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:
- Code frequency
- Coder productivity
- Volume of questions received
- Practitioner productivity
- Unspecified code usage
- Query increases or decreases
- Days from claim submission to payment receipt
- Claim denial rate
- ICD-10 denial types and reason codes
- Payment amount by payer
- Clearinghouse and payer edits
- 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.
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