By Robert Lane, CPA, PFS, Partner of Accounting and Consulting Services
After the transition from ICD-9 to ICD-10 went into effect in October 2015, the Centers for Medicare and Medicaid Services (“CMS”) allowed medical practices a one-year “grace period” in which to get up to speed with the new reimbursement codes. During the past year, physicians have had a safety net when they’ve made mistakes. But effective October 1, the grace period is over.
It’s vital that physicians understand that, even if their practices have done well during this period, it doesn’t necessarily mean they’re properly prepared for the change. So it’s time to revisit whether you’re ready to fully implement ICD-10.
In general, ICD-10 codes are more granular and specific than ICD-9 codes. For instance, during the grace period, payers required only a three-digit placeholder with each code. But post–grace period, the requirement expands to five- to seven-digit codes.
As part of the grace period, some insurance payers have been allowed to reimburse without penalty, as long as a particular ICD-10 code has fallen into the correct family of codes. Of course, some private payers, such as Aetna, Anthem, Humana, Kaiser Permanente, and United Healthcare, have chosen not to follow the grace period. This is because it was merely a recommendation — not legislated by Congress — and thus not required.
Take the right steps
Even if you haven’t noticed a downturn in reimbursements or an increase in denials, it’s time to evaluate where you are in this process. Here are six steps you can take.
- Evaluate staff training. Ensure that you and your staff — particularly those directly responsible for billing and coding — have a complete understanding of ICD-10 codes. If you notice problem areas or confusion, hire an expert or look for classes, supplemental materials, and information to help fill the gaps.
- Review denials. It’s good business practice to review denials to learn if you and your staff are having problems in particular areas. After the grace period, it’s more important than ever. Often staffers involved in billing aren’t appropriately trained to determine why a claim was denied. With the ICD-10 transition, that weakness might be magnified. Staff should be trained on the basics of ICD-10 — especially on code specificity and what to look for when reviewing a denied claim.
- Conduct a coding and documentation audit. Even if your practice has made it this far with no particular rise in denials, it’s an excellent time to review and audit procedure, and diagnosis codes. In particular, focus on whether your documentation provides a complete, detailed, and accurate portrait of medical necessity. A complete audit isn’t necessary unless major issues arise.
- Focus on high-volume diagnoses. When performing an audit, pay particular attention to high-volume diagnoses, and any diagnoses that you might be able to specify in more detail. For example, though only a single ICD-10 code exists for chronic hypertension, other, more specific codes are used when the hypertension results from another disease, such as pulmonary hypertension, or renal hypertension. So it’s important to identify and document the causal relationships.
- Double-check EMR software. Another aspect of the grace period’s end is that the ICD-10 code freeze lifts. The bottom line is that anywhere from 2,000 to 6,000 new codes are being added or revised. If your software isn’t up to the task, or hasn’t been updated, a complicated situation will only become worse.
- Start thinking and speaking in “ICD-10.” If you haven’t already, it’s time to learn a new language: ICD-10. This might require thinking and speaking more specifically — in other words, not just talking about chronic kidney disease, but talking about the specific stage of the disease, and mentioning the causes.
Continue to monitor code changes
If you and your practice have already mastered ICD-10, excellent! But don’t forget that the system will continue to change and evolve. With the coding freeze lifted, more codes and modifications are coming. Stay current with these changes as they arise — your collections and your practice will be the better for it.
Tips for accurately documenting cases using ICD-10
One of the biggest changes from ICD-9 to ICD-10 has to do with specificity. The coding requires significantly more detail. In your clinical documentation, provide information concerning the following details as needed:
- Episode of care (initial, subsequent, sequela),
- Acuity of disease (mild, moderate, severe, acute, or chronic),
- Laterality (left, right, bilateral),
- Type and cause of disease or condition,
- Underlying condition,
- Manifestation of disease (for example, sepsis as a result of a perforated appendix),
- Linking of diagnosis (for example, peripheral vascular disease due to tobacco use),
- Causal organism (virus, bacteria, and other infectious organisms), and
- Relationship of drugs, tobacco, or alcohol to the disease as well as use, abuse, or dependence on those substances.
You’ll also need to provide support that shows medical necessity.