How physicians can prepare now before CMS removes the ICD-10 safety net

May 25, 2016

On October 1, the Centers for Medicare & Medicaid Services’ grace period for denials of claims under ICD-10 will end. Physicians will do well to recognize that while the updated and expanded standards for coding specificity offer a new level of accuracy, they may also affect the bottom line.

On October 1, the Centers for Medicare & Medicaid Services’ (CMS) grace period for denials of claims under ICD-10 will end. Physicians will do well to recognize that while the updated and expanded standards for coding specificity offer a new level of accuracy, they may also affect the bottom line.

Prior to the ICD-10 rollout out last year, CMS announced that Medicare claims would neither be denied nor audited based on their coding as long as practices submitted an ICD-10 code from the appropriate family of codes. But that doesn’t mean a permanent free pass. 

“Physicians need to ensure they are up-to-date with the added specificity in ICD-10,” says David McCann, managing director of Berkeley Research Group in Hunt Valley, Maryland, and a trained coder. Especially with high-volume diagnoses, he says, close review of coding options should become the norm. 

The months leading up to the October deadline will be vital for  staff training and reinforcing correct ICD-10 coding, says Mary Jean Sage, CMA-AC, president of The Sage Associates, a consulting firm in Pismo Beach, California. “It’s important that when the grace period is lifted, practices are thoroughly prepared and not just preparing.”

Every practice needs to plan for decreased staff productivity and prepare for the possibilities of other financial challenges during the remainder of the ICD-10 grace period. 

“The last thing a practice wants to do is begin training when the claims are finally being denied,” Sage says. 

 

 

Get ready now

Lisa Thomsen, MD, a family practitioner in Glendora, California, says her practice has not experienced any denials or claims adjustment post-ICD-10 because payers are only requiring a three-digit placeholder with each code. Come October 1, however, that will expand to five to seven digits, “which will impact the coding accuracy, thus the financial consequences” for incorrectly coded claims. 

Thomsen says even
seasoned physicians with years of ICD-9 experience routinely have a small percentage of denied claims. “In addition, the clearinghouses for these claims have their electronic glitches and server capacity issues,” she says. “You can always count on the unexpected to occur, so all practices should brace themselves.”

Even without mistakes, navigating the new standards is likely to slow down processing. “The biggest complaint I hear from practices is that it now takes more time to select an appropriate code,” Sage says. “Finding the correct code comes with practice.”    

The key is adopting a new mindset. “Start using the ICD–10 lingo,” Thomsen says. “This means changing your old thinking.”  

Use nomenclature that aids in triggering the necessary codes. This might mean with a diagnosis of chronic kidney disease, for example, specifying stage 1-5, also noting that it is due to diabetes or hypertension.  

“This mindset forces you to think more specifically,” Thomsen says. “Your biller and coder now know the complete diagnosis.  They don’t have to waste time reading through your notes.”

Ongoing education is critical, McCann says. Review publications and sources of guidance continually. He advises doing an audit to identify documentation gaps and provide ongoing monitoring of high-volume diagnoses and those that can be further specified.