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ICD-10: What Should You be doing in 2016?


ICD-10 was much like YK2 in its introduction to the billing process so everyone should breathe a sigh of relief right? Not so quick as some providers are starting to find out.

Editor’s Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Carol Gibbons, RN, BSN, NHA, who is CEO of CJ Consulting, which specializes in healthcare revenue cycle management. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.


ICD-10 was much like YK2 in its introduction to the billing process, so everyone should breathe a sigh of relief right?  Not so quick as some providers are starting to find out.  With the Medicare grace period, most carriers have been very lenient in allowing claims to go through the system without denials.  However, they are starting to reel in that lenient process and deny claims, or put them in a hold bucket for review.  What should you be doing?


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1. Monitor your claims that have not been paid in 45 days.  This is your first clue that you have been dumped into a bucket for review. Some carriers are noting claims marked for review, but expect more of this as we move further into 2016.

2. Monitor your claims for specificity.  Blue Cross was the first to say they would not pay "unspecified claims."  Have you looked for a code for chest pain that is not unspecified? 


Related post:

Keeping up with ICD-10 education


3. If you have a superbill that allows providers to circle a diagnosis code, try to delete as many unspecified codes as possible. You might even invest in a product that allows you to ask questions and get answers from and expert coder for the next year as your staff gets more familiar with the ICD-10 process.

Next: Communicate, communicate, communicate


4. If you use an unspecified code, monitor the documentation in the chart to assure there is supporting information to get the claim paid when you appeal your denial. If you have a large dollar value claim that the coding from ICD-9 does not translate to ICD-10, ask an expert to review the claim with you to get additional advice about the correct specificity to improve the probability of getting the claim paid at the first pass. AHIMA has a product that you can purchase that allows you to submit 12 questions over the course of 12 months to get assistance with challenging coding questions.


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5. Communicate with other providers and monitor newsletters to get information about denials, which allows you to act quickly to make changes and get your claims through the system successfully. If you join AAPC, they have an “Ask the Expert” section where you can ask a coding question.  If you are a member, the cost is only $25 per question or $50 if you are not a member.

6. Communicate with your clearinghouse to identify trends that you may not see in your individual claims.  They can tell you what is happening across thousands of claims, which might help you target your documentation and coding better.

7.  Consider a chart audit by a coder very experienced in ICD-10 coding to help you modify superbills and institute coding rules in your software to prevent providers from using inappropriate codes.

Next: Most important above all else...


8.  Work with your software vendor to assist you in setting up templates that give the physicians rules regarding specific codes on disease processes.  Some of the newer software products on the market have the ability to set notifications or templates to guide physicians in coding specific problems.  In primary care, one of these templates might be for injuries since there are multiple ICD-10 codes required to describe the circumstances surrounding the injury.


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9.  Check all insurance company websites monthly for new LCD's as they change ICD-9 codes to ICD-10 so you are not blindsided with denied claims.  Many LCD's are just now getting updated across all carriers. If you are providing a service that required you to monitor the LCD for appropriate diagnosis you need to look at LCD’s at least monthly.  One of the troublesome studies is a Carotid Ultrasound where the acceptable diagnosis seem to change at least once per year and varies across multiple commercial products.

10. Every time you see a free webinar available on coding or on claims management, enroll your billing staff.  The more training you can provide to your billing and coding staff, the more likely you are to sail through 2016 without a reduction in your revenue.

11.  The most important for last, if you have decided you need a certified coder in your practice, look to your current staff before you hire a brand new coder who had just finished training. Sending one of your current staff through the coding course and increase their salary will more likely give you a coder that understands billing criteria versus a new graduate from a coding school.  Hiring that brand new coder would be like taking a Medical School graduate and putting them in charge of an emergency room.

Next: Useful tips


It might even be useful to start a report that you provide to the physician on a monthly basis that gives:

A.   Number of Claims Files

B.    Number of claims rejected

C.    Number of rejected claims that were caused by coding errors

D.   Number of claims that have not had a payment associated in 30 days

With this report you can hold billing staff accountable and identify negative trends quickly so an expert can be consulted to improve your process and get back on track. If you monitor the process during the year, then in October when Medicare starts processing claims based on specificity, you will already be on track to avoid denials. 


Carol Gibbons RN, BSN, NHA

CJ Consulting




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