By Lisa A. Eramo
Although many experts in the healthcare industry predicted that chaos would occur once we flipped the switch to ICD-10 on October 1, just the opposite seems to be true.
“It has been the calm before the storm, and we’re not even really sure whether the storm is going to hit,” says Anita Archer, CPC, director of regulatory and compliance services at Hayes Management Consulting. “Everyone has been holding their breath for the expected impact.”
Archer, who works mostly with large multi-specialty and academic practices, says she has heard very little in terms of major technical or operational glitches during the first few weeks of the transition. A few physicians experienced problems when using automated cross-walks for encounter forms and problem lists; however, those problems were mostly resolved within 24 hours. Even one of her largest clients—an 1,800 physician academic practice—reported virtually no issues. In a recent survey of customer data, Kareo found that 99% of claims submitted in the first month of ICD-10 were successful.
“We haven’t seen the spikes that we were expecting, but it’s still early,” she says.
Where could potential ICD-10 payment problems and/or denials still occur once payers adjudicate more claims?
Archer suspects that practices could encounter problems related to the following:
- Denials due to a lack of medical necessity. Many payers are still in the process of updating LCDs to reflect specific ICD-10 codes, making it difficult for practices to prepare.
- Referrals with ICD-9 codes. Practices may struggle with referrals that include ICD-9 codes or even non-specific ICD-10 codes. These referrals may cause operational headaches for staff members who must then follow-up with the referring physician for more information. Payers will not accept ICD-9 codes for services rendered on or after October 1, 2015. Archer says one way to alleviate this is to ensure that patients have the proper code before presenting for their appointment. Educate patients about their responsibility to obtain this information from their referring physician.
- Episode of care. Archer says some urgent care clinics and orthopedic practices have struggled with assigning a seventh character to denote the episode of care, making this an area ripe for denials. The seventh character denotes the episode as initial (A), subsequent (D), or a sequela (S) for injuries, poisonings, and certain other conditions. Specifically for fractures, the seventh character also includes information about whether the fracture is open or closed and, during the healing phase, whether the fracture’s healing is routine or occurring with complications such as delays, nonunion or malunion. Seventh-character extensions for some open fractures also capture the Gustilo open fracture classification.
Steps to take now
Consider these steps to mitigate any revenue loss in ICD-10:
1. Set up a process for denial management. “You need to look at your denials more closely than you probably would have done historically,” says Archer. As part of your denial management strategy, categorize your denials as follows:
- Denials by payer
- Diagnosis-related denials
- LCD/NCD-related denials
- Denial percentage by payer and/or clearinghouse
- Volume of denials by reason
Once your denials are categorized, ask this question: What is the root cause of these denials?
Denial management also includes a plan for timely responses. Ask these questions: Who will be charged with monitoring denials as they come in? Who will respond to the denials and when? Will coders be responsible for reviewing and re-submitting claims?
“Don’t store up denials, put them on a shelf, and try to get them done later because that may never happen,” says Archer. Look at your payer guidelines to determine the timeframe in which you need to respond.
2. Identify a few key performance indicators (KPIs)—and monitor them frequently. Archer says KPIs don’t need to be burdensome or overwhelming for the practice. Start with a few basic ones such as:
- Total days in A/R
- Aged accounts receivable
- Percentage or number of unbilled claims
- Number of encounters billed
How do these numbers compare in the six month pre- and post-ICD-10? This will give you a high-level of practice performance and any payer problems.
In terms of frequency, the larger the practice, the more frequently you should monitor these metrics; however, a good rule of thumb is to monitor them weekly or daily, if possible. Monitor the aged accounts receivable monthly. If your 60-day buckets are growing, that’s an indication of a problem.
3. Make ongoing ICD-10 education a priority. Archer says to find time in your day for ICD-10 education. Everyone in the practice should receive ongoing or remedial ICD-10 education, as necessary. Again, this doesn’t need to be burdensome. A 30-minute “lunch and learn” once a month or every few months could suffice.
For more resources to help you manage ICD-10, visit the Kareo ICD-10 Resource Center.
About the Author
Lisa A. Eramo is a freelance writer/editor specializing in health information management, medical coding, and healthcare regulatory topics. She also works as a healthcare content specialist for Agency Ten22. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal and AHIMA Advantage. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.