How to Avoid an ICD-10 Claims Disaster

Guest post by Michele Hibbert-Iacobacci, CMCO,CCS-P, vice president of information management support, Mitchell International.

Michele Hibbert-Iacobacci
Michele Hibbert-Iacobacci

Recent ICD-10 end-to-end testing conducted by CMS and the American Medical Association yielded an 87 percent claim acceptance rate. This means that of the 29,286 test claims received, only 25,646 were accepted. Imagine thousands of claims denied due to providers submitting improper codes, stalling the bill review process and creating pain for everyone involved.

The one percentage drop in claims accepted from the month prior is a poor indication for the months ahead, as 100 percent of the test participants claimed to be fully ready for the October 1 ICD-10 implementation date. It’s only logical that many carriers and providers wonder what will happen to those that aren’t ready.

The end-to-end testing results also raise complicated questions: Which ICD-10 codes will be seen most frequently post-implementation date? And will these codes match what providers will put on the bills they send?

It’s no secret that ICD-9 has a lot fewer codes than ICD-10 and a situation is simply less complicated with less contextual data to worry about. As a result of the influx of new codes presented by ICD-10, we can expect to see providers assigning way more codes than necessary to bills in a pin the tail on the donkey-type attempt to choose the right code. For example, there are ten codes for a fracture to the tibia in ICD-10, as opposed to one in ICD-9. So many options may lead a provider to place all ten on a bill, to ensure payment is received.

It will be challenging for untrained providers to submit the correct ICD-10 codes, and as such, productivity will decrease alongside increasing reimbursement challenges and potential claim denials. Carriers, on the other side, will be forced to conduct extensive reviews of each bill to determine the actual injury cause and appropriate code.

To handle the huge influx of ICD-10 codes, providers can design a system where the office coders are provided with quick references to the most prevalent codes used in the practice. Over time, the overall billing experience will improve as coders become more skilled in identifying proper codes and carriers become more precise in reviewing bills. At first, carriers will be tolerant toward the reporting of multiple or vague codes. However, with each passing day post-implementation of ICD-10 carriers will become increasingly strict. Providers will be required to submit correct coding pending the value provided by the classification system accurately describes patient conditions.

It has been observed that hospitals have focused on training and have become more qualified in using the new classification system by requiring certifications in ICD-10 coding. Carriers in the P&C industry looking to identify the most appropriate code should refer back to where the most expert coding has occurred on the claim. Usually this information is provided by the hospital emergency room during an examination closest to the date of loss. Carriers should look for correlation throughout the history of the claim, up until the point where providers begin to use the proper coding. Otherwise, carriers could potentially pay for all sorts of improperly coded maladies on bills. ICD-10 codes, while many, provide more precise coding results. Again, overtime these coding nuances will be addressed by carrier review and attention to the entire claim.

An example of a potential multiple coding situation occurs for whiplash injuries. If a patient is seen in the emergency room, an ICD-10 code of S13.4 “Sprain ligaments of cervical spine” would correctly be reported. Continuing care after the emergency room visit may evolve into reporting other diagnoses codes applicable to the cervical spine but not a whiplash injury. Examples of using: S13.8 “Sprain of joints and ligaments of other parts of neck,” and S16.1 “Strain of muscle, fascia and tendon at neck level” may also be billed in order for providers to insure they are paid. Correct coding would require use of S13.4 alone for the whiplash injury unless the provider is diagnosing additional problems, which should be documented in the office notes.

During the transition from ICD-9 to ICD-10, it is crucial for carriers and providers to adopt a patient attitude. We will get there. It is not the objective of ICD-10 to cause more codes to be used on bills, especially in the outpatient/office setting. The benefit of using ICD-10 is the development of value-based healthcare leading to a higher quality of care from providers. The cornerstone of this value-based healthcare? ICD-10 data collection. ICD-10 provides clear descriptions and allows for the specific classification of conditions, which ultimately eliminate the most time consuming aspects of using ICD-9 as it relates to documentation needs.

Write a Comment

Your email address will not be published. Required fields are marked *