The ICD-10 grace period officially ends on October 1; however, only time will tell if-and when-payers begin to demand greater specificity. In the meantime, consider these five tips to ensure compliance in the short and long term.
The ICD-10 grace period officially ends on October 1; however, only time will tell if-and when-payers begin to demand greater specificity. In the meantime, consider these five tips to ensure compliance in the short and long term...
Don’t default to the first code in the EHR drop-down menu, says Deborah Grider., CCS-P, CDIP, CPC, a healthcare consultant. Instead, look for the most specific code. “Doctors don’t always pay attention to their diagnosis codes because they get paid based on their CPT codes,” says Grider. “But I always tell them that your diagnosis codes do drive payment because if the diagnosis codes don’t support medical necessity, you’re not getting paid.”
For example, a physician may “favorite” a code in the EHR for diabetes (e.g., E08.21, diabetes mellitus due to underlying condition with diabetic nephropathy) because he or she treats this condition most frequently. However, what if every claim includes this same exact diagnosis? Even with its specificity, the code may not be the best option for every visit, especially if a patient has another manifestation of the diabetes.
Daley says payers could notice reporting patterns in which the diagnosis code is always the same-particularly when the code is highly specific. This may trigger an audit, he adds.
Every practice should keep close tabs on the following KPIs, says Grider:
â Coder and physician productivity. “Slower productivity means slower cash flow, and if you don’t do an assessment, you won’t know that this is happening,” says Grider.
â Unspecified codes. Run a frequency report for the practice’s most common diagnoses. Do any of the codes for these diagnoses tend to end in “0” or “9” (indicating an unspecified diagnosis)? If so, determine whether documentation improvement, coder education, or both are required.
â Overall denial rate (and denial rate by payer). How does this rate compare with that of ICD-9 during the same month of the previous year?
â Reasons for denials. Examine each denial to better understand the reason, says Grider. For example, is the denial due to an invalid or incomplete code? If the practice is paper-based and keying in its own codes, is there a denial due to a transposition of characters? Is the clearinghouse functioning properly? One of Grider’s clients discovered that its clearinghouse was accidentally deleting the 7th character on all injury codes, causing a rejection.
Does the documentation match the actual ICD-10-CM code selected? For example, a physician documents “right hip fracture” but selects an ICD-10-CM code in the EHR for “trochanteric fracture of the right femur.” “The documentation doesn’t match the code selected. This is a big issue, especially with Medicare audits,” says Grider.
Certified coders not only possess an in-depth knowledge of official coding guidelines, they can also help the practice stay on track with coding updates and denial management. In addition, certified coders can help develop a “cheat sheet” of documentation requirements for the practice’s top 25 diagnoses as well as the key terms that physicians must type in the EHR to produce the most specific code.