Electronic Health Reporter

Guest post by Michele Hibbert-Iacobacci, vice president, Mitchell International.

The casualty claim arena involves evaluating and payment of claims for claimants who have suffered from an auto accident or workers’ compensation injury. This side of the health payment continuum has been omitted from the Health Insurance Portability and Accountability Act (HIPAA) as a covered entity.

This means that casualty claim insurers are not required to abide by the standards set forth in HIPAA and that these standards only apply to the health payer. Omitting the ICD-10 in casualty claims from standards does have merit, but when it comes to standardization, all health claims should be adjudicated and paid in the same manner. Why should a provider charge differently and be paid differently when the payer of the claim is not on the health side? This is a question many casualty payers ask and not being part of the standardization only raises the question more.

There is no option for submission of claims by the covered entity to not be compliant by October 1, 2014 with the International Classification of Diseases, 10 Revision (ICD-10). Why is it a good idea to omit the casualty payer from these standards if the majority of health payments are made using this new standard? In addition, if providers are covered entities, then why would the casualty payer not speak the same code language? It’s almost like trying to communicate in a foreign country without the benefit of knowing the language.

The benefits of the new and singular classification system to either the carrier or provider has been proven and documented. There are clear benefits to the provider, namely:

• Decreased administrative burden—less time for the provider staff in making copies and responding to requests for additional documentation – the new codes are full of additional information.
• Submission of only ICD-10 and discontinuing the use of ICD-9 for casualty claims.  Why should providers take on the burden of both code sets for different payer types?
• The new codes are distinct with a focus on outcomes as they provide a key concept in coordination of care.  Coordination of care in the new health insurance world will be greatly emphasized as more people are covered by health insurance and casualty insurance than ever before.

The largest challenge with readiness of ICD-10 is the coordination of all touch points related to the use of diagnosis coding. ICD-10 touches many areas of a provider and carrier business and the impact cannot be minimized. Creating a program around the multiple areas that utilize the code sets and building a program to implement was to date the most valuable aspect of successful execution.  During readiness assessments on both provider and payer side the benefits of the classification system became more evident.

Providers may experience several different issues during implementation that should be mitigated with proper management. These may include:

• Payers may delay payments because of readiness issues, so carriers need to be able to handle the costs associated with changes in accounts receivable timelines.
• Provider billing will take a productivity loss at first—this has been proven in many studies and observation of countries such as in the Canadian implementation experience. The effect can be lowered by proper training, practice, implementation of electronic health records (EHR) and the use of computerized assisted coding software.
• ICD-10 code sets take knowledge to operate and apply successfully – specifically in the area of anatomy and physiology. Providers can experience office staff frustrations mixed with enthusiasm.
• Office and hospital staff will also likely be addressing issues caused by the payer not paying bills properly and while these issues can be morale changers, they can also empower the staff to provide quality review.

Carriers will not need all individuals who encounter the new code sets to be experts in coding, although it doesn’t hurt to have a few key individuals with this skill set—they just need to make sure they understand how the code set is used. Some of the benefits and issues Property & Casualty (P&C) carriers will have to address are:

• Changes in medical bill review — ICD-10 code sets are detailed, there is more opportunity to either have more straight through processing or investigate more claims based on specific criteria.
• Carriers will receive ICD-9 codes on provider bills even after the implementation date of October 1, 2014. This may be because the provider is not a covered entity under HIPAA or they have an exemption. Either way, carriers need to be versatile enough to handle both situations and pay bills appropriately.  Performance of dual coding and understanding the differences will benefit claim adjudicators and carriers for creation of beneficial review criteria that is not available today.
• Carriers will need to understand any gaps in bill review systems after ICD-10 code set implementation. Some edits in bill review systems were done because ICD-9 was so non-specific it created more work to review the care. With ICD-10, now many of the answers are in the code itself with the complete descriptions.

As an example of being concise with ICD-10 for P&C claims would be in dealing with our most prevalent diagnosis of whiplash (soft tissue) of the neck also termed in ICD-9 as “Cervical Sprain/Strains.” The current ICD-9 code for this injury is 847.0. ICD-10 has created three separate codes that distinguish the types of soft tissue affected by this type of injury, they are:

• S13.4 – Sprain of ligaments of cervical spine
• S13.8 – Sprain of joints and ligaments of other parts of neck
• S16.1 – Strain of muscle, fascia and tendon at neck level

The distinction in ICD-10 has separated the ligament from other soft tissues in the neck.  This distinction may provide more insight into the severity of an injury and potential treatments that are appropriate due to the specificity. Other codes in the ICD-10 injury section have more complete descriptions and allow the provider to describe more about the injury and the site. The additional information will cause efficiency gains between the insurer and provider because less clarification and back-and-forth communication will be required. Encounter codes are an added value in having the ability to know whether trauma codes are a new encounter, follow-up care or sequela.

It will be a different atmosphere in attempting to emulate the benefits of not only ICD-10 and HIPAA standards in casualty claims, but also observing the quality aspects of the new healthcare reform that focuses on wellness, quality and return to health.

It is difficult to embrace these new changes when casualty claims maintains itself in a retrospective review mantra and fee for service. ICD-10 can only benefit claims review in casualty claims. After all, we now even have a complete section in ICD-10 that demonstrates car airbag injuries and where the person was sitting in the car. When ICD-9 was invented – airbags did not exist.

Michele Iacobacci’s responsibilities include managing the Health Information Management Group, Litigation Support and Professional Services. Iacobacci has spent 10 years working with inpatient and outpatient medical billing and reimbursement on the provider side, working at four differently large inpatient facilities as a coding and reimbursement manager. For the past 25 years, her focus has been working with major casualty insurers in implementing rules committees, quality assurance, risk management, compliance programs and review processes necessary in delivering objective bill review systems. She is a certified clinical coding specialist (CCS-P), and a member of the American Health Information Management Association (AHIMA) and has authored many contributed for industry publications such as Claims Magazine and Best’s Review.