I cannot believe it is finally here. After much debate and two delays ICD-10 is about to become a reality. Many of us are meeting this challenge with excitement and a bit of apprehension. I must admit the fear of the unknown right now is causing me a bit of apprehension and sleepless nights as well. 

 

Many physicians are just not prepared and are scrambling now to get ready. Many medical practices still are in denial and are procrastinating about getting ready. For physician practices that do not utilize an Electronic Health Record how will they manage and communicate diagnosis coding in the ICD-10 world? 

The superbill will not work with the number of codes. Many practitioners think because the Centers for Medicare & Medicaid Services (CMS) has allowed a grace period that they don’t need to prepare now which is not exactly accurate. Even with the grace period, the provider must code a claim in the appropriate category and must make sure laterality is documented and coded. Other payers may not allow a grace period when selecting a specific code. So for those practices that have procrastinated and have not prepared my advice is get ready quickly. Time is running out.

What are the ten top potential challenges after ICD-10 goes live?

  1. Delay in payment
  2. Claim denials for medical necessity, invalid codes, wrong category selected, and laterality.
  3. Claim denials due to medical policy.
  4. Additional requests for medical records.
  5. Reduction in productivity (up to 50 percent or more).
  6. Need for more queries to clarify documentation and/or coding.
  7. System failures.
  8. Electronic Health Record inaccuracies.
  9. Lack of coding and documentation education.
  10. Reduction or delay in revenue.

You have about five weeks to get ready.  So what should providers do now?

Contingency planning is so important as part of successful implementation. Here are some top considerations when developing your contingency planning. I have classified these by coding and compliance and revenue cycle:

Coding

  1. Take the top 25 diagnosis reported by provider and/or hospital and map the ICD-9 codes to ICD-10 codes.  Look at what documentation will be required for ICD-10.
  2. If using an Electronic Health Record, go into the test environment and test the ICD-10 codes to determine if your EHR has a pick list or if using IMO (Intelligent Medical Objects) or another application that the qualifiers or logic defines specificity and guides the practitioner in the correct code selection.
  3. If not previously completed, conduct an ICD-10 readiness audit to determine if the documentation will support a specific ICD-10 code or if the practitioners need some education and guidance.
  4. Ensure providers, coders, and others are well trained.
  5. Audit and monitor continuously to ensure documentation is sufficient for ICD-10. Follow up with practitioners whose coding and/or documentation needs work.  Keep in mind if you do not communicate how will the practitioner know there is a problem?
  6. The first few weeks when ICD-10 goes live have an experienced coder or consultant available to assist providers with questions regarding the codes and/or documentation. A coding hot-line or a person on site to assist practitioners would be a plus.
  7. Two to three months after ICD-10 is fully implemented in your organization determine additional education needs and provide follow up or additional training.
  8. Develop a clinical documentation improvement process to ensure that coding and documentation is compliant.
  9. Create a query process to clarify documentation and/or coding errors.  Keep in mind expect questions and queries to increase at a minimum by 25 percent.
  10. Make certain you have conducted a productivity analysis and monitor reduction in productivity the first year.  This affects not only workflow but revenue as well.
  11. Typically in the Electronic Health Record, medical practices use problem lists attached to an ICD-9 code.  These will need to be converted to ICD-10 codes on or after October 1. 
  12. If using a superbill find an electronic alternative in lieu of using a paper superbill.  It will be very difficult to fit all of the codes on to a paper superbill.
  13. Communication is critical the first year of ICD-10.  Keep practitioners and staff up to date with changes in the Electronic Health record, coding rules, problems encountered, etc.
  14. Develop “cheat sheets” or resources for the physicians to assist with coding and documentation.
  15. Make sure templates and/or “smart text or smart phrases” practitioners use in the Electronic record are up to date and have been modified for ICD-10.

Revenue Cycle

  1. Obtain a line of credit to cover overhead for 3-6 months in case payment is delayed.
  2. Analyze the number of claims by payer you submit annually. Know your major payers.
  3. Develop a solid denials management process. Define risk triggers based on key revenue cycle metrics.
  4. Make sure your billing office/patient financial services department is well staffed and have staff dedicated to work denials/suspended claims.  In addition make sure that you have enough manpower to handle a potential increase from payers for requests for medical records (documentation) and the potential increase in patient inquiries.
  5. Ensure you have developed a productivity standard and monitor revenue cycle productivity at a minimum the first 12 months after implementation.
  6. Pay very close attention to your explanation of benefits and Remittances to ensure you are receiving accurate payment.
  7. Take care of denials and suspended claims quickly.  This should be top priority.
  8. Run your Accounts Receivable Report every 2 weeks to make sure you are keeping your AR at a reasonable percentage for at least the first six months and then monthly thereafter.  If you don’t have goals set for your AR days, set them before ICD-10 goes live.  Keep in mind if your AR gets out of control, revenue drops.
  9. Make certain you have solid policies and procedures in place for compliance, coding standards, productivity, and revenue cycle.  If you have current policies get them out and review and make modifications if necessary. If policies do not exist, develop them before October 1, 2015.
  10. Make sure you get all claims submitted with ICD-9 codes prior to October 1st if possible.
  11. Attempt to clean up outstanding denials and claim errors prior to Oct. 1, 2015.
  12. Work diligently to reduce your AR by collecting outstanding payments and follow up on outstanding claims that have not been paid before Oct 1, 2015.

Put your contingency plan in writing and update the plan as problems occur. If you have an ICD-10 Steering Committee, do not disband the committee after the first of October. The committee should continue to meet monthly to mitigate problems and challenges as they occur. Lastly it might be a good idea to communicate with patients and let them know of this significant change. They may receive denials from payers that will increase phone calls to your billing office or patient financial service department.

The countdown has begun so stay optimistic with a positive attitude. Keep a keen eye on coding, documentation, and revenue throughout this transitional period. Remember we are all in this together; hospitals, physicians, health care facilities, payers, vendors and others. 

 

Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner

Deborah Grider has 34 years of industry experience and a recognized national speaker, consultant and American Medical Association Author who has been working with ICD-10 since 1990 and is the author or Preparing for ICD-10, Making the Transition Manageable, Principles of ICD-10 and the ICD-10 Workbook, Medical Record Auditor, and Coding with Modifiers for the AMA.  She is a senior healthcare consultant with Karen Zupko & Associates.  Deborah is also the 2017 American Health Information Management Literacy Legacy Award Recipient. She is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.

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