Once you start tracking this information and comparing it to your denial and rejection rates, you may find a correlation between the two. As this CureMD article warns, “Negligence in monitoring this information can result in delays and inconsistent coding procedures.” So, the sooner you start managing coding questions, the better.




Benchmarking is the clearest indicator of your ICD-10 success, and now that you know what to look for, you can take the steps to better evaluate your own performance. Are you benchmarking in your own practice? Have questions? Submit them using the form below.

No News is Good News: ICD-10 Denial Rates Remain Low

March 14th, 2016

If you’ve been paying attention to CMS’s blog—or ours—you may already know that CMS released its final 2015 ICD-10 metrics at the end of February. In the release, CMS compared data from the fourth quarter of 2015—the three months immediately following the ICD-10 transition on October 1, 2015—to historical baselines. Surprisingly, there was little difference between the claim submission and denial numbers pre- and post-transition—and the total percentage of rejected claims actually decreased after the ICD-10 launch: from a historical rate of .17% to .07% in Q4 of 2015.

In a recent press release, one of the industry’s largest clearinghouses, McKesson’s RelayHealth Financial, announced its own denial rate: 1.6% of the more than 262 million claims that the company processed between October 1, 2015, and February 15, 2016, were denied. According to RelayHealth, “This denial rate is expressed as a percentage of claim dollars that were initially denied for ICD-impacted denial categories in relation to dollars billed on remitted claims. This rate reflects only the denial categories of Authorization/Pre-Certification, Medical Coding, Medical Necessity, and Untimely Filing.” The denial rate—which hasn’t changed significantly since November 2015—represents about $12.9 billion in denied claims (the total estimated dollar amount of claims submitted was $810 billion). According to this article—which summarizes the announcement—“more than 2,400 hospitals and 630,000 providers used RelayHealth Financial revenue cycle management solutions during that time.”

In the press release, Marcy Tatsch, RelayHealth Financial’s vice president and general manager of reimbursement solutions, says, “The good news is that we’re not seeing a marked increase in claim denial rates when it comes to ICD-10, and there is heightened interest in denial management and prevention.” But it’s not all sunshine and rainbows: “The bad news is that as many as one in five claims is still denied or delayed within the normal hospital and provider revenue cycle world, which can mean a dip of as much as 3% in a hospital or health system’s revenue stream.” So, what can you do to improve your own denial rate? Tatsch suggests that providers keep a pulse on overall denial trends by continuing to track the KPIs on the RelayHealth Financial Denials Dashboard as well as “ramp up their broader denial prevention and management efforts.” RelayHealth also created an online resource to help providers strategically reduce and manage denials.


How’s your clinic doing in terms of denials? Have you experienced any rejections since the switch to ICD-10? Complete the form below to tell us your story.

Medicare’s Final ICD-10 Findings

March 10th, 2016

Thankfully, the transition to ICD-10 took place without nearly as much commotion as most of us expected—and prepared for. In fact, according to this article, CMS released its final ICD-10 Medicare claims data at the end of February—and that data showed that “claim denials and submissions post-ICD-10 deviated very little from historical benchmarks.” In other words, three cheers to the entire healthcare industry for turning what could have been chaos into something completely manageable. The article—which summarizes this CMS blog post—notes that CMS attributes much of that success “to its own efforts in physician-facing, collaborative, and education-focused coding initiatives.”

In the post, CMS’s acting administrator, Andy Slavitt, writes, “The ICD-10 implementation had all the hallmarks of how CMS could drive a successful implementation and aim for excellence. The approach we took, which has become our doctrine for getting things done, had four major elements.” Specifically, CMS demonstrated:

  1. A customer-focused mindset
  2. A high degree of collaboration
  3. Responsiveness and accountability
  4. Strong attention to metrics

While we here at ICD-10 for PT are happy to acknowledge CMS’s fruitful efforts and wholeheartedly agree with the importance of these four elements, we believe that a lot of the credit for the ease of this transition rightly goes to you—and all of the other healthcare practitioners who stepped up to the plate to ensure their practices were ready to use the new codes well before October 1, 2015.

With that being said, let’s get on to the findings. Here they are in a handy-dandy table we adapted from CMS:

Final 2015 ICD-10 Claims Dashboard | Medicare Fee-for-Service Metrics

Metrics Historical Baseline Q4 2015 (Oct–Dec)
Total Claims Submitted 4.6 million per day 4.6 million per day
Total Claims Rejected 2% of total claims submitted 1.9%
Total ICD-10 Claims Rejected* .17% of total claims submitted .07%
Total ICD-9 Claims Rejected* .17% of total claims submitted .07%
Total Claims Denied 10% of total claims processed 9.9%

*CMS notes that while the other metrics are based on historical claims submission data, the metrics for total ICD-10 and ICD-9 claim rejections are estimates based on end-to-end testing conducted in 2015, because CMS had not collected this data in the past.


How do Medicare’s claim stats compare to your practice’s? Did you experience any claim rejections or denials following the switch? Fill out the form below to tell us your story.

4 Tips for Preventing ICD-10 Denials—and Getting Paid

February 1st, 2016
EMR, ICD-10, Insurance, Preparation

For many practices, transitioning to ICD-10 has been no easy feat—especially considering the massive number of codes that are now available. Luckily, though, as a result of all the preparation leading up to the October 2015 go-live date, there haven’t been nearly as many claim denials as there could have been—or may be once Medicare’s grace period comes to end later this year.

