August 24, 2015

Clinical Labs Likely to Face Challenges Under ICD-10

By Robin Zweifel, BS, MT (ASCP)

When ICD-10 implementation becomes a reality on Oct. 1, 2015, clinical laboratories will continue to experience challenges related to the submission of test requisitions, no matter how prepared they are internally. Administrative problems that exist under ICD-9 will not go away; in fact, they could worsen under ICD-10 if the ordering providers are not ready for the change.

As with ICD-9, incomplete or noncompliant test requests can impact laboratory revenues, interfere with patient testing, and, in some instances, delay patient care. Laboratory personnel will need to be just as, if not more, diligent about these requests than ever, and the following information may help them.

Ensure Education

Many laboratory staffs assume that other healthcare organizations, health systems, or physician groups have provided (or will be providing) the training necessary to ensure that ordering physicians can comply with ICD-10 guidelines. Alternatively, they are hoping that ordering physicians are seeking information about ICD-10 preparation and implementing compliant processes independently. 

If none of these scenarios is the case, it will be up to laboratories to educate referring providers, then hopefully they can apply the knowledge received, which will require updating their physician office electronic medical record (EMR) systems and interfaces. Although the sophistication and capability of these systems vary, they must at the very least be able to communicate using ICD-10 codes.

The laboratory requisition generated from the system may or may not provide relevant diagnostic information pertinent to the testing. It is not unusual for requests to include a diagnosis related to the reason the patient was seen by the physician – but this may not be the reason that supports the medical indicator for testing.

Visit Codes

One example of this can be found when ICD-9 diagnosis code V70.0 (routine general medical examination at a healthcare facility) appears on the requisition (on Oct. 1, that diagnosis code will change to Z00.00 – general adult medical examination without abnormal findings). These diagnosis codes are only for the routine evaluation and management of a patient, not for testing related to existing diseases or other conditions that require additional follow-up. 

Medicare provides coverage when a physician bills V70.0. However, when a clinical laboratory submits a claim containing this code, it is statutorily non-covered, and will be denied.

If during the course of the scheduled visit for a routine exam a condition is identified and laboratory testing is ordered to determine a definitive diagnosis, the physician must update the encounter form with the appropriate sign or symptom that prompted the physician to order the test or tests.

In a worst-case scenario, the physician’s EMR system would not be sophisticated enough to print or generate a test request with the related diagnosis in addition to the diagnosis for the CPT visit code for the encounter.

Ideally, the physician’s EMR system will accommodate the two different encounters and the two different diagnoses for them, and it should allow for the physician encounter diagnosis to be separated from the lab test order. 

The Usual Solution

Front-office staff or accessioning staff at laboratories process the insurance forms and test requisitions and enter the diagnosis codes into the library information system (LIS). The specimens are processed and testing is initiated. Results are generated and charges drop once tests are resulted.

Because clinical laboratory staff members are not interpreting professionals, the test results will not impact the diagnosis submitted. Health information management (HIM) professionals do not review or validate most diagnoses submitted on outpatient claims for clinical laboratory tests, nor do they apply the standard coding guidelines.

The claim will not pass through the edits for reimbursement if it is a statutorily non-covered diagnosis, and the billing department is left with only one option: write off the claim.

As the preventive care benefits of commercial and Medicare payors expand, more and more plan members and beneficiaries will receive preventive care and diagnostic screening benefits, such as those identified by V70.0 and soon Z00.0. As a result, laboratories will see more and more requisitions submitted with these codes, but not the code that will allow the lab to be paid.

Outdated Diagnosis Code

Test requisitions that cannot be processed because the diagnosis is missing or outdated (e.g., with ICD-9 rather than ICD-10) will raise administrative questions such as the following: 

  • Will the laboratory hold the specimen and delay testing until the appropriate diagnosis can be solicited from the physician?
  • Or will the laboratory process specimens, perform testing, and hold the claim until it has the diagnosis? If so, what steps will the laboratory need to take to obtain a compliant diagnosis?
  • If available, will the test results be released or held until the diagnosis is obtained?
  • If the decision is made to always perform testing and to expend the labor and reagent costs, what action will laboratories take when they cannot obtain an ICD-10 diagnosis code and, therefore, cannot submit claims? Even though labor and reagent costs already will have been expended, the claim will have to be written off.
  • What impact will the decision to delay testing have on patient care?

Proactive Steps

Adoption and implementation of ICD-10 will impact productivity at all testing phases (pre-analytic, analytic, and post-analytic) within the clinical laboratory. To lessen the repercussions, consider the following.

  • Educate referring providers about the need to supply comprehensive documentation and to comply with coding guidelines.
  • Be sure that laboratory staff research and share diagnosis coverage requirements of the various payer plans.
  • Track coding errors and noncompliant test orders that impact specimen processing and turnaround times, especially the ones that delay patient care. Focus on the high-dollar and frequent-offender clients first.
  • Develop a reporting metric to track denials that occur because of missing, incomplete, or non-covered diagnoses.
  • Communicate the above results to ordering providers. If they make improvements, communicate those as well.

Tough Love

Laboratory directors may have to make tough business decisions regarding client relationships when providers demonstrate a track record for noncompliance and when the level of noncompliance increases due to lack of correct ICD-10 coding. Determine how to proceed with provider accounts that show no or minimal improvements and include it in the business plan.

Work with providers to ensure that updates and system improvements are implemented in a timely manner. Communicate and share information with providers related to interface changes being implemented through laboratory systems.

On and After Oct. 1

With the proper reporting and established metrics in place prior to Oct. 1, you should be able to identify increases in specimen processing and claim processing delays, as well as suspended charges.

Ensure that personnel in strategic positions are adequately trained and increase their number during the last quarter of 2015. Knowledgeable staff can identify trends in a timely manner, develop and implement a corrective action plan, and follow through with validation and reconciliation.

About the Author

Robin Zweifel is a senior vice president of revenue capture services for Panacea Healthcare Solutions, Inc.

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