So, whether you’ve already faced a denial or you’re wanting to get ahead of the game for when payers start enforcing stricter rules, here are four tips for preventing ICD-10 denials and ensuring you get paid:

1. Check your Codes

Whether you’re using an EMR or still documenting on paper (yikes), the responsibility for submitting the right ICD-10 codes for your patients ultimately falls on you, so take some time to double-check that the codes you should be submitting are the ones that actually are going through. You can do this by performing an internal audit to quality check your documentation against your claims. This is especially important if you’re using an EMR without an intelligent ICD-10 tool. If that’s the case, and you think the software has you covered, think again.

2. Be Specific

The whole point of implementing ICD-10 is to increase diagnostic specificity for patient data. So regardless of what payers are considering acceptable to process payments right now, they’re eventually going to require you to use ICD-10 to its fullest—and most specific—extent.

With that in mind, use this year to practice navigating to not only the right family of codes, but also the most specific codes you can identify that tell the complete story of your patients’ conditions—seventh characters and all. Just be sure that your documentation backs up the level of specificity your codes represent. As this Medical Economics article points out, you don’t want to be left repaying your reimbursement after an audit uncovers that your documentation doesn’t fully support your claim.

3. Do Your Research

The ICD-10 implementation deadline has come and gone, but that doesn’t mean you should stop learning about the coding system or how to navigate tricky coding situations. Rather, your best bet to prevent ICD-10 denials and ensure you’re getting paid is to stay up to date on as much ICD-10 news as you possibly can. Furthermore, you’ll want to keep a pulse on the changing requirements for each individual payer. After all, each insurance provider has its own set of claim specifications. As the above-cited Medical Economics article explains, “Payers may also want specific modifiers added or they may want a specific code used for a procedure.” In other words, you should “know what your payers want before you submit your claims.”

4. Switch to the Right EMR

Your EMR doesn’t need to brew your morning coffee, but it does need to help you stay ICD-10 compliant. Your EMR should do the following:

If your physical therapy software doesn’t do any of the above, then it’s time to replace it with one that does. And fast. ICD-10—as well as every other reporting regulation—only will continue to evolve, in terms of both complexity and intensity. Shouldn’t your practice be evolving with a more comprehensive compliance software, too?


There you have it: Four tips for preventing ICD-10 denials so you get paid for your services. How has your practice been preventing denials? Fill out the form below and tell us your story.

How to Deal If Your EHR/EMR Doesn’t Support ICD-10

January 26th, 2016

So, you need to code using ICD-10, but your EHR or EMR didn’t upgrade to the new code set? The solution here is simple—and absolute: You need new software. (Don’t act like you didn’t know that was coming.) Sure, the CMS grace period allows you a small amount of flexibility, but it definitely doesn’t provide you with a get-out-of-ICD-10-free card. If you’re currently working with an out-of-date vendor, you’re probably already losing revenue due to denied claims, which means you’re up a creek. The good news? We’ve got a paddle. To correct your course, here’s what to look for in your new software:

An intelligent ICD-10 tool

Your EHR/EMR doesn’t need to be smarter than a fifth grader (unless you know any ten-year-old medical coders), but it does need to be highly intelligent when it comes to ICD-10. Here are a few questions to ask potential vendors to ensure your new software gets an A for more than effort:

  • Does it prompt you to document specific details of the patient’s injury or condition?
  • Does the code selector prompt you to choose more specific codes when greater specificity exists? (And let you know when you’ve selected an invalid or non-billable code?)
  • Does the EMR base its ICD-10 code library solely on GEMs? (That’s bad, BTW.)
  • Does the EMR claim to have an automatic one-to-one crosswalk from ICD-9? (Also bad.)

A library of both ICD-9 and ICD-10 codes

Some non-HIPAA-covered entities (like auto and workers’ compensation companies) weren’t required to make the switch to ICD-10. If you ever have to submit claims to these payers, you may still need the ability to use ICD-9 codes, so make sure your new software is equipped with both code sets.

Free system updates

ICD-10 is not the last code set update we’ll ever see—not by a long shot. In fact, the World Health Organization plans to endorse ICD-11 in 2018. And there are updates coming to ICD-10 in October 2016. Plus, the government frequently releases regulatory updates to HIPAA, PQRS, FLR, AEIOU, and sometimes Y (just kidding). But seriously—there are tons of reasons why your new EHR/EMR could slip behind the times, and you don’t want to get stuck footing the bill for any mandatory changes. That’s why you should pick a vendor that updates your system:

  1. automatically,
  2. at no charge to you, and
  3. with as little downtime as possible.

Not sure how much downtime is acceptable? Take a look at this article from PTEMR.net.

Free ICD-10 training, support, and resources

You can’t put a price on great customer service—and if your EHR/EMR vendor truly is invested in the success of your practice, it won’t, either. Look for vendors that offer educational resources and a support team ready to assist you via phone and email—all for the low, low price of $0. (P.S. The best EHR/EMR companies make this kind of support available on all topics, all year round.)

PT-Specific Design

Of course, ICD-10 functionality isn’t your only consideration when picking a new EHR/EMR vendor. You’ll want to make sure your new software comes complete with all the other features that make it easy for a physical therapist to succeed in business, including:


Without a solid EHR/EMR partner in this ICD-10 world, your financial outlook may be fairly bleak right now. But if you find a system that’s the right fit for your practice, then pretty soon you’ll be rowing your boat gently down the revenue stream once again. Keep in mind that once you select your new software, you’ll still need to develop your game plan for a smooth switch; check out the tips in this article to ensure a headache-free transition